1. Renal tumors Dr. Samir Al Bashir

2. BENIGN RENAL TUMORS Angiomyolipoma: – Vessels, smooth m & fat – Seen in 25-50% of patients with tuberous sclerosis Oncocytoma – 10% of renal tumors – Encapsulated tan or brown in color – Eosinophilic cells packed with mitochondria

3. Angiomyolipoma

5. RENAL CELL CARCINOMA (RCC) 1-3% of all visceral cancers, 85% of all renal cancer Most common 60-70 years ; M:F = 2:1 Risk factors – Smoking, obesity, hypertension – Unopposed estrogen Rx – Asbestos, petroleum products & heavy metals – CRF & acquired cystic disease (30 folds ) – Familial (4%) Von Hippel-Lindau (VHL) syndrome Hereditary clear cell carcinoma Hereditary papillary carcinoma

6. Renal cell carcinoma

7. Morphology of RCC Grossly: Mainly polar, spherical yellow variegated tumor with hemorrhagic, necrotic & cystic areas. May extend into renal v. Microscopically: – Clear cell carcinoma: (70-80%) – Papillary carcinoma: (10-15%) – Chromophobe renal carcinoma (5%) – Sarcomatoid carcinoma

8. Renal cell carcinoma

10. Clear cell carcinoma Most common,70-80% of renal cancer Clear cells with clear or granular cytoplasm Majority are sporadic Familial forms : von Hippel-Lindau

11. Clear cell carcinoma

12. Papillary RCC 10-15% of all renal cancer Papillary growth pattern Frequently multifocal &bilateral Appear as early stage tumor Sporadic : Trisomy 7,16,17 loss of Y chromosome Familial :MET protooncogene on chromosome 7& trisomy 7

13. Papillary RCC

14. Chromophobe renal cell carcinoma 5% of all RCC Arise from cortical collecting ducts or their intercalated cells Multiple losses of entire chromosomes (1,2,6,10,13,17,21) General good prognosis Tumor cells have clear flocculent cytoplasm with prominent,distinct cell membranes

15. Chromophobe renal cell carcinoma

16. Clinical features of RCC Hematuria (50%), costovertebral pain, mass (all 10%) Asymptomatic/incidental finding. Constitutional symptoms (Fever ) Present with mets (lungs and bones ) Paraneoplastic syndromes – Polycythemia 5-10%. – Hypercalcemia. – Cushing’s syndrome. – Hypertension – Feminization or masculinization Prognosis: 5 yr survival is around 70%

17. NEPHROBLASTOMA (WILM ’ S TUMOR) Uncommon renal tumor but one of the commonest childhood neoplasms. Risk factors: – Congenital malformations with abnormalities of Ch 11 (WT-1 & WT-2) MI: Blastemal, stromal and epithelial elements Presents with abdominal mass, hematuria, pain or hypertension Prognosis: Currently 90% long term survival

18. Wilm’s tumor Grossly: Large well- circumscribed soft tan- gray homogenous tumor

19. Wilms tumor

21. Renal pelvis carcinoma Transitional & squamous carcinomas of renal pelvis 5-10% of renal neoplasms Often small and present early with – Painless Hematuria – Pain or mass due to hydronephrosis May be multifocal Prognosis: variable, depend on stage & grade Despite removal by nephrectomy :50% 5 YSR

22. Urothelial carcinoma of renal pelvis

23. Ureters Sites of narrowing: – Ureteropelvic junction. – Ureterovesical junction. – Crossing of iliac vessels. In female pelvis, they lie close to uterine arteries and the cervix. Operations of the female genital tract and diseases of the cervix and uterus may affect ureters.

24. Causes of Ureteral Obstruction Intrinsic – Calculi – Strictures – Tumors – Blood clots – Neurogenic Extrinsic – Pregnancy – Periureteral inflammation – Endometriosis – Tumors

25. Bacterial Cystitis Etiology: – Escherichia coli – Klebsiella pneumonia – Streptococcus fecalis – Proteus vulgaris – Pseudomonas euroginosa – ?Chlamydia, ureaplasma, mycoplasma (tendency to develop stones) Predisposing factors: – Sexually active females – Short female urethra. – Foreign bodies (stones, catheter). – Diverticula. – BPH Dx. – Symptoms, culture. Pathology: acute inflammation, erosions.

26. Schistosomal Cystitis Etiology: Scistosoma hematobium. Cercariae penetrate the skin. Mature worms lay eggs in the bladder wall. Pathology: granulomatous inflammation with calcified eggs. Complications: lower UTI, hydroureter, hydronephrosis. Bladder carcinoma, especially, sq. cell carcinoma.

27. Bladder Cancer Epidemiology 7% of male cancers. 2% of female cancers. Mean age 65Y (50-80). Male:Female 3:1. >90% are transitional (urothelial) cell carcinoma.

28. Bladder Cancer, Etiology Mostly unknown Possible causes – Dye and rubber industry Aromatic amines 2 - naphthylamine 4-aminobiphenyl Benzidine Azo dyes – Cigarette smoking – Cyclophosphamide – Phenacetin containing analgesics S. Hematobium infestation Induction time ~22Y

29. TCC

30. Urothelial (Transitional) Cell Carcinoma Configuration Papillary Nodular Cell distribution Even Clustered Nuclear features Pleomorphism Fine chromatin Coarse chromatin Large nucleoli +++ 0 +++ 0 + +++ 0 ++ + +++ 0 + ++ +/- + +++ 0 +++ + +++ ++ Papilloma Low grade High grade

31. TCC patterns

32. Urothelial (Transitional) Cell Carcinoma Gross appearance Invasion Adjacent dysplasia & CIS Recurrences Progression of disease 10 year survival Papillary <10% none 50% <10% >90% Nodular flat, papillary 80%-90% Frequent 80%-90% 65% 40% Low gradeHigh grade

33. Papilloma

35. Low grade TCC

36. TCC

37. High grade TCC

38. TCC

39. Urothelial carcinoma in situ High grade intraurothelial neoplasia A non-papillary, flat lesion in which the surface epithelium contains cells that are cytologically malignant. Accounts for less than 1-3% of urothelial neoplasms Is seen in association with invasive carcinoma (45-65% ) Asymptomatic or with frequency,urgency or even hematuria

40. CIS

41. Other bladder tumors Squamous cell carcinoma 5% - Schistosomiasis - Tobacco smoking Adenocarcinoma 2% Sarcomas Paraganglioma Carcinoid