RENAL TUMORS

FARWA HASSAN
ZAIN UL ABIDEEN
RENAL ANATOMY
RENAL ANATOMY
 fddsfsddsBENIGN RENAL TUMORS
• Are non-cancerous growths of the kidney that do
not metastasize to other sites in the body .
• They are not life-threatening but they can cause
complaints if they exert pressure effects on
adjacent structures.
• As there is universal increase in the use of
radiological imaging, benign renal masses are
being detected more frequently .
 BENIGN RENAL TUMORS

• METANEPHRIC ADENOMA
• ONCOCYTOMA
• ANGIOMYOLIPOMA(renal hamartoma)
• LEIOMYOMA
• LIPOMA
• FIBROMA
• RHABDOMYOMA
• NEUROFIBROMA
• HEMANGIOMA
 METANEPHRIC ADENOMA
• Most common benign renal parenchymal tumor.
• Discovered occasionally at postmortem or incidentally during
radiological imaging .
• Asymptomatic .
• Despite the classification of adenoma as a benign
tumor, difficult to differentiate from renal carcinoma.
• Unknown etiology .
• Small and slow growing .
• Look very much like
malignant RCCs.
• Previously, all renal tumors
<3 cm were considered
adenomas. However, even
such small tumors can be
METANEPHRIC ADENOMA
adenoma

kidney
Metanephric adenoma
Normal renal parenchyma
 ONCOCYTOMA
• Benign, unifocal renal tumor that averages 5 to 8 cm in
diameter but can reach larger sizes; however, the presence of
malignant elements has been known to occur.
• More often in men than women .

• Unknown etiology

• Found incidentally .

• Partial or radical nephrectomy is the safest method of

treatment because of unreliability of differentiating it from
RCC preoperatively. .
ONCOCYTOMA
MICROSCOPY
 ANGIOMYOLIPOMA (RENAL
HAMARTOMA)
• Unusual tumors of the kidney .
• Often but not always associated with
TUBEROUS SCLEROSIS .
• Histologically, they are composed of fat
cells, blood vessels, and sheets of smooth
muscle cells.
• Profuse internal hemorrhage can occur.
• Malignant elements are present in about
one- quarter of them and may lead to
metastasis .

• Asymptomatic lesions smaller than 4 cm

should be followed with yearly ultrasounds.

• Larger tumors should be considered

for embolization or renal-sparing
surgery.

• Conservative surgical therapy is necessary

because of frequent bilaterality and
multiplicity.
 Normal
kidney

angomyolipoma angiomyolipoma

Normal
kidney The tumor has adipose tissue (the
"lipoma" component) which blends
with interlacing bundles of smooth
muscle (the "myo" component) in
which are scattered vascular spaces
the "angio" component.
 LEIOMYOMA
• Rare
• Small
• Typically found in smooth muscle –containing
areas of the kidney including renal capsule
and renal pelvis .
LEIOMYOMA

Renal parenchyma

liomyoma
MICROSCOPY

liomyoma

Renal
tubules
 LIPOMA
Seen in middle aged females .

• Best detected radio-logically by CT scan .

• ( due to high fat content .)
• Seen in middle aged females
LIPOMA MICROSOCOPY

lipoma

Mature adipocytes

Normal
kidney
 FIBROMA
• Very small in size ( average 0.5 cm ) or less
• Asymptomatic .
• More commonly found in women than men.
• Usually occur on the rim of the kidney
• May reach large size before being detected
• Because they can’t be distinguished from malignant growths, they
are often removed through partial or complete nephrectomy .
 fibroma

This small round white nodule in the medulla is an

incidental autopsy finding. They are generally 0.5
cm in size or less.
MICROSCOPY
Normal renal parenchyma

fibroma
MALIGNANT RENAL TUMORS
PEADIATRIC RENAL TUMORS

• Wilm’s tumor ( nephroblastoma )

RENAL TUMORS IN ADULTS

• Squamous cell carcinoma
• Renal cell Carcinoma
 RENAL CELL CARCINOMA
EPIDEMIOLOGY
• The most common neoplasm of the kidney
(75%) or up to 85% .
• Arises from renal tubular cells .
• ( 2 – 3 ) % of all adulthood cancers .
• ( 40 % ) of patients die of cancer .
• Most common in 6th & 7th decades .
• Male : Female ratio 2:1
 RENAL CELL CARCINOMA
RISK FACTORS
• Male gender
• Race ( African Americans > Caucasians )
• Age (40 – 60 )
• Smoking ( increase risk by 40%)
• Obesity
• High caloric diet
• Lack of physical activity.
• Occupational exposure ( asbestose ,cadmium )
• Family history of RCC .
• Specific treatments like dialysis – drugs
• certain pain relievers - like Phenacetin, diuretics
• Hypertension
• Genetic and hereditary conditions

 Von Hippel-Lindau (VHL) Disease

 Hereditary Papillary Renal Cell
 Carcinoma Birt-Hogg-Dube Syndrome
 Hereditary Leiomyomatosis Renal Cell
Carcinoma Syndrome.
 Hereditary Renal Oncocytoma
 Polycystic Kidney Disease
smoking

High caloric diet

Drugs

Lack of physical acti

STAGING OF RCC
 RCC

Renal cell carcinoma arising in the middle pole of the kidney. Fairly
circumscribed, The cut surface demonstrates a yellowish areas, white areas,
brown areas, and hemorrhagic red areas.
 RENAL CELL CARCINOMA

HISTOLOGIC TYPES
• Clear cell RCC .
• Papillary RCC .
• Chromophobe RCC .
• Collecting duct RCC .
• Unclassified RCC .
 CLEAR CELL RCC

H&E

CD 10
PAPILLARY RCC
CK 7
H&E
CHROMOPHOBE RCC

HALE’S IRON STAIN

H&E
COLLECTING DUCT CARCINOMA

H&E
• Paraneoplastic syndromes may occur as a result of
renal tumor production of 1,25 dihydroxycholecalciferol,
rennin, erythropoietin, and other hormone substances
• RCC is known to produce biologically active products
that result in clinically significant syndromes,
including; Adrenocorticotropic hormone (Cushing’s
syndrome), Prolactin (galactorrhea), Insulin
(hypoglycemia), Gonadotropins (gynecomastia and
decreased libido; or hirsutism, amenorrhea, and male
pattern balding).
• A paraneoplastic syndrome confer a poor prognosis.
Patients whose paraneoplastic metabolic disturbances
fail to normalize after nephrectomy suggests presence
of clinically undetectable metastatic disease and have
very poor prognosis.
• Stauffer’s syndrome is a reversible syndrome of hepatic
dysfunction in the absence of hepatic metastases
associated with RCC and can occur in up to 20% of
patients.
• Hepatic function abnormalities include elevation of
alkaline phosphatase and bilirubin, hypoalbuminemia,
prolonged prothrombin time, and
hypergammaglobulinemia.
• Stauffer’s syndrome tends to occur in association with
fever, fatigue, and weight loss and typically resolves after
nephrectomy. It may be due to overproduction of
granulocyte-macrophage colony stimulating factor by the
tumor.
 • Hypertension, supraclavicular adenopathy, and flank or
abdominal mass with bruit.
• Approximately 30% of patients with renal carcinoma
present with metastatic disease.
• Metastatic disease involve organs ;
 Lung (75%)
 Soft tissues (36%)
 Bone (20%)
 Liver (18%)
 Cutaneous sites (8%)
 Central nervous system
(8%)
• Varicocele and findings of paraneoplastic syndromes raise
clinical suspicion for this diagnosis.
 INVESTIGATION
Laboratory studies in the evaluation of renal cell carcinoma
should include a workup for paraneoplastic syndromes.

• Complete Urine analysis

• CBC
• Electrolytes
• Renal profile
• Liver function tests Calcium
• ERS PT
• APTT
• Other tests indicated by
presenting symptoms
 IMAGING
• ACT scan without and with intravenous (IV) contrast (renal protocol) is
the method of choice to evaluate a renal mass .
• Any mass that enhances with IV contrast should be considered an RCC
until proven otherwise.
• CT provides information on renal vein and inferior vena cava
involvement, lymph node metastases, and perirenal involvment of the
adjacent organs.
• MRI, help differentiate solid and cystic renal masses and is
particularly useful in patients who cannot receive IV contrast
agents.
• MRI has become the best study to evaluate the IVC for tumor
thrombus.
 Metastatic Workup

Metastatic workup should include routine chest

radiograph, IVU, CT, liver function tests, and serum
calcium. A bone scan should be obtained in any
patient with skeletal pain or other evidence of
metastatic disease .
 SQUAMOUS CELL CARCINOMA
OF THE RENAL PELVIS

• Rare
• Often associated with chronic
inflammation resulting from stones.
• Metastasize early and the prognosis is
poor .
• Radiosensitive
MICROSCOPY

Adapted from
webpathology.com
 CLINICAL PRESENTATION
• More than 50% of these tumors are asymptomatic.
• Classic triad: pain, hematuria, and flank mass occur only rarely and indicate
advanced disease.

More frequent sign and symptoms are:

• Pain
• Hematuria
• Flank mass
• Weight loss
• Hypertension
• Hypercalcemia
• Erythrocytosis
• Varococele,
usually left sided
due to obstruction
of the testicular
vein
 TREATMENT
• Surgery :
 Simple enculation
 Partial nephrectomy .
 Radical nephrectomy .
Radical nephrectomy: Removal of kidney , perinephric fat, fascia
gerota,suprarenal gland, upper half of the ureter. (lymph nodes not part pf
radical nephrectomy).

• Chemo/radiotherapy .

• Immune therapy.
 FOR LOCALIZED DISEASE
• Radical nephrectomy includes the
removal of the tumour-bearing kidney.
• It remains the gold standard curative
therapy for patients with localised renal
cell carcinoma (RCC)

• Nephron-sparing surgery considered for

patients with a localised tumour less
than 4 cm in diameter.

• It involves partial nephrectomy with

preservation of as much functioning
kidney tissue as possible.
 FOR ADVANCED DISEASE
Palliative nephrectomy
• In patients with Metastatic disease for alleviation
of symptoms such as pain, hemorrhage, malaise,
hypocalcaemia, erythrocytosis, or hypertension.

• Several randomized studies are now showing

improved overall survival in patients presenting
with Metastatic kidney cancer who have
nephrectomy followed by either interferon or IL-2.
 MINIMALLY INVASIVE SURGERY

• Kidney tumors be removed (ablated) with intense heat or cold, in which

special needles are inserted through the skin, guided by imaging from a CT
scan and ultrasound.

• Percutaneous cryoablation — Cryoprobes freeze the tumor with intense cold.

The treatment lasts about 30 minutes.

• Percutaneous radiofrequency ablation — Electrodes deliver radiofrequency

energy to the tumor, and the intense heat destroys the tumor in five to 15
minutes.

• Angioemoblization

Patient who are not suitable candidates for surgery Ablation :

 LAPAROSCOPIC SURGERY
Laparoscopic surgery

• The recovery from a

laparoscopic nephrectomy
is remarkable.
Suffer a lot less from the
smaller scars than the
conventional surgical
scar.
Any laparoscopic
procedure is a highly
technical undertaking and
no-one can guarantee that
conversion to the older
style open operation will
not be necessary.
 NON SURGICAL TREATMENT
• Unfortunately, RCC is very resistant to chemotherapy and
there is no standard effective treatment of RCC with present-
day chemotherapy drugs. Some drugs, such as vinblastine,
floxuridine, and 5-fluorouracil are mildly effective.

• Immune therapy; (interferon alpha , IL2) Anti-angiogenesis

therapies; to reduce the blood supply to the tumor, slowing
or stopping growth of the tumor

• Targeted therapies; to growth of the cancer

 PROGNOSIS
• T1 about 95%

• T2 about 88-90%

• T3 about 60%

• T4 about 0-25%
 FOLLOW UP
• For stage I and II disease:
Complete history, physical examination, chest radiographs, LFTs, BUN ,
serum creatinine, and calcium are recommended every 6 months for 2
years and then annually for 5 years.
Abdominal CT scan is recommended once at 4-6 months .

• For stage III renal cell carcinoma,

Physical examination, chest radiographs, LFTs, BUN, serum creatinine, and
calcium are recommended every 4 months for 2 years, then every 6 months
for 3 years, and then annually for 5 years.
Abdominal CT scan should be performed at 4-6 months, then
annually or as indicated.

• Careful surveillance of patients with end-stage renal disease by

ultrasonography and CT scan is recommended.
 WILM’S TUMORS
Epidemiology
• Most common paediatric renal malignancy
• Incidence of Wilms tumor is 8 cases per million
children under age 15
• About 500 new cases per year
• Accounts for 6% of all childhood malignant tumors
Presents between age 1-5; most commonly age 3
• 66% before age 5
• 95% before age 10
• No tumor-specific symptoms
• 1/3rd patients may have anorexia, vomiting, malaise
• Most common presentation is painless abdominal
mass
Physical Exam
• Smooth, palpable large abdominal mass
• May reveal HTN
• Hematuria
• Check labs – associated with Von Willebrand’s
Disease in up to 10% of cases
• Is thought to rise from
foci of persistent
metanephric cells called
nephrogenic rests
• These normally occur in
1% of newborn kidneys
and regress in early
childhood
• Multiple foci of
nephrogenic rests is
called
nephroblastomatosis
 Wilms’ Tumor Histology
Wilms’ tumor consists
of three cell types
a) Tubular
b) Blastemal
c) Stromal
All three are present in
Wilms’ tumor and
considered Favorable
Histology
 TREATMENT
• Despite malignancy, excellent results if it can be
treated aggressively with combination of
radiotherapy, surgery and chemotherapy

• Pts who receive pre-op chemo and those who have

primary resection have an equal rate of
complications, but more complications are seen in
the primary resection group.
HAVE A NICE KIDNEY

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