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Kidney tumor - adult malignancies

Adult renal cell carcinoma

Urothelial carcinoma of renal pelvis-variants

Reviewers: Sean Williamson, M.D. (see Reviewers page)
Revised: 30 June 2012, last major update June 2012
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

Variants: low grade, high grade, microcystic, micropapillary

Low-grade urothelial carcinoma of renal pelvis

Micro description
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● Similar to low-grade urothelial carcinoma of the bladder

Micro images
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Fusion of papillae, mild nuclear pleomorphism, small nucleoli


Low grade tumor

Cytology description
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● Not as specific as for high grade tumors
● Suggestive features are 5 or more papillary groups, cellular overlapping, anisonucleosis, hyperchromasia (Diagn Cytopathol 1997;16:437)

High grade urothelial carcinoma of renal pelvis

Epidemiology
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● 70% male, mean age 70 years (range 28-92 years)

Clinical description
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● Associated with phenacetin nephropathy (25%), Thorotrast radiologic dye, cyclophosphamide, horseshoe kidney, hereditary nonpolyposis colorectal cancer syndrome
● Patients present with hematuria due to fragmentation within renal pelvis
● 40-50% have preexisting or coexisting bladder urothelial tumors
● 5 year survival of 10% due to invasion of wall of pelvis and calyces; 50% if complete surgical resection

Poor prognostic features
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● Extra-renal invasion, coexisting bladder tumor

Treatment
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● Standard therapy is nephroureterectomy including bladder cuff since multicentric and often implants within bladder
● Renal-preserving surgery may also be effective (J Endourol 2009;23:341)

Case reports
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● With ipsilateral renal cell carcinoma (Can Urol Assoc J 2009;3:64)
● Soft, gray-red masses with smooth glistening surfaces (Am J Surg Pathol 1992;16:515)

Gross description
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● Soft, gray-red masses with smooth glistening surfaces

Gross images
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Noninvasive papillary tumor fills the dilated renal pelvis

Micro description
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● Resembles other urothelial carcinomas
● Carcinoma in situ may be present in non-adjacent areas
● Often extends along collecting tubules (resembling CIS of cervix extending into cervical clefts) but are not adenocarcinomas
● Vascular invasion in 35%
● Rarely is sarcomatoid, resembles giant cell tumor of bone or has rhabdoid features (Hum Pathol 2006;37:168)
● Analgesic abuse is associated with thickening of small stromal vessels

Micro images
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Invasive high grade tumor


Loss of tumor cell polarity along fibrovascular pole, moderate to marked nuclear pleomorphism,
coarse chromatin, scattered prominent nucleoli


High grade nuclear features and mitotic figures

Cytology description
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● High nuclear/cytoplasmic ratio, isolated cells, anisonucleosis, nuclear hyperchromasia, coarse chromatin (Am J Clin Pathol 2002;117:444)

Positive stains
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● Low molecular weight keratin (CK 8/18, CK19, CK7, CK20), squamous type keratins (CK 5, CK14, CK17, CK13), p53

Negative stains
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● Vimentin

Molecular description
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● 31% have microsatellite instability (Mod Pathol 2002;15:790)

Cytogenetics description
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● Complex aberrations include -9, -17p, +8q, -13q, -18q, +17q

Microcystic variant of urothelial carcinoma of renal pelvis

General
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● Usually described in bladder

Case reports
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● Cases in renal pelvis (Arch Pathol Lab Med 2002;126:859)
● Focal neuroendocrine differentiation (Virchows Arch 2009;454:223)

Micro description
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● Invasive urothelial carcinoma with prominent cystic features; cysts are irregular in size and deeply infiltrative, lined by variable layers of cuboidal or flattened cells with minimal atypia

Micro images
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Various images

Differential diagnosis
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● Cystitis glandularis or cystitis cystica: not deeply infiltrative, no high grade atypia, often lobular growth pattern in upper urinary tract (Am J Surg Pathol 2003;27:1243)
● Nephrogenic metaplasia: not invasive, circumscribed growth
● Adenocarcinoma: more marked atypia, mitotic activity and necrosis

Micropapillary variant of urothelial carcinoma of renal pelvis

Epidemiology
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● Rare variant, more common in bladder
● Mean age 64 years (range 22-76 years)

Clinical description
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● Aggressive; usually associated with high stage at presentation, nodal metastases, distant metastases and poor prognosis (Arch Pathol Lab Med 2009;133:62, Am J Clin Pathol 2006;126:86)

Case reports
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● 68 year old man whose tumor has focal micropapillary areas (Am J Surg Pathol 1996;20:125)
● 73 year old woman (Med Sci Monit 2007;13:CS47)

Micro description
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● Invasive component has small infiltrating clusters of tumor cells within lacunae (small round empty spaces that represent fixation artifact, not actual lymphovascular spaces), resembling ovarian serous carcinoma
● Noninvasive pattern has slender micropapillae on surface of tumor
● Micropapillary component represents 10-80% of total tumor, remainder is classic urothelial carcinoma
● Lymphovascular invasion always present (in addition to the apparent invasion within lacunae)

Micro images
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Micropapillary processes


Lymphovascular invasion

Positive stains
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● CK7, CK20, MUC1 (on stroma forming surface), p53

Negative stains
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● bcl2

End of Kidney tumor - adult malignancies > Adult renal cell carcinoma > Urothelial carcinoma of renal pelvis-variants

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