RENAL TUMORS

RENAL TUMORSRENAL TUMORS

DEPARTMENT OF UROLOGY IAŞI – 2013


benign renal tumors – adenoma, oncocytoma, angiomyolipoma, leiomyoma, lipoma, hemangioma, juxtaglomerular tumors

adenoma – most common, glandular tumors of the renal cortex oncocytoma – large epithelial cells with finely granular

eosinophilic cytoplasm (oncocytes) angiomyolipoma – US & CT are frequently diagnostic (high fat

content), symptoms (bleeding or pain) renal-sparing surgery or renal arterial embolization


benign renal tumors – adenoma, oncocytoma, angiomyolipoma, leiomyoma, lipoma, hemangioma, juxtaglomerular tumors

ADENOCARCINOMA OF THE KIDNEY(RENAL CELL CARCINOMA - RCC)

2.5% of adult cancers and ≈ 85% of all primary malignant renal tumors

most commonly in the 5-6th decades; M:F = 2:1Etiology occupational exposures (asbestos, solvents, cadmium),

chromosomal aberrations, tumor suppressor genes cigarette smoking (2×)


hereditary forms – von Hippel-Lindau disease (angiomatous cerebellar cyst, angiomatosis of the retina, tumors or cysts of the pancreas, multiple bilateral cysts or adenocarcinomas of both kidneys); hereditary papillary renal carcinoma

acquired cystic disease of the kidneys – hemodialysis (> 30×)Pathology origin – proximal renal tubular epithelium originate in the cortex and tend to grow out into perinephric

tissue no true capsule; may have a pseudocapsule of compressed renal

parenchyma, fibrous tissue and inflammatory cells histologically – mixed adenocarcinoma (clear cells, granular cells

and, occasionally, sarcomatoid cells)


Pathogenesis direct invasion perinephric fat and adjacent visceral structures direct extension renal vein, IVC distant metastases – lung, liver, bone (osteolytic), ipsilateral

adjacent lymph nodes, adrenal gland, brain, the opposite kidney, subcutaneous tissue

Tumor Staging T1 – ≤ 7 cm, limited to the kidney T2 – > 7 cm, limited to the kidney T3 – extends into major veins or directly invades adrenal gland or

perinephric tissues, but not beyond Gerota’s fascia T4 – directly invades beyond Gerota’s fascia


N1 – single regional lymph node N2 – > 1 regional lymph node M1 – distant metastasisFuhrman Nuclear Grade 1-4 – nuclear size, shape, presence or absence of prominent

nucleoliSymptoms and Signs classical triad (10-15%) – gross hematuria, flank pain, palpable mass gross or microscopic hematuria (60%) dyspnea and cough, seizure and headache or bone pain –

metastatic disease ‘incidentalomas’ !


Paraneoplastic Syndromes erythrocytosis hypercalcemia hypertension nonmetastatic hepatic dysfunction (Stauffer) - elevation of alkaline

phosphatase and bilirubin, hypoalbuminemia, prolonged prothrombin time and hypergammaglobulinemia

Laboratory Findings – anemia, hematuria, elevated ESRImaging KUB, IVU – calcification overlying the renal shadow, space-

occupying lesion US – renal mass, extension of tumor thrombus into the IVU


CT – mass that becomes enhanced with the use of i.v. contrast media staging by visualizing the renal hilum, perinephric space, renal vein and vena cava, adrenals, regional lymphatics and adjacent organs

Renal Angiography – nephron-sparing surgery

Radionuclide Imaging – bonescan

MRI (angiography) Positron Emission Tomography

(PET) - detecting recurrence orprogression

Fine-Needle Aspiration


Differential Diagnosis other solid renal lesions – cysts, angiomyolipomas, renal abscess,

granulomas and arteriovenous malformations, renal lymphoma, transitional cell carcinoma of the renal pelvis, adrenal cancer, metastatic disease

Treatment localized disease open or laparoscopic radical nephrectomy,

open or laparoscopic partial nephrectomy (T1a), ex vivo partial nephrectomy (bench surgery followed by autotransplantation), enucleation of multiple lesions

removal of floating caval thrombi immunological treatment: interferon (α,β,γ), interleukin-2 antiangiogenic agents – Sunitinib, Bevacizumab, Sorafenib,

Temsirolimus

UROTHELIAL TUMORSUROTHELIAL TUMORS

DEPARTMENT OF UROLOGY IAŞI – 2013

BLADDER TUMORSBLADDER TUMORS

2nd most common cancer of the GU tract (1 – prostate) average age at diagnosis – 65 yRisk Factors & Pathogenesis cigarette smoking (2×) α- and β-naphthylamine occupational exposure (chemical, dye, rubber, petroleum,

leather, printing industries) benzidine, β-naphthylamine,4-aminobiphenyl

cyclophosphamide, ? artificial sweeteners physical trauma – infection, instrumentation, calculi activation of oncogenes and inactivation or loss of tumor

suppressor genes (9, 11p21, 17p53) ‘field defect’ of the urothelium


Histopathology epithelial malignancies (98%)

papilloma transitional cell carcinoma (TCC) – 90% – invasion, recurrence &

progression tumor grade – ! carcinoma in situ (CIS) nontransitional cell carcinomas – adenocarcinoma, squamous

cell carcinoma (chronic infection, vesical calculi or chronic catheter use), undifferentiated carcinomas, mixed carcinoma

rare epithelial carcinomas (villous adenomas, carcinoid tumors, carcinosarcomas and melanomas)

rare nonepithelial cancers [pheochromocytomas, lymphomas, choriocarcinomas, mesenchymal tumors (hemangioma, osteogenic sarcoma, myosarcoma)]


direct extension tumours (prostate, cervix, rectum) metastatic tumours (melanoma, lymphoma, stomach, breast, kidney, lung)

Staging – TNM (2002) T – primary tumour

Ta – non-invasive papillary carcinoma Tis – carcinoma in situ T1 – invades subepithelial connective

tissue T2 – invades muscle T3 – invades perivesical tissue T4 – invades prostate, uterus, vagina, pelvic or abdominal

wall


N – lymph nodes N1 – single ≤ 2 cm N2 – single > 2 cm ≤ 5 cm, multiple ≤ 5 cm N3 – > 5 cm

M – distant metastasis M1

Grading – WHO (2004) urothelial papilloma papillary urothelial neoplasms of low malignant potential

(PUNLMP) low-grade papillary urothelial carcinoma high-grade papillary urothelial carcinoma


Symptoms hematuria (85-90%) irritative voiding symptoms – frequency, urgency, dysuria (! CIS) bone pain (metastases), flank pain (retroperitoneal metastases or

ureteral obstruction) – advanced diseaseSigns bimanual examination under anesthesia – bladder wall thickening

or palpable mass (large-volume or invasive tumors) hepatomegaly, supraclavicular lymphadenopathy (metastatic) lymphedema – occlusive pelvic lymphadenopathyLaboratory Findings hematuria, pyuria, azotemia, anemia urinary cytology


Imaging (evaluate the upper urinary tract, assess the depth of muscle wall infiltration and the presence of metastases)

IVU – pedunculated, radiolucent filling defects; fixation or flattening of the bladder wall; UHN

CT & MRI – evaluate extent of bladder wall invasion and detect enlarged pelvic lymph nodes

chest x-ray and radionuclide bone scanCystourethroscopy and Tumor Resection –

diagnosis and initial staging (+ bimanual examination & random bladder biopsies)


Natural History (2 processes) tumor recurrence tumor progression (+ metastasis)Selection of Treatment – based on tumor stage (TNM), grade, size,

multiplicity and recurrence pattern superficial bladder cancer TUR ± intravesical chemotherapy or

immunotherapy low-grade, small tumors TUR + surveillance high-grade, multiple, large, recurrent tumors or associated

with CIS TUR + intravesical chemotherapy or immunotherapy

recurrence of T1G3, after intravesical therapy radical cystectomy


invasive localized tumors (T2, T3) radical cystectomy / irradiation or surgery and systemic chemotherapy

unresectable local tumors (T4) systemic chemotherapy, followed by surgery or irradiation

regional or distant metastases systemic chemotherapy followed by irradiation or surgery

Treatment intravesical chemotherapy (prophylactic or therapeutic) – weekly

for 6 weeks Mitomycin C, Thiotepa, Doxorubicin Bacillus Calmette-Guerin (BCG) - immunotherapy


surgery transurethral resection radical cystectomy partial cystectomy

radiotherapy – external beam irradiation (5000-7000 cGy) chemotherapy – cisplatin, methotrexate, doxorubicin, vinblastine,

cyclophosphamide, 5-fluorouracil; MVAC

UPPER UROTHELIAL UPPER UROTHELIAL TUMORSTUMORS

renal pelvis and ureter rare – 4% of all urothelial cancers bladder : renal pelvis : ureter ≈ 51:3:1 mean age – 65; M:F = 2-4:1 widespread urothelial abnormality – risk

single upper-tract bladder (30-50%) and contralateral upper-tract (2-4%)

bladder low risk (< 2%) of upper tract smoking and exposure to industrial dyes or solvents excessive analgesic intake Balkan nephropathy – interstitial inflammatory disease


Pathology transitional cell carcinomas (90-97%) rare – papillomas, squamous carcinomas, adenocarcinomas, mesodermal

tumors (fibroepithelial polyps, leiomyomas, angiomas, leiomyosarcomas) metastatic sites – regional lymph nodes, bone, lung direct extension – renal, ovarian, cervical carcinomas metastatic tumors – stomach, prostate, kidney, breast, lymphomasStaging – TNM (2002) Ta – noninvasive papillary carcinoma; Tis – carcinoma in situ; T1 –

invades subepithelial connective tissue; T2 – invades muscularis; T3 – (renal pelvis) invades beyond muscularis into peripelvic fat or renal parenchyma; (ureter) invades beyond muscularis into periureteric fat; T4 – invades adjacent organs or through the kidney into perinephric fat


N1 – single ≤ 2 cm; N2 – single > 2 cm ≤ 5 cm, multiple ≤ 5 cm; N3 – > 5 cm

M1 – distant metastasisGrading – G1 – well differentiated; G2 – moderately differentiated;

G3-4 – poorly differentiated/undiferentiatedSymptoms and Signs gross hematuria (70-90%) flank pain (ureteral obstruction – blood clots, tumor fragments,

tumor itself or regional invasion) anorexia, weight loss, lethargy – metastatic disease flank mass – hydronephrosis or large tumor supraclavicular or inguinal adenopathy or hepatomegaly –

metastatic disease


Laboratory Findings hematuria, liver function levels, pyuria, bacteriuria urine cytology (urinary sediment, ureteral catheter, barbotage,

ureteral brush)Imaging IVU – intraluminal filling defect, unilateral

nonvisualization of the collecting system,hydronephrosis ( nonopaque calculi, bloodclots, papillary necrosis, inflammatory lesions)

retrograde uretero-pyelography – dilationof the ureter distal to the lesion (‘goblet’,Bergman's sign) nonopaque ureteralcalculi – narrowing of the ureter distal tothe calculus


US, CT, MRI - soft-tissue abnormalities of the renal pelvis, ureterohydronephrosis, regional (lymph node) or distant metastases

Ureteropyeloscopy – retrograde rigid and flexible, ? antegrade (percutaneous); surveillance following conservative surgery

Treatment standard therapy – nephroureterectomy (+ small cuff of bladder)

– open or laparoscopic tumors of the distal ureter – distal ureterectomy and ureteral

reimplantation into the bladder


conservative surgery (renal-sparing) – open or endoscopic excision

absolute indications: single kidney, bilateral tumors, marginal renal function

relative indications: low-grade noninvasive tumors instillation of BCG or mitomycin C (through single or double-J

ureteral catheters) follow-up – routine endoscopic surveillance

? postoperative irradiation cisplatin-based chemotherapy - metastatic TCC

Documents

RENAL TUMORS