Renal Cancer: Handorf Flashcards
(39 cards)
1
Q
How common are the common primary neoplasms in adults?
A
- Clear cell carcinoma (70%)
- Papillary carcinoma (10%)
- Chromophobe carcinoma (5%)
- Oncocytoma (5%)
- Other (urothelial, squamous, 10% -> primarily of the collecting system)
2
Q
What are the benign renal neoplasms?
A
- Some papillary neoplasms (small, 25% of autopsies) can be called adenomas because they are probably not going to grow into papillary carcinomas
-
Oncocytoma: a benign renal epithelial neoplasm made of large cells w/mitochondria-rich eosinophilic cytoplasm
1. No specific genetic signature
2. Grossly mahogany brown with central stellate scar on cross-section (30%) -> radiology
3. May be multiple; RARELY exhibit aggressive behavior
4. Can get quite large and never metastasize or exhibit malignant behavior
3
Q
How are renal neoplasms removed?
A
- Partial nephrectomy now in stead of nephrectomy (for benign and malignant neoplasms)
- Why might a urologist want to do a nephrectomy rather than a partial removal? Matter of time and money (for older generation of urologists)
4
Q
What is this?
A
- Adenoma
- Couple hundred microns across; not big lesions
5
Q
What do you see?
A
- Round, mahogany brown, central stellate scar in the one on the right
- Do not look invasive or necrotic
- Can be multiple and bilateral
6
Q
What is this?
A
- Round, mahogany brown, central stellate scar in the one on the right
- Do not look invasive or necrotic
- Can be multiple and bilateral
7
Q
What do you see?
A
- Oncocytoma: clustered intercalated tubular cells
- Nuclei (regular) seem large compared to the RBC’s (7-10 microns), nucleoli
- Fairly vascular tumors
- No mitotic figures
- Diagnostic key is the cytoplasm -> loaded with organelles because very pink cytoplasm (protein-making factory)
8
Q
What is this?
A
- Oncocytoma
- Diagnostic key is the cytoplasm -> loaded with organelles
- Electron micrograph: protein-making factory
9
Q
What are the patterns of spread in renal carcinoma?
A
- Direct
- HEMATOGENOUS: known for this kind of spread -> can also invade vena cava after renal vein
1. Lung, bone metastases
2. Most pts w/these metastases die of hemorrhage - Contiguous venous spread
- Lymphatic
- Urine
10
Q
What cells comprise renal cell carcinomas? What do they look like? What are some common complications?
A
- Tubular epithelium cells
- A lot of carcinomas may also look encapsulated (don’t appear to invade) -> may fool you
- Necrosis and hemorrhage are common because known for being very neo-vascular (center will be necrotic because the vessels come in from the outside) -> veno-invasive/occlusive adds to hemorrhagic effects (even metastases very likely to be hemorrhagic)
11
Q
What are the risk factors, signs, and symptoms for renal carcinoma?
A
- Risk factors: age, smoking, being a man
-
Signs and symptoms:
1. Microscopic hematuria: not gross
2. Complain of dull flank pain (can get lost in the noise of pain complaints -> can present pretty late in its course, so it may be pretty large)
3. Classic triad: flank pain, microscopic hematuria, abdominal mass -> we find these much more than we used to due to excessive CT scans (not because we can palpate them)
12
Q
What is clear cell carcinoma?
A
- Malignant neoplasm of cells w/clear or eosinophilic cytoplasm in a delicate vascular network
- Usually solitary, polar, and yellow often with cysts, necrosis, and hemorrhage
- Vast majority express abnormality on chromosome 3p (whether sporadic or von Hippel Lindau).
- Clinical stage is most important prognostic feature, and after that nuclear grade (Fuhrman)
- Excess VEGF due to HIF not being degraded
- Clear cell neoplasm ALWAYS malignant
- Can’t rely on nuclear features to call it a cancer -> encapsulated or not is not a good measure of whether or not it’s a cancer in these cases
13
Q
What is this?
A
- Malignant neoplasm -> clear cell carcinoma
1. Why? Because this is the most common type - Dark brown, lumpy, fat, encapsulated
- Renal cell carcinomas tend to be upper or lower pole, not in the middle
14
Q
What is this?
A
Renal vein with a tumor in it
15
Q
What do you see here?
A
- Just another example of a renal cell carcinoma: note that you can’t use encapsulation and local invasion as a decision point for whether these are malignant or not
16
Q
What do you see on the left? And the right?
A
- Low power: normal kidney on left, tumor on right
- Vascularity in the image on the right -> nuclei are absolutely inconsequential (almost no nuclei, and no nucleoli -> still renal cell carcinoma; nuclear grade the most important consideration after stage)
17
Q
What do you see here? What is the difference between the image on the left and that on the right?
A
- Clear cell carcinoma
- Left: low-grade -> small, regular, no nucleoli
-
Right: high-grade -> variable size of nuclei, nucleoli visible in some cases
1. No, or few, mitotic figures -> NOT about these, but rather size, shape, and number of nucleoli
18
Q
What is this graph showing you? Why has survivability improved recently?
A
- Furman nuclear grade v. survival
- Just grade-based -> this was before a lot of the new immunotherapies
-
Survivability has improved due to:
1. Finding tumors earlier, and taking them out (before they get to 3, 4, 5cm danger zone)
2. Immuno-therapies really helpful in keeping these people alive (some knocking on the door of curing these patients)
19
Q
What genetic abnormalities are associated with clear cell carcinoma?
A
- VHL involved in sporadic AND hereditary clear cell (on chromosome 3)
20
Q
What is the significance of this image?
A
- Tumor can grow into and up vena cava, even into the heart
- May not grow up wall, so you can actually just pull these out some times
- Think about the hemodynamic functions that would be impaired with one of these -> implications of big tumor blocking IVC
21
Q
What is renal papillary carcinoma?
A
- Malignant renal parenchymal tumor with a papillary or tubulopapillary architecture
-
Bilateral and multifocal tumors are more common than with other renal malignancies
1. Many renal cancers have this characteristic, but especially this one - No standard cytogenetic characteristic (except with hereditary variant—7q)
- Acquired dialysis related renal cystic disease -> 50 fold increase in risk of renal cancer (60% clear cell/40% papillary)
- Furhman (nuclear grading system) does not apply -> ONLY applies in clear cell
22
Q
What is this? How can you tell?
A
- Papillary carcinoma
- Nothing much that can distinguish this from clear cell, so you have to look at it under a microscope
23
Q
What do you see here?
A
- Dialysis acquired renal cystic disease
- Appearance of a papillary carcinoma: typically pts with renal transplants do not have kidney removed, but still have to screen the extra kidney because risk of developing clear or papillary cancers with this acquired cystic disease
24
Q
What is this? How do you know?
A
- Papillary carcinoma
- Appearance of papillary structure makes it papillary cancer
25
What genetics are associated with papillary carcinoma?
- Not a lot of relation to genetic abnormalities, although tend to be trisomy 7 or MET if they are associated with genetic abnormalities
26
What is chromophobe carcinoma?
- Characterized by _large pale cells with prominent cell membranes_
- No specific genetic signature
- Generally _lower mortality_ (lower stage)
- Fuhrman nuclear staging does not apply
- Positive for **_Hale’s colloidal iron stain_** (stains blue)
- _Histologically tend to look worse, but behave better than clear cell_ (big, ugly nuclei, nucleoli)
27
What is this?
- Chromophobe carcinoma: lots of hemorrhage
28
What do you see here?
- Chromophobe carcinoma
1. Mixture of clear and not clear cells
2. Thicker-walled vessels
- Distinction can be a challenge between the 3 malignant cancers
29
What is this?
- **_Chromophobe carcinoma_**
- Stains blue on _Hale's colloidal iron stain_
30
What is renal pelvis carcinoma?
- Urothelial cells
- _Transitional cancer_: if you are getting these in bladder (_SMOKERS)_, you are going to get them in collecting system over time too
31
What is this? How can you tell?
- **_Renal pelvis carcinoma_** (urothelial - transition cell)
- NOT polar (centrally located -\> where collecting system is)
32
What is this?
- **_Renal pelvis carcinoma_** (urothelial - transition cell)
- Not distinguished looking under the microscope
- NOT adenocarcinomas -\> _going to tell more what it is from where its coming from_ than based on what it looks like under the microscope
33
What is this?
- _Renal pelvis carcinoma_ - squamous cell
- Squamous cancer can occur in pelvis, but a minority of these
34
What is Wilm's tumor (nephroblastoma)? Disease script?
- Embryonal pediatric tumor of the kidney, which may also be seen rarely in adults
- Peak incidence between _second and fifth year of life_ (95% of kidney cancer in children)
- Post therapy _5 yr survival 90%_
1. Very aggressive, so yields to radiation, chemo
- Microscopically, a mixture of cellular elements (blastemal, stromal, and epithelial)
- **_Disease script_**: 2-5 y/o (can be 20 y/o, but not common) -\> mom’s giving a bath and finds abdominal mass (no fat pad in belly like in adults)
35
What is this? What are the associated syndromes?
- Big, nasty, encapsulated mass in the kidney
- **_Syndromes_**:
1. _WAGR_: wilms tumor, aniridia (absence of iris, usually both eyes), genital abnormalities, and mental retardation
2. _Denys-Drash_: gonadal dysgenesis and renal abnormalities
3. _Beckwith-Wiedemann_: enlargement of individual organs or segments, esp. 1/2 of the body (hemimegaly; silenced insulin like growth factor 2)
36
What is this?
- Wilm's tumor, nephroblastoma
37
What do you see here? How can you tell?
- Wilm's tumor/nephroblastoma: highly aggressive tumor
38
What do you see here?
- _Metastatic carcinoma_
- As vascular as kidney is, not a hugely common site for metastasis
1. Metastatic cancer is most common in the lung, brain, liver, but PRIMARY cancer is the most common in the kidney
39
What is this?
- Small cell cancer of lung metastatic to glomerulus (not common)
