RENAL TUMORS

CLASSIFICATION
I- According to the original site :

 Primary renal tumors .

 Secondary renal tumors.

2- According to the behavior of the tumor :

 Benign tumors e.g. adenoma, angiomyolipoma,

lipoma, …..
 Malignant tumors e.g. renal cell carcinoma,
nephroblastoma, transitional cell carcinoma, …
3– According to the original tissue type :
1. Tumors of the renal capsule :
• Fibroma.
• Leimyoma.
• Lipoma.
2. Tumors of the mature renal parenchyma :
• Benign tumors e.g. adenoma.
• Malignant tumors e.g. renal cell carcinoma.
3. Tumors of the immature renal parenchyma :
• Nephroblastoma (Wilm’s tumor).
• Embryonic carcinoma.
4- Tumors of the renal pelvis :
• Transitional cell carcinoma.
• Squamous cell carcinoma.
• Adenocarcinoma
5-Vascular tumors:
- Angiomyolipoma (HAMARTOMA ) .
- HAEMANGIOMA & LYMPHANGIOMA .
6-Neurogenic tumors:
-Neuroblastoma.
7-Mesenchymal tumors:
- peri -renal solid tumors.
 BENIGN RENAL TUMOURS
Generally, they are considered malignant till proved otherwise.
once you find a space occupying lesion.

RENAL CORTICAL ADENOMA

 Gross picture : Small mass less than 2 cm and non-
capsulated.
 Microscopic feature : Uniform acidophilic clear cells.
 Manifestations : solid lesion in sonar, space occupying
lesion in I.V.U.& CT.scan.Frozen section differentiates it from
renal cell carcinoma .
- IT IS USUALLY DIAGNOSED AT AUTOPSY .
-Treatment : Partial or wedge resection.
 RENAL ONCOCYTOMA
-Gross picture : Light brown, well circumscribed encapsulated
tumor arising from the collecting duct with a central
fibrosis. The central fibrosis or scar can be detected by CT or
MRI. There is no necrosis or hypervascularity.

-Histology : Large eosinophilic cells with granular cytoplasm

and typical polygonal form with marked increase in the
number of mitochondria differentiate it from the low grade
renal cell carcinoma.
-Manifestations :
• Asymptomatic.
• The classic triad ; renal pain, renal mass and haematuria.

-Treatment :
• Nephron sparing surgery with a frozen section control for
margins, if there is a sure diagnosis.
RENAL HAMARTOMA (ANGIOMYOLIPOMA)
It may occur as an isolated renal disease (70-
80%) or as a part of tuberous sclerosis (20-
30%) which includes :
• Neurological manifestations : Mental
retardation and epilepsy.
• Adenoma sebaceum.
• Renal hamartoma which is usually bilaterally
and multiple.
Microscopically : Unusual blood vessels,
sheets of smooth muscle cell and adipocytes.
 Diagnosis
Clinically : More predominant in females,
specially the tuberous sclerosis associated
type.
• asymptomatic and discovered accidentally.
• There may be a large tumor giving renal
mass with GIT symptoms.
• Sudden severe loin pain &hypotension due
to massive bleeding.
 CT : It is diagnostic for the high fat content and

confirmed by the Hounsfield units ≤ 10.

Fig. : Angiomyolipoma. Note that it is solid and has a tan to yellowish-tan cut
surface. It is also multifocal (a smaller nodule appears in the upper pole
 Treatment
- Selective arterial embolization :
It is indicated in symptomatic tumors.
- Renal surgery :
indicated in :
Large tumor with failed embolization.
Multiple tumors, specially with calcifications.
MALIGNANT RENAL TUMORS
RENAL CELL CARCINOMA (RCC)
It is the commonest renal tumor and represents
about 3 % of all adult malignancy. It occurs
commonly at the age of 50-70 years, but it can occur
at younger ages. Male to female ratio is 2 : 1.
Etiology :
There is no specific causative agent. The only
generally accepted environmental risk factor for
RCC is tobacco smoking.
Pathology :
-Gross Picture :
Round to ovoid, a pseudo-capsule, not grossly
infiltrative, except for some sarcomatoid variants.

-Cut section :
 Yellow, tan, or brown tumor with necrotic or
hemorrhagic areas ; few are uniform in gross
appearance ; cystic degeneration in 10% to 25%.
 Calcification can be stippled or plaque-like in 10% to
20%.
 Bilateral involvement in 2% and multi-centric in 10%
to 20%.
Fig. : Renal cell carcinoma arising in the lower pole of the kidney.
Spread
Direct infiltration :
- collecting system & or renal capsule .
Venous spread :
- venous permeation , compression or infiltration .

Histological classification:
- Clear cell : Rounded or polygonal cell with abundant
cytoplasm.
- Granular cell : Small cells with esinophilic granular
cytoplasm.
- Tubulo -papillary variant cells : The cells are columnar in
shape.
- Sarcomatoid variant : There is a spindle cell pattern with
poor differentiation
 Staging
I- T N M staging .
II- Robson”s staging :
 Stage I : Tumor within the renal capsule.
 Stage II : Tumor invasion to the peri nephric fat
(confined to Gerotas’ fascia).
 Stage III : Tumor involvement to the regional
lymph nodes and /or the renal vein or the IVC
( III A, B, and C).
 Stage IV : Adjacent organs or distant
metastasis.
. Clinical Presentation
I- Urological :
 Incidentally detected : In 50% of cases now
"radiologist's tumor".
 The classic triad : The triad of flank pain, gross
haematuria, and palpable abdominal mass is
now rarely found "too late triad.“
 Haematuria is profuse ,total ,with no or minimal
lower urinary tract symptoms
 The malignant kidney has , firm , hard or
heterogeneous consistency, with irregular
surface , mobile or fixed according to tumor
stage .
 Clinically pyonephrosis , polycystic kidney may
closely mimic renal tumors .
II- Non-urological
a) General:
-weight loss,fever,cervical lymphadenopathy.
b) symptoms of metastatic disease or extra-renal
spread(2nd.varicocele , increased intracranial
tension due to brain metastases).
c) Para- neoplastic syndromes are found in 20%
of patients with RCC (internist's tumor).
1-Hypertension.
2-Anaemia,polycythemia,Hypercalcaemia.
3- abnormal liver functions.
4-Neuropathy.
A renal mass and IVC thrombus detected by ultrasonography.
Plain X-Rays ; a. femur metastasis. B. cannon-ball metastasis
Plain X-Rays :
- Enlarged renal shadow, psoa’s line may be obliterated.
- Bone metastasis could be detected.
- Chest X-Ray : Cannon-ball metastasis.
Intravenous urography :
-Non-visualized kidney.
-Filling defect in nephrogram (d.d.renal abscess, renal cyst)
-Curve linear deformity with tapered end (polycystic
disease).
-Amputated calyx (d .d . moth eaten calyx of TB).
COMPUTED TOMOGRAOHY SCANNING:
- with contrast is the most cost-effective imaging modality.
-It is beneficial in staging.
 MRI :
It is indicated in specific cases as
raised renal functions tests,
pregnancy or to diagnose inferior
vena cava thrombus.
Selective renal angiography :
- Before doing nephron - sparing
surgery ; tumor in a solitary kidney.
- Evaluation of a small renal tumor.
 DIFFERENTIAL DIAGNOSIS
A) CLINICALLY
RCC has to be differentiated from
some renal swellings :
- polycystic disease.
- pyonephrosis.
B) RADIOLOGICALLY:
RCC has to be differentiated from
other causes of space occupying lesions :
-renal abscess . -T.B. irregular calyx
- simple renal cyst. -polycystic disease .
 Treatment of RCC
I- Localized RCC :
-Radical nephrectomy : If the tumor is
operable i.e. stage II (confined to GEROT’s
fascia).
- Nephron - sparing Surgery :
- In small tumors.
- bilateral renal tumors.
- tumor in a solitary kidney.
2- Inoperable RCC:
palliative nephrectomy
3- Adjuvant therapy:
immunotherapy (interleokins &interferon)

.
TUMORS OF THE RENAL PELVIS

Incidence :
10% of all renal tumors

Etiology :
-Cigarette Smoking (2-naphthylamine )
-Prolonged irritation : Chronic infection and calculi.

Pathology :
 Transitional cell carcinoma (TCC). It is a
transplantable tumor.
 Squamous cell carcinoma (SCC).

 Adenocarcinoma.
Fig. : TCC ; Gross picture the calyces show focal papillary tumor masses
of urothelial carcinoma
Signs and Symptoms :

 Gross or microscopic haematuria occurs

in over 75%.

 Flank pain occurs in up to 30%.

 Mass : It is rare and commonly due to the

associated hydronephrosis.

 Other symptoms of the advanced stages :

Weight loss, anorexia, and bone pain.
Investigations :
- IVU :
. It is the standard investigation
. Filling defect in renal pelvis .
- SONAR : solid lesion in renal pelvis
- C .T .
- MRI and MRU : It is indicated when
the renal chemistry is raised.
- Cystoscopy : Because the TCC is
transplantable and also multicentric,
the urinary bladder is examined for
a co-existent tumor. Also the
ureteral orifice is examined.

- Ureteroscopy : The tumor is seen

and its shape and number are
evaluated.
- Cytology : A urine sample is taken
for detection of any malignant cells.
.Fig. : IVU; filling defect in the lower calyx of the left kidney (due to TCC)
TREATMENT OF RENAL PELVIC
TUMORS
A)NEPHRO-URETRECTOMY
+
RADIOTHERPY+_
CHEMOTHERAPY
B) URETROSCOPIC LASER
APLATION IN SOLITARY KID.
+
RADIOTHERAPY
 WILMS' TUMOR
(NEPHROBLASTOMA)
Incidence :
 Most common primary malignant renal
tumor of childhood.
 7 to 10 cases per million.
 Median age is 3.5 years.
 Bilateral disease occurs in 5% to 7%
of patients.
Fig. : Wilm’s tumor : gross picture (left) and microscopic picture (right).
Pathology:
 Pseudo capsule.

 The tumor is soft and friable, with

necrotic or hemorrhagic areas.

 Expresses a variety of cell types.

"triphasic“ containing muscle ,
cartilage & squamous epithelium .
Diagnosis and Evaluation :
I- Clinical presentations :
 Classic presentations :
• Smooth abdominal mass in 90%. The tumor is quite
large in relation to the size of the child.
• Abdominal pain.

 Atypical presentations :
Wilms' tumor syndromes such as aniridia,
hemi-hypertrophy, and genitourinary
anomalies.
II- Differential diagnosis :
I) Neuroblastoma :
It is radio-graphically indistinguishable from
Wilms’ tumor, but neuroblastoma differs in:
-More likely to present with skull metastasis.
-Has a higher frequency of calcifications.
-It produces various tumor markers including
vanillyl-mandelic acid and other
catecholamines.

2.OTHER RENAL SWELLINGS:

Investigations :
1. Abdominal ultrasonography : It detects the renal mass which
is usually huge.
2. Plain X-Rays :
- Plain X-Ray of the urinary tract : It may show :
• Enlarged renal shadow.
• Displacement of the bowel detected by the gas pattern.
- Chest X-Ray : It may show metastasis.

3. Intravenous urography : It may show :

1. Compression or elongation of the pelvis and calyces with their
displacement.
2. Non-secreted kidney.

4. CT scan can demonstrate :

1. Size of the tumor.
2. Infiltration of the surrounding structures.
3. Enlarged lymph nodes.
 Treatment
1. Radical nephrectomy : Via a Trans- peritoneal
approach. Accurate staging is essential,
sampling of suspicious nodes is an essential
component.
2. Preoperative therapy:
• Preoperative chemotherapy is of benefit for :
• Patients with bilateral involvement.
• Inoperable disease at surgical exploration.
• IVC extension.
• All other patients should undergo primary
nephrectomy.
3. Post operative therapy:
 Stage I or II FH :
• 18-week pulse-intensive regimen of
vincristine (VCR) and adriamycin (AMD).
• Stage II UFH, stage III and Stage IV FH :
 VCR, AMD, and doxorubicin (DOX), plus ;

 10.8 Gy abdominal irradiation.

• Stage IV UFH :
 VCR, cyclo-phosphamid

 de (CPM) .

 Abdominal irradiation based on the local

tumor stage. 12 Gy to both lungs.