Malignant Renal tumors

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Malignant Renal tumors

• DR.Gehan Mohamed

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Malignant renal tumors

• It may be
• primary tumors i.e arise from kidney tissue
  itself
• Secondary tumors represent a metastasis from
  any malignant tumor present anywhere in the body
  and reach kidney.

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Primary malignant renal tumors include

• A- malignant epithelial tumors
• 1- Renal cell carcinoma (hypernephroma renal
  cell adenocarcinoma) represents 80-85 ,it is
  subdivided into
• a- Clear cell renal cell carcinoma
• b- Papillary renal cell carcinoma
• c- chromophobe renal cell carcinoma
• d - Collecting duct carcinoma
• 2- Transitional cell carcinoma 8 arise from
  transitional epithelium which line renal pelvis.
• B- malignant mesodermal tumors (i.e arise from
  smooth muscles or blood vessels or fat present
  in the kidney )
• which called Renal sarcomas e.g
  leiomyosarcoma (malignant tumor arise from smooth
  muscle) ,generally poorer outcome .
• C- mixed malignant epithelial and mesenchymal
  tumors e.g Nephroblastoma (Wilms tumor in
  children)

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We will study in details

• RENAL CELL CARCINOMA(RCC) more common in adult
  age.
• Wilms tumor (nephroblastoma) more common in
  children (2-5 years)

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RENAL CELL CARCINOMA(RCC) usually form golden
yellow mass (as it rich in lipid ),this mass
commonly present at upper or lower poles of
the kidney
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EPIDEMIOLOGY

• male to female distribution 21
• Occurs in 5th to 7th decade of life
• 55 of the cases are sporadic but 45,occurs
  with familial predisposition .

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Risk factors for RCC

• Tobacco greatest risk factor
• Occupational exposure to asbestos, petroleum
  products.
• Obesity, Hypertension
• Chronic phenacetin or aspirin use
• Acquired polycystic kidney disease secondary to
  dialysis results in 30 increase risk specially
  the papillary type of RCC.

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Diagnosis

• Clinical presentation
• investigations

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Clinical presentation

• Many kidney tumors go undetected due to the lack
  of symptoms and are incidentally detected during
  the medical evaluation of an unrelated problem.
• Kidney tumors can cause symptoms by compressing,
  stretching or invading structures near or within
  the kidney.

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Renal Cell Carcinoma Symptoms

• Hematuria Blood in the urine (making the urine
  slightly rusty to deep red)
• Pain in the side that does not go away
• A lump or mass in the side or the abdomen
• Weight loss, fever, anemia
• Feeling very tired or having a general feeling of
  poor health.
• high blood pressure

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If cancer spreads beyond the kidney, symptoms
depend upon which organ is involved such as

• a - Shortness of breath or coughing up blood may
  occur when cancer is in the lungs
• b - bone pain or fracture may occur when cancer
  in the bone
• c- neurologic symptoms may occur when cancer is
  in the brain

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Paraneoplastic syndromes are symptoms and signs
produced due to hormone like substances secreted
from the tumor cells and not secondary to
distant metastasis

• Anemia- anemia of chronic disease
• Hepatic dysfunction
• Hypercalcemia
• Cachexia and Fever
• Erythrocytosis as 1-5 of these tumors produce
  erythropoietin
• Secondary AA amyloidosis 3-5

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Investigations

• 1-Radiographic evaluation
• - Ultrasound to detect solid versus cystic
  lesions.
• - Contrast CT test of choice to evaluate
  tumor size, location, lymph node involvement
• -MRI to evaluate collecting system and blood
  vessel involvement.
• -Angiography
• MRI with angiography
• Used for embolization of large lesions
  preoperatively
• Take Biopsy to confirm diagnosis and detect
  histopathologic types of RCC.
• 2-Immunohistochemical staining using CD10,inhibin

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Histopathologic types of RCC

• a- Clear cell renal cell carcinoma
• b- Papillary renal cell carcinoma
• c- chromophobe renal cell carcinoma
• d - Collecting duct carcinoma

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Pathogenesis of Clear cell type of RCC

• 1- arise from epithelium of proximal convoluted
  tubule.
• 2- there is deletion in the short arm of
  chromosome 3 or translocation between chromosome
  3 and 6.
• 3- so there is loss of VHL gene(tumor suppressor
  gene) present on chromosome 3 so there will not
  be inactivation of hypoxia inducible
  factor(HIF) , and insulin like growth hormone.
• 4- So active HIF stimulate new blood vessel
  formation(angiogenesis) by production of vascular
  endothelial growth factor .
• 5- so there is enough blood supply to the newly
  growing tumor cells.

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• Clear cell renal cell carcinoma formed of
• a- sheets of cuboidal cells with clear
  cytoplasm rich in glycogen and fat(red arrow).
• b- these sheets are separated by thin
  branching capillaries (blue arrow).

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Clear cell renal cell carcinoma
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Immunoreactivity of RCC to CD10
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Pathogenesis of papillary type of RCC

• 1- arise from epithelium of distal convoluted
  tubule.
• 2- there is trisomy of chromosome 7,16,17 .
• 3- so there is mutation in MET gene present on
  chromosome 7.
• MET gene produce protein act as receptor for
  different growth factors which stimulate growth
  and proliferation of tumor cells, so mutated MET
  gene is called oncogene (i.e this gene promote
  tumor growth and formation )

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Papillary renal cell carcinoma
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Staging and Prognosis
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Stagging of RCC
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Wilms tumor (nephroblastoma)
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Wilms tumor

• It is a Malignant renal tumor
• There is Wilms tumor gene mutation.
• common in children 2-5 years.
• It arises from nephrogenic rests(NR)
• Microscopic picture characterized by triphasic
  pattern
• a- dark blue immature blastema cells
• b- stromal cells
• c- epithelial elements in form of
  abortive glomeruli and abortive tubules.

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Pathogenesis of wilms tumor
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Wilms tumor
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Wilms tumor (nephroblastoma)