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Section 1: Genitourinary Cancer
1 Uncommon Tumors of the Kidney
Khaled Ali,1 Ming Zhou,2 Steve Campbell,3 Ronald M. Bukowski,1 and Brian I. Rini1
2
Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Glickman Urological Institute, Cleveland, OH, USA
Department of Pathology, 3 Department of Urologic Oncology, Cleveland Clinic, Cleveland, OH, USA
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Introduction
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needle aspiration techniques.7 It is anticipated that this current
classification system will be reassessed in the future.8
MA
Molecular diagnostic techniques
in renal neoplasms
The application of molecular and cytogenetic techniques has
resulted in improved understanding of these tumors. In the
forefront among these technologies are comparative genomic
hybridization (CGH), fluorescent in situ hybridization (FISH),
allelic loss analysis, classical cytogenetics, and karyotyping.
The von Hippel–Lindau tumor suppressor gene (VHL) resides
in the short arm of chromosome 3 (3p25.3) and is commonly
inactivated by gene mutation or promoter hypermethylation
in sporadic clear cell RCC. It is also the causative gene for
the von Hippel–Lindau syndrome.9,10 Papillary RCC, chromophobic RCC, carcinoma of the collecting ducts of Bellini,
metanephric adenomas, and renal oncocytomas have also
exhibited characteristic chromosomal anomalies.11–13 RCC
associated with chromosomal translocation involving the
TFE3 gene on Xp11.2 has been described as a distinct clinicopathological entity.14
Definitive diagnosis of the various histological subtypes
based on hematoxylin and eosin (H&E) morphology is possible in the majority of cases. In the minority circumstances
where distinction becomes difficult, immunohistochemistry
and other molecular techniques are being increasingly relied
upon to make the distinction.15 Renal cell carcinoma marker
(RCC Ma) is a monoclonal antibody against the proximal
tubular brush border antigen, which is relatively specific for
renal neoplasms that originate from the proximal renal tubules,
including clear and papillary RCC, despite a rather low sensitivity.16 The antibody is positive in nearly 80% of clear cell
and papillary RCC, is variably expressed in chromophobe
RCC, and is absent in oncocytomas and CDCs. CD10 is
another marker that helps in the differential diagnosis, by
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Tumors of the kidney account for about 3% of adult malignancies.
About 64,770 new cases of kidney cancer (40,250 in men and
24,520 in women) were estimated by the American Cancer
Society for the year 2012.2 Renal cell carcinomas (RCC) constitute the bulk of these malignancies and historically they
were widely known as hypernephroma, a term that was coined
by Grawitz in the 19th century, reflecting his belief that they
arose from the adrenal gland. RCCs are derived from the epithelial cells of renal tubules and account for more than 80% of
primary renal malignant neoplasms. Transitional cell carcinomas, although arising in the renal pelvis, are frequently classified as renal tumors, and account for 7–8%. Other tumors, such
as oncocytomas, collecting duct carcinomas (CDCs) of Bellini,
and renal sarcomas, are uncommon but are becoming more
frequently recognized pathologically. Nephroblastoma (Wilms
tumor [WT]) is common in children and accounts for 5–6% of
all primary renal tumors.
This chapter focuses on the classification, pathology, genetics,
clinical and radiographic manifestations, and surgical and systemic management of the less common malignant and benign
tumors of the kidney.
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Classification of renal neoplasms
The first classification of renal tumors was proposed by
Konig3 in 1826 based on gross morphological characteristics.
Extensive study of renal neoplasms in the last couple of decades has led to a standardized nomenclature by the European
and American authorities (Box 1.1).4 The 2004 World Health
Organization (WHO) classification, which includes nearly 50
distinct entities, is based on a combination of immunohistochemistry, histology, and clinical and genetic features that are
widely accepted and relatively reproducible.5 Several large
series have shown this classification to have prognostic
significance6 and that it is relevant to diagnosis by fine
Textbook of Uncommon Cancer, Fourth Edition. Edited by Derek Raghavan, Charles D. Blanke, David H. Johnson, Paul L. Moots, Gregory H. Reaman, Peter G. Rose and Mikkael A. Sekeres.
© 2012 John Wiley & Sons, Inc. Published 2012 by John Wiley & Sons, Inc.
2
Box 1.1 WHO histological classification of tumors of the kidney.
• Neuroblastoma
• Pheochromocytoma
Renal cell tumors
Hematopoietic and lymphoid neoplasms
•
•
•
•
•
•
•
•
•
•
•
•
Clear cell renal cell carcinoma
Multilocular cystic renal cell carcinoma
Papillary renal cell carcinoma
Chromophobe renal cell carcinoma
Carcinoma of the collecting ducts of Bellini
Renal medullary carcinoma
Xp11 translocation carcinoma
Carcinoma associated with neuroblastoma
Mucinous tubular and spindle cell carcinoma
Renal cell carcinoma, unclassified
Papillary adenoma of the kidney
Oncocytoma
Metanephric tumors
• Metanephric adenoma
• Metanephric adenofibroma
• Metanephric stromal tumor
Nephroblastic tumors
Occurring mainly in children
•
•
•
•
Clear cell sarcoma
Rhabdoid tumor
Congenital mesoblastic nephroma
Ossifying renal tumor of infants
Occurring mainly in adults
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Leiomyosarcoma (including renal vein)
Angiosarcoma
Rhabdomyosarcoma
Malignant fibrous histiocytoma
Hemangiopericytoma
Osteosarcoma
Angiomyolipoma
– Epithelioid angiomyolipoma
Leiomyoma
Hemangioma
Lymphangioma
Juxtaglomerular cell tumor
Renomedullary interstitial cell tumor
Schwannoma
Solitary fibrous tumor
Mixed epithelial and mesenchymal neoplasms
• Cystic nephroma
• Mixed epithelial and stromal tumor
• Synovial sarcoma
Neuroendocrine tumors
• Carcinoid
• Neuroendocrine carcinoma
• Primitive neuroectodermal tumor
• Lymphoma
• Plasmacytoma
• Leukemia
Germ cell tumors
• Teratoma
• Choriocarcinoma
Metastatic tumors
Adapted from Eble et al.4 with permission from IARC Press.
being expressed in clear cell and papillary RCC, and absent in
chromophobe RCC and oncocytomas.17 Vimentin is variably
expressed in clear cell and papillary RCC and is absent in
chromophobe RCC and oncocytomas.18 Cytokeratins represent a widely used diagnostic immunohistochemical marker
in differentiating renal tumors. Cytokeratin 7 (CK7) is strongly
positive in most chromophobe RCC, absent in clear cell RCC,
and variably expressed in oncocytomas. Routine metaphase
cytogenetics, performed on cultured tumor cells, has been
used to identify cytogenetic changes associated with each
RCC histological subtype. Using specific probe sets, FISH
can be used to identify those RCC with characteristic chromosomal alterations.
Papillary adenoma
Background
Historically, adenomas were recognized as lesions smaller
than 3 cm based on the work of Bell.19 This was then modified
in 1970 by Murphy and Mostofi who felt that histological differentiation of adenomas from true adenocarcinomas was possible.20 Renal papillary adenomas are small, discrete, and arise
from the renal tubular epithelium. In autopsy studies, they
increase in frequency with age (7–40%). At present, the WHO
classification system identifies papillary adenomas as epithelial lesions with a tubulopapillary architecture measuring less
than 5 mm.4 An incidence of 7% of papillary adenomas in
nephrectomy specimens has been reported. As many papillary
adenomas are not easy to identify grossly, the true incidence
of renal papillary adenoma may be even higher if broader
sampling is achieved in surgical specimens.21
Pathology
Papillary adenomas are less than 5 mm in diameter with
a low nuclear grade. They appear as pale yellow-gray,
Chapter 1: Uncommon Tumors of the Kidney
well-circumscribed nodules, generally below the renal
capsule in the renal cortex. They are usually not encapsulated; however, some have thin pseudocapsules. On microscopic examination, they have tubular, papillary, or
tubulopapillary architecture similar to papillary renal cell
carcinoma. The cells have scanty cytoplasm with round to
oval nuclei and do not have high nuclear grade (Fuhrman
nuclear grade 3 or 4). Cytogenetic features include trisomy
(chromosome 7 and 17) and loss of the Y chromosome.22,23
The resemblance of this tumor to renal papillary carcinoma
has led to the view that it may represent a precursor lesion of
RCC, although this is not firmly established.
Clinical presentation and treatment
Most of these lesions are discovered incidentally. They appear
more frequently in patients with underlying kidney disease
related to atherosclerosis, scarring, acquired renal cystic disease
secondary to hemodialysis, and other malignant conditions of
the kidney.24 With small tumors being increasingly detected
incidentally, the current view is to regard all of them as probable early cancers. Renal tumors with diameters 0.5–2 cm often
behave in an indolent fashion, although the biological behavior
is difficult to ascertain; therefore tumors less than 2 cm are
sometimes termed “renal epithelial tumors of uncertain malignant potential” and are observed for progression, while larger
tumors may require surgical excision, depending on the clinical
scenario. Thus, the primary management of these tumors is surgical, with no established role for chemotherapy or radiation.
Carcinoma of the collecting ducts of Bellini
Background
Collecting duct carcinoma (CDC) is a rare renal tumor
derived from the cells of the collecting duct of Bellini, and
(a)
comprises less than 1% of renal malignancies.25 Fleming and
Lewi described the detailed pathological features of CDC as
a distinct entity based on several case reports.26
Pathology
This tumor is characterized by a medullary location, with a
size ranging from 2 cm to 12 cm, firm whitish-gray appearance,
and irregular infiltrative border. It grows radially from the
renal hilum to invade into the renal cortex, the renal capsule,
and the renal sinus. Histologically, it has an irregular
tubulopapillary growth pattern embedded in a desmoplastic
stroma (Fig. 1.1a). The tubules are lined with hobnail cells
with a scant eosinophilic cytoplasm. The cells display highgrade nuclei with brisk mitotic activity and prominent nucleoli
(Fig. 1.1b). Occasionally, sarcomatoid changes or mucin can
be seen. Molecular events and cytogenetic changes, which
contribute, are poorly characterized and a distinct pattern has
not yet emerged. The immunohistochemistry profile is variable, being commonly positive for phytoagglutinins and high
molecular weight cytokeratin, with coexpression of vimentin,
and negative for CD10 and villin.27
Clinical presentation
Collecting duct carcinoma is a highly aggressive tumor, which
usually presents in an advanced stage, with gross hematuria,
abdominal/back pain, and a flank mass, 40% of the patients
being asymptomatic. At diagnosis, it will frequently have distant metastases in the lung, liver, lymph nodes, bone, or
adrenal gland. It is more common in males (ratio of about
2:1) with a wide range of age groups (13–83 years with a
mean of 55 years). On computed tomography (CT) scan, this
tumor appears as a centrally arising infiltrative mass with
preservation of the renal contour and minimal enhancement
with contrast. Patients can have generalized inflammatory
(b)
Figure 1.1 Collecting duct renal cell carcinoma consists of high-grade tumor cells (b) forming complex and angulated tubules or tubulopapillary structures
embedded in a remarkably desmoplastic stroma (a).
3
4
symptoms secondary to cytokine release from the tumor and
the inflammatory reaction associated with the tumor.26–28
Treatment and prognosis
The diagnosis of CDC is generally made postoperatively, since
radiological distinction from other RCCs is difficult. The prognosis is generally very poor with most patients rapidly developing systemic metastases with a median survival of 22 months.29
The role of nephrectomy has been debated because of the frequent metastases at presentation and appears to be useful at
most for palliation.30 On the basis of the pathological, immunohistochemical, and cytogenetic similarity to transitional cell
carcinomas (TCC) as compared with conventional clear cell
RCC, the preferred approach in the treatment of metastatic disease has been with chemotherapy rather than immunotherapy.31
In the largest reported series, Dimopoulos et al. reported
retrospectively the MD Anderson experience involving 12
patients with CDC treated from 1980 to 1990.29 Seven of eight
patients with metastatic disease were treated with different
chemotherapy combinations, with the methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) regimen being the
most common. Only one patient achieved a minor response
lasting 5 months. Six patients were treated with a combination
of interleukin-2 and interferon (IFN)-α, with a response seen
in one patient. Peyromaure et al. reported two complete
responses with cisplatin and gemcitabine combination chemotherapy, which lasted 9 and 27 months.32 Radiotherapy in these
series has appeared to have minimal benefit for local recurrence. Chao et al. in a review noted that some patients having
regional nodal disease without distant metastasis have had
long-term disease-free survival with adjuvant therapy.33
Cisplatin-gemcitabine has significant activity with a favorable
toxicity profile in urothelial cancers. Therefore, a platinumbased regimen is the preferred first-line chemotherapy regimen. There are anecdotal reports of objective responses in
CDC patients treated with either sunitinib or sorafenib,34–36
although other case reports demonstrate no activity of this
approach.37 Therefore, participation in clinical trials of novel
therapy is strongly encouraged for these patients given the lack
of biological insight and limited therapeutic options.
believed to arise from the epithelium of the distal portion of the
collecting duct. The right kidney is involved three times more
commonly than the left kidney, and the mean tumor size ranges
from 4 cm to 12 cm (mean of 7 cm). Renal medullary carcinomas are widely infiltrative, and have variable areas of hemorrhage and necrosis. Histologically, a variety of growth patterns
have been described, with reticular growth pattern and compact adenoid cystic morphology being the common features.
Most renal medullary carcinomas have areas of poorly differentiated cells with solid sheets of tumor cells. The tumor cells
contain vesicular or clear nuclei with prominent nucleoli and
amphophilic cytoplasm, which can have a squamoid or rhabdoid quality. The tumor cells are usually high grade and as with
CDC, there is often marked desmoplasia and inflammation.40–43
The immunohistochemical profile is similar to CDC but can be
helpful in distinguishing renal medullary carcinoma from other
poorly differentiated kidney tumors.
Molecular genetic studies on RMC are rare. Although previously published cases of CDC and RMC reported monosomy of
chromosomes 8, 10, and 11, in a series of nine RMCs studied by
comparative genomic hybridization, no chromosomal change
was observed in eight cases and a loss of chromosome 22 was
seen in one case.42 A more recent series of three RMC patients
(one patient with sickle cell disease and two without sickle cell
disease) using conventional cytogenetic and single nucleotide
polymorphism (SNP) arrays analysis failed to demonstrate a
consistent pattern of chromosomal abnormalities between two
cases tested. However, all three cases showed increased
hypoxia-inducible factor 1α expression. It is thus apparent that
no distinct chromosomal numerical or structural defect is
constantly observed in renal medullary carcinomas.44
Interestingly, two recent case reports demonstrated anaplastic lymphoma kinase (ALK) rearrangement in sickle cell
trait-associated renal tumors.45,46 Further characterization is
required but this observation could translate into a therapeutic
option (crizotinib, an inhibitor of ALK) in this traditionally
treatment-refractory disease.
Renal medullary carcinoma (RMC) was first described by
Davis et al.38 as a sickle cell nephropathy and termed so
because of its predominantly medullary location. In a literature
review of renal medullary carcinoma by Dimashkieh et al.,39
hemoglobinopathy was found in 53 of the 55 cases (50 patients
had hemoglobin AS, two patients had hemoglobin SC, and one
patient had hemoglobin SS disease).
Renal medullary carcinoma is a highly aggressive tumor that
occurs almost exclusively in young people (mean age 22
years), predominantly males (male-to-female ratio 2:1) in
patients with sickle cell trait. The common presenting symptoms are gross hematuria, abdominal/flank pain or weight loss.
Common sites of metastasis at diagnosis include lung, retroperitoneal or mediastinal lymph nodes, bone and liver. Of the
patients with adequate staging information available from the
two largest case series, 18% had stage III disease and 82%
had stage IV disease on presentation.38,41,42,47–49 Radiological
findings in renal medullary carcinoma have been shown to be
not specific, although they might provide an indication to the
diagnosis given the proper clinical background.50
Pathology
Renal medullary carcinoma is a centrally located tumor with
an infiltrative growth pattern similar to that of CDC. It is
Renal medullary carcinomas are now widely regarded as a
highly aggressive variant of RCC, with an almost uniformly
Renal medullary carcinoma
Background
fatal outcome. Early reports of RMC discovered a median
survival of 14 weeks after diagnosis. The mean survival after
surgery has been about 4 months.38,51,52 Strouse et al. have
reported that only one of the over 80 reported patients is alive
at 2 years.47 This patient had a small tumor (<2 cm) confined to
the kidney at the time of resection.
Chemotherapy has been shown to increase survival beyond
4 months in anecdotal reports, but with no reported long-term
survivors. In a review of chemotherapy, of the 15 patients
assessable for response, there was one complete response, two
partial responses, one minor response, one stable disease and
10 patients had progressive disease. Cases from 1995 through
2003 have been reviewed by Simpson et al. who reported on
28 patients. Survival averaged 32 weeks, with notable highest
survival in patients on treatment with methotrexate, vinblastine, doxorubicin, and cisplatin – 46 weeks.52,53
Numerous current reports suggest limited but some activity
(occasional objective responses of limited duration) in patients
with RMC.54–56 A recent case reported by Motzer et al. suggested a complete response to bortezomib (PS-341), a proteasome inhibitor.57 There are ongoing clinical trials testing the
activity of molecular targeted therapy on non-clear cell renal
carcinoma but the available data are too preliminary to allow a
definitive recommendation and clinical trial participation is
encouraged.58,59 In healthy patients with systemic disease,
treatment plans similar to those for urothelial cancers and
CDC, with combination cisplatin-based chemotherapy, are a
reasonable choice along with inclusion in phase 1 clinical trials. Reports on the role of radiation therapy in the adjuvant
setting post surgery and chemotherapy showed no definitive
benefit,41 but reports of palliative radiation for bone metastasis
have demonstrated a decline in pain and some reduction in
lesion size.56,60,61
XP11 translocation neoplasms
Background
Xp11 translocation neoplasms are a subset of RCCs, characterized by various translocations involving chromosome Xp11.2,
resulting in fusion of the TFE3 gene to a variety of recipient
genes and overexpression of TFE3 protein. They affect children and young adults predominantly, although some older
patients have been reported. Molecular analysis of several different Xp11.2 translocation carcinomas has shown that some
bear a translocation that is identical to the breakpoints and
ASPL-TFE3 gene fusion seen in alveolar soft part sarcoma
(ASPS).14 These were recognized as a distinctive subclass in
the 2004 WHO renal tumor classification. An unusual renal
epithelial neoplasm with a chromosomal translocation involving t(6:11) has been described, which resulted in the overexpression of another transcription factor gene in the same gene
family as TFE3 – TFEB.62,63
Six gene fusion partners of TFE3 have been reported to
date. Five of these six partners have been identified, whereas
the identity of the sixth, which is sited on chromosome 3, is
still to be determined. The five known gene fusion partners of
TFE3 are PRCC, ASPL, polypyrimidine tract-binding protein-
5
associated splicing factor (PSF), non-POU domain-containing
octamer-binding (NONO; p54nrb), and clathrin heavy-chain
(CLTC) genes, respectively situated on chromosomes 1q21,
17q25, 1p34, Xq12, and 17q23. The t(X;17) (p11.2;q25) or
ASPL-TFE3 translocation RCC and ASPS contain the identical
ASPL-TFE3 fusion transcript yet the t(X;17) translocation is
always balanced in the Xp11.2 translocation RCC and unbalanced in the ASPS.64
Pathology
On gross examination, these lesions closely resemble conventional (clear cell) renal carcinomas. They are tan-yellow, and
often necrotic and hemorrhagic. The most distinctive histopathological appearance is that of papillary structures lined
with clear cells, a finding that is uncommon in other renal
carcinomas (Fig. 1.2). They often have a nested architecture,
with cells containing clear and granular cytoplasm. The histology of Xp11 translocation carcinomas varies with specific
chromosomal translocations. The ASPL-TFE3 renal carcinomas are notable for cells with voluminous, clear to eosinophilic cytoplasm, discrete cell borders, vesicular nuclear
chromatin, and prominent nucleoli. They were previously
labeled as the “voluminous cell variant” of pediatric RCC.
Hyaline nodules containing psammoma bodies can be seen. In
comparison, the PRCC-TFE3 renal carcinomas ordinarily
have less abundant cytoplasm, fewer hyaline nodules with
psammoma bodies and a more nested, compact architecture.
The immunohistochemistry is positive for TFE3 protein, RCC
marker antigen, and CD10. In contrast with traditional RCC,
only half of them express epithelial markers such as cytokeratin and epithelial membrane antigen.
Clinical presentation and prognosis
Although RCC is uncommon in children (<5% of all renal
tumors), approximately a third of RCC in children and young
Figure 1.2 Renal cell carcinoma associated with t(X;17) (p11.2; q25)
consists of nested to pseudopapillary structures lined with tumor cells with
abundant clear, sometimes eosinophilic, cytoplasm.
6
adults appears to belong to this translocation family of tumors.
Some reports have suggested that children who had prior exposure to cytotoxic chemotherapy are at risk for developing
Xp11.2 translocation RCC.65,66
Even though Xp11.2 translocation RCC has a comparatively good prognosis in childhood, adult-onset Xp11.2 translocation RCC is reported to have a poor prognosis.67–69 The
basis for this is the fact that most patients present with
advanced disease at diagnosis and that as yet, there is no effective systemic treatment. Chemotherapy and immunotherapy
have not proven to be successful on metastatic lesions.67,68,70
The clinical behavior of these tumors is still not well characterized. Generally, these carcinomas present at an advanced
stage, with lymph node metastases at diagnosis despite their
small size in a majority of cases. Even with these advanced
stage presentations, the clinical course tends to be variable.
This clinical behavior resembles that of ASPS, which has a
similar genetic translocation. It can recur 20 or 30 years after
the initial diagnosis.
Adequate surgical resection might possibly improve the
prognosis. It has been reported that the implication of lymph
node dissection in patients with Xp11.2 translocation RCC was
greater than that for conventional RCC.68,71 Only anecdotal
reports of the adjuvant use of chemotherapy and immunotherapy in pediatric patients are available and thus adjuvant therapy should not be used outside a clinical trial.14
Recently, targeted therapy has demonstrated objective
response and prolonged progression-free survival (PFS) in
patients with metastatic Xp11.2 translocation RCC. Malouf
et al. reported on 21 patients with metastatic Xp11.2 RCC
who were treated with vascular endothelial growth factor
(VEGF) and mammalian target of rapamycin (mTOR)-targeted therapies.70 Patients treated with sunitinib were found
to have a median PFS of 8.2 months in the first-line setting,
while in the setting of second, third or fourth line it showed
a median PFS of 11 months. Patients treated with sorafenib
had a median PFS of 6 months, whereas patients treated with
temsirolimus had a median PFS of 3 months. Seven patients
(33%) experienced objective responses. All patients treated
with sunitinib and one patient treated with temsirolimus
achieved responses. With a median follow-up of 19 months,
the median overall survival (OS) was reported to be 27
months. Another retrospective study reported by Choueiri
et al. reviewed 15 patients with metastatic Xp11.2 RCC, of
whom 10, three, and two received sunitinib, sorafenib, and
monoclonal anti-VEGF antibodies, respectively.72 Five
patients had prior systemic treatments. When treated with
VEGF-targeted therapy, three patients demonstrated a partial response, seven patients had stable disease, and five
patients developed progressive disease. The median PFS and
OS of the entire cohort were 7.1 months and 14.3 months,
respectively.
Lately mesenchymal-epithelial transition (MET) tyrosine
kinase receptor has been studied as a future potential therapeutic target in Xp11.2 RCC. A selective inhibitor of c-Met receptor tyrosine (ARQ-197) kinase has demonstrated safety and
tolerability in a phase 1 trial. A phase 2 clinical trial in patients
with microphthalmia transcription factor-driven tumors,
including translocation-associated RCC, has been completed
and is awaiting study results.70,72,73 Therefore, use of targeted
therapeutic agents, preferably in a clinical trial, is favored for
this type of tumor, recognizing the relatively limited activity of
these agents.
Mucinous tubular and spindle cell carcinoma
Background
These tumors were first described by Farrow et al ., who
collected a series of eight distinctive tumors that appeared
to originate from the collecting tubules.74 Further studies
of this collection of tumors resulted in their classification
as “low-grade collecting duct carcinoma,”75 a term that
may not accurately reflect the biology of these tumors.
Several other reports also postulated that they represented
a low-grade CDC with less biological aggressiveness.27
However, subsequent characterization and reports of these
tumors showed that they had clinical and pathological features quite distinct from CDC. Currently, they are recognized as a separate entity of renal cell tumor in the WHO
classification.4,76–79
Pathology
Grossly, these tumors are well circumscribed, solid or cystic,
large (mean size 6 cm), with a gray or light tan appearance,
and a homogeneous, myxoid, and glistening cut surface.
Microscopically, they are composed of compressed tubular
structures and spindle cells separated by pale mucinous
stroma. These can have a configuration simulating leiomyoma or sarcoma.80 Mitotic activity is minimal with a low
Furhman nuclear grade of 1–2. The morphological, immunohistochemical, and ultrastructural features of these lesions
indicate an origin from distal nephron segments. They have a
complex and variable immunohistochemical profile; with
positivity for a wide range of cytokeratins and epithelial
membrane antigen. Proximal nephron markers such as CD10
and villin are mostly absent. They also show positivity for
Ulex europaeus, peanut, and soya bean agglutinins.76 On
electron microscopy, they have the usual epithelial features
resembling the loop of Henle or a distal convoluted tubule.
Cytogenetic changes involving chromosome losses of 1, 4, 6,
8, 13 and 14 and gains of chromosomes 7, 11, 16, and 17 have
been described.
Although more common in middle-aged and elderly women,
these tumors can occur in a wide age range (17–82 years with
a mean of 53 years) but predominantly in women (female-tomale ratio of 4:1). They usually present as asymptomatic
masses on radiological studies. Occasionally, they can present
with flank pain or hematuria. Although generally benign in
behavior, there are case reports of metastatic disease, presumably due to the sarcomatoid element sometimes found in these
tumors.81,82
7
Previously these mucinous tubular and spindle cell carcinoma
(MTSCC)/tumors may have been misdiagnosed as leiomyoma, sarcoma, or CDC. It is crucial to make the diagnosis of
these tumors as being distinct from the other tumors in view of
the indolent nature of this disease, to prevent undue and excessive treatment. No case series of systemic treatment have been
reported to date. There is one case report in the literature of a
61-year-old woman who presented with metastatic MTSCC
with a 3 cm right renal mass, a 3 cm left adrenal mass, bulky
retroperitoneal adenopathy, a right pulmonary nodule, left
hilar adenopathy, and widespread sclerotic bone metastases.
Sunitinib was initiated at 50 mg, and symptomatic improvement was noticed a few days after starting treatment. Restaging
scans at 12 weeks showed a decrease in size of the retroperitoneal nodal mass and left adrenal lesion whereas other lesions
were stable, consistent with a partial response to therapy. At
24 weeks, the patient continued to show clinical benefit from
therapy, and a restaging scan showed stable disease.83
Therefore, this extraordinarily rare tumor is managed surgically, and, if metastatic, clinical trials should be considered.
If trials are unavailable, VEGF-targeted therapy can be considered but based only on the single case report. There are no
data supporting the use of chemotherapy in this disease.
(a)
Oncocytoma
Background
Oncocytomas first came to attention as benign kidney tumors
after a case series reported by Klein and Valensi in 1976.84
They constitute about 3–5% of renal tumors in most large
series.85 However, tumors similar to oncocytomas had been
described earlier, by Zippel et al. The term oncocyte means
“swollen cell”; the cells are swollen because of numerous
cytoplasmic mitochondria. Similar tumors can occur in the
salivary gland, thyroid, parathyroid, and adrenal sites.86
Pathology
Oncocytomas are well-circumscribed, nonencapsulated neoplasms with a characteristic central stellate scar, seen in 33%,
and most commonly in large tumors (Fig. 1.3a). The median
size is about 5 cm but they can be as large as 20 cm. The color
is classically mahogany-brown, but can be tan to pale yellow.
Hemorrhage can be seen in 20%. They are composed of solid
nests and sheets of oncocytes with abundant granular eosinophilic cytoplasm, residing in an edematous, mucopolysaccharide-rich extracellular stromal matrix (Fig. 1.3b). They are
thought to arise from the intercalated cells of the collecting
duct. The nuclei usually do not exhibit pleomorphism; with an
evenly dispersed chromatin, discrete central nucleoli and
mitotic activities are rare to absent. Features such as perinephric fat and lymphovascular invasion can be seen and do
not appear to confer a worse prognosis.87,88 However, “atypical
features” such as gross involvement of the renal vein, extensive papillary architecture, foci of clear cells, sarcomatoid
(b)
Figure 1.3 Renal oncocytoma forms a well-circumscribed, nonencapsulated
mass with homogeneous cut surface and a central scar (a). The tumor cells
(oncocytes) are uniform, round to polygonal with granular eosinophilic
cytoplasm and regular round nuclei with evenly dispersed chromatin. They
are nested in a loose hypocellular and hyalinized stroma (b).
dedifferentiation, prominent necrosis, and frequent or atypical
mitoses carry a different connotation and are inconsistent with
a diagnosis of oncocytoma.89
The most common differential diagnoses for oncocytomas
are chromophobe RCC and clear cell RCC with eosinophilic
cells. Making a distinction between these tumors on a cytological aspiration specimen can be difficult.90 Hale colloidal
8
iron staining, parvalbumin, and vimentin are negative (although
focal luminal), as opposed to the diffuse cytoplasmic, colloidal
iron staining that can be observed in oncocytoma, and antimitochondrial antibody is positive in oncocytoma and can help in
the differential diagnosis.87 On electron microscopy, they are
characterized by numerous normal-appearing mitochondria
accounting for the cytoplasmic granularity; leading to the
use of the term “mitochondrioma” by some authors.86,89,91
Microvesicles that are seen in chromophobe RCC are absent in
oncocytoma.
Oncocytosis is a condition in which the kidneys contain
multifocal oncocytomatous nodules, with oncocytic changes in
the renal tubules and cysts in the surrounding regions of the
kidney. Multifocality and bilaterality can occur in 5–13% of
resected oncocytomas. It behaves in a similar fashion to the
solitary tumors. Sometimes, a lesion can contain both oncocytomatous and chromophobe RCC components, a condition
referred to as “hybrid oncocytic tumor (HOT tumor).”
Therefore, it is crucial to thoroughly examine and adequately
sample a lesion that grossly resembles an oncocytoma.92 The
coexistence of oncocytoma with chromophobe RCC and their
morphological similarities have sparked a debate as to whether
these two entities represent the two extreme ends of the spectrum with a common origin from the intercalated cells of the
collecting duct. Recent molecular evidence suggests that renal
oncocytoma and chromophobe RCC share not only some morphological similarities, but early cytogenetic alterations also,
including loss of chromosomes Y, 1, and 14.
Birt–Hogg–Dube syndrome is a familial, autosomaldominant syndrome in which the gene, FLCN (folliculin), has
been localized to the short arm of chromosome 17. This is
characterized by dome-shaped skin papules in the facial area,
renal tumors (27% of patients), pulmonary cysts, and spontaneous pneumothorax.93 The most common renal tumor is a
hybrid of chromophobe RCC and oncocytoma with multiple
tumors in a majority. The possibility of this familial syndrome
should be entertained in a diagnosis of renal oncocytosis.94
Oncocytoma can present anywhere between the ages of 14 and
90 years with no gender predilection. It is detected mostly as
an incidental finding on routine imaging studies. Occasionally,
patients may have hematuria, flank pain, or a palpable mass.
On CT scan, the lesion is usually hypodense, well circumscribed, and peripherally located with a central scar.95
Current literature supports the benign nature of the disease,
with surgery being curative.96 Metachronous lesions have
been reported as late as 9 years after initial diagnosis.97 If the
clinical data or preoperative information confirm oncocytoma, it can be treated safely by partial nephrectomy.
Therefore, preoperative diagnosis can avoid excessive treatment. However, most patients do undergo nephrectomy
because of the inability of current diagnostic methods to
reliably distinguish this from renal cell carcinoma, and the
occasional coexistence of chromophobe RCC and clear cell
RCC with oncocytoma (not readily distinguished on a limited amount of biopsy material). Synchronous and metachronous oncocytoma has been described and surgical
management remains the preferred approach. There is no
defined role for systemic therapy of renal oncocytoma.
The presence of distant disease suggests an alternative
histological diagnosis.
Angiomyolipoma
Background
Renal angiomyolipoma is a benign mesenchymal lesion initially described by Grawitz et al. in 1900.98 It accounts for
approximately 1% of surgically removed renal tumors. It was
also described by Bourneville and Brissaud as part of the
tuberous sclerosis complex (TSC) around the same time.99,100
In 1989 Hartwick et al. reported an epithelioid angiomyolipoma with uncommon histological patterns mimicking malignancy, which after further investigation revealed malignant
characteristics in some cases. It has recently been classified as
a variant of angiomyolipoma with malignant potential.80
Pathology
Grossly, renal angiomyolipoma is a large, yellow-gray mass
lesion, well demarcated from the kidney but not truly encapsulated. Generally they are solitary but if present in multiple
numbers, the picture is that of a dominant tumor with associated smaller lesions. When they grow larger, they usually
cause a mass effect rather than infiltrating into surrounding
tissue. They are composed of a varying proportion of thickwalled, poorly organized blood vessels, smooth muscle bundles, and mature adipose tissue (Fig. 1.4a), and the varying
proportion of each component accounts for the gross appearance of the lesion. Smooth muscle cells are frequently spindle shaped and occasionally rounded epithelioid. Regional
lymph node involvement is thought to represent multicentric
involvement rather than metastases.101,102 Infrequently, direct
tumor extension into the inferior vena cava and the
renal venous system, in the absence of distant metastases, has
been described.
The higher prevalence of angiomyolipoma in females has
raised the speculation that there may be a sex hormonal potentiation of angiomyolipoma growth. Progesterone and estrogen
receptors have been detected in these tumors along with reports
of rapid growth during pregnancy.
The immunohistochemical profile is characterized by a
coexpression of melanocytic (e.g. HMB-45) (Fig. 1.4b) and
smooth muscle (e.g. smooth muscle actin) markers. They can
also be positive for CD68, neuron-specific enolase, S-100,
desmin, and hormonal receptors whereas the epithelial markers are consistently negative.4,103–105
Two genes are known to cause tuberous sclerosis: TSC gene
1 (TSC1) on chromosome 9q34, which encodes hamartin, and
TSC2 on chromosome 16p13, which produces tuberin, a
GTPase-activating protein. The biology of these genes has
(a)
9
(b)
Figure 1.4 (a) Angiomyolipoma characteristically consists of three elements: blood vessels (lower right), adipocytes (lower left), and smooth muscle cells
(upper). Melanocytic markers, such as HMB-45, are positive in some tumor cells (b).
been elucidated extensively in recent years. Angiomyolipoma
frequently has loss of heterozygosity at one of the two TSC
loci in both the sporadic and tuberous sclerosis-associated
tumors.99
Epithelioid angiomyolipoma is a potentially malignant
mesenchymal neoplasm closely related to classic angiomyolipoma. There is a higher association (>50%) with tuberous
sclerosis. Patients are frequently symptomatic, both sexes are
equally affected, and the mean age of presentation (38 years)
is generally younger compared with classic angiomyolipoma.
Scarcity of adipose tissue makes radiological diagnosis more
difficult. About a third of reported epithelioid angiomyolipoma cases have metastasis to lymph nodes, liver, lungs, or
spine.106–109 Microscopically, there are sheets of epithelioid
cells with abundant granular eosinophilic cytoplasm, enlarged
vesicular nuclei, and prominent nucleoli. Areas of classic
angiomyolipoma can be found interspersed focally. Tumors
with necrosis, increased mitotic activity, nuclear atypia, and
infiltration into surrounding tissue should be regarded
as potentially malignant. The immunohistochemical profile
is positive for melanocytic markers such as HMB-45, but not
as consistently positive for smooth muscle markers such as
actin.4,80 Although rare, epithelioid angiomyolipoma should
be kept in perspective when a diagnosis of angiomyolipoma
is made.
The prevalence of this tumor in the general population is
low.110,111 Angiomyolipoma can present either sporadically
(80%) or in association with the TSC (20%). There is a female
preponderance (4:1) in the sporadic form, but not in the tuberous sclerosis-associated tumors. Tuberous sclerosis is an autosomal-dominant disease with incomplete penetrance. It was
initially described by Bourneville in 1880, in a girl with mental
retardation, epilepsy, and characteristic sclerotic brain lesions
(tubers).100 Later, in 1900, Bourneville and Brissaud noted the
association of the syndrome with renal tumors. Vogt described
the classic triad of seizures, mental retardation, and adenoma
sebaceum.112 This triad has been substituted by a constellation
of findings that establish the diagnosis. When patients with
tuberous sclerosis are followed up, more than half of them
show development of angiomyolipoma.
In a pooled analysis by Nelson et al., the authors suggest
that tuberous sclerosis-associated angiomyolipoma, in contrast
with sporadic cases, is likely to present at an earlier age (mean
age 30 versus 52 years), with larger tumors (8.9 versus 5.4 cm),
frequent multicentricity (97% versus 13%) and hemorrhage
(44% versus 14%).113 Steiner et al. found that tuberous sclerosis-associated tumors were more likely to grow (67% versus
21%) and require surgical intervention (50% versus 28%) during the 4 years of follow-up.114 De Luca et al. reported on 51
patients with sporadic angiomyolipoma who had either immediate surgery or were on observation. Ninety-two percent of
the observed patients (mean tumor size 1.5 cm) showed no
radiographic growth of angiomyolipoma during the 5-year
follow-up. The larger tumors (>4 cm) were more likely to
grow (46% versus 27%) or require surgical intervention (54%
versus 7%) than smaller tumors.115
Angiomyolipoma can present with symptoms such as flank
pain, a palpable tender mass, and gross hematuria or as an
incidental finding on radiological studies. Morbidities secondary to angiomyolipoma are related to retroperitoneal hemorrhage (Wunderlich syndrome)116 and renal failure secondary
to encroachment of normal renal tissue.117 Identification of fat
in a renal lesion is the key to radiological diagnosis. Some of
the lesions contain a minimal amount of fat that may not be
detected and may lead to a nephrectomy. There have been
reports of fat in RCC tumors, secondary to invasion and
entrapment of perirenal fat. Magnetic resonance imaging
(MRI) can help in differentiating angiomyolipoma from RCC
in select cases and in evaluation during pregnancy. Diagnosis
10
of incidental angiomyolipoma should also prompt a workup
for tuberous sclerosis.
Historically there was an association between RCC, angiomyolipoma, and the tuberous sclerosis syndrome. Clear cell
RCC appears to develop at a higher rate in patients with tuberous sclerosis syndrome than in general. Eble et al. also suggested that some tumors historically diagnosed as RCC in this
set of patients may actually have been epithelioid angiomyolipoma, overestimating the association.118
Renal angiomyolipomas are typically slow-growing tumors,
and morbidity is secondary to their growth. With the lack of
randomized trials, there is considerable controversy as to the
exact indication for treating asymptomatic angiomyolipoma,
and organ preservation with partial nephrectomy is a preferred
approach. Asymptomatic, small, benign-appearing lesions can
be observed. Minimal hematuria will usually resolve with
hydration and bed rest. In this approach, patients should be
cautioned to avoid contact sports and should be followed up
closely to evaluate the growth pattern of the lesion.
The primary reasons to intervene should be suspicion
of malignancy in a lesion with low fat content, alleviation of
symptoms secondary to spontaneous hemorrhage, and risk of
rupture or other complications. Surgical removal or core
biopsy with immunohistochemical staining should be considered when there is no diagnostic certainty. Symptomatic angiomyolipoma can be managed by either angio-embolization or
surgical removal.113 When clinical risk factors such as childbearing age, large tumor, suspected TSC or anticipated difficulty with periodic reimaging are present, asymptomatic
angiomyolipoma can be managed by observation or intervention, according to individual preference.
Retrospective data demonstrate that patients presenting
with symptoms or hemorrhage are more likely to have larger
tumors. Oesterling et al. proposed a 4 cm threshold for the
risk of symptoms and intervention in asymptomatic
patients.119 Prospective data from De Luca et al.115 and others
suggest that larger lesions may become symptomatic with
time, especially in patients with the TSC. These studies have
also shown that it is not necessary to treat all large asymptomatic lesions, since they may grow slowly without morbidity.
On the basis of available evidence, we suggest that an intervention in an asymptomatic patient should be based on the
comprehensive evaluation of the clinical scenario including
tumor size, tumor growth pattern, and presence of tuberous
sclerosis, patient comorbidities, renal function, pregnancy
plans, and compliance.
Surgical intervention for angiomyolipomas is usually
reserved for patients with symptoms not responsive to conservative measures, with lesions having renal vein or soft
tissue invasion, or with suspicion of malignancy on imaging.
Nephron-sparing surgery is the preferred modality because of
the benign nature of the tumor. Fazeli-Matin and Novick
reported on 27 patients with angiomyolipoma who underwent
partial nephrectomy, of whom 21 had a solitary or impaired
contralateral kidney.120 All operated kidneys were functional
after surgery, including seven with tumors larger than 12 cm.
None of the patients required dialysis postoperatively and none
had recurrent angiomyolipoma symptoms at a median followup of 39 months.
Pregnancy can complicate the management of young women
with angiomyolipoma. While the incidence of hemorrhage during pregnancy is low, the consequences can be catastrophic with
potential harm to the mother and fetus. Hormonal links also suggest that these tumors may grow faster secondary to the altered
milieu, leading to tumor rupture. Optimal diagnostic methods
may be limited by pregnancy, and it may be difficult to distinguish tumor rupture from uterine or placental rupture. This
lends greater credence to the belief that women with known
angiomyolipoma greater than 4 cm who intend to conceive
should be treated prophylactically to avoid the risk of rupture.
Bissler et al. reported a 24-month nonrandomized openlabel trial, in which all 25 patients were diagnosed with either
tuberous sclerosis or sporadic lymphangioleiomylomatosis
and least one angiomyolipoma 1 cm in size or more.121
Sirolimus was administered in the first 12 months and tumor
size was reduced to some extent but after stopping treatment, a
tendency to increase in tumor size was observed. Of the 25
patients enrolled, 20 completed the 12-month evaluation, and
18 completed the 24-month evaluation. At 24 months, 5 out 18
patients showed a continual reduction in angiomyolipoma volume around 30% or more. Additional data support the role of
mTOR in the biology of these neoplasms with case reports of
response to mTOR inhibitors.122 At present, the use of available mTOR inhibitors (temsirolimus, everolimus) is encouraged
for metastatic, malignant angiomyolipomas while surgery is
the mainstay of therapy for localized, typical angiomyolipomas.
Carcinoids
Background
Primary renal carcinoid is an extremely rare, well-differentiated
neuroendocrine tumor with unclear etiology. The origin of this
tumor is still unclear, since neuroendocrine cells are not normally present in the renal parenchyma. In 1997, Krishnan et al.
reported a 20% horseshoe kidney association with the 50 cases
of renal carcinoid reported in the literature at that time.123 The
relative risk for a person with horseshoe kidney to develop this
tumor is estimated to be 82-fold higher than the general population.124 It was first reported by Resnick in 1966 in a patient
with carcinoid syndrome;125 however, the majority of the
organ-confined tumors do not produce the carcinoid syndrome,
which is akin to carcinoids in other organ systems.
Pathology
Grossly, this lesion presents as a solitary, well-circumscribed,
moderately firm tumor with a bulging appearance. The
color is variable; the appearance is homogeneous with
variable focal hemorrhage and calcification.4 The histopathological features appear to be similar to carcinoid tumors
in other organ systems. The cells are uniform in size and
arranged in a trabecular pattern. They have small nuclei with
“salt and pepper” chromatin and eosinophilic cytoplasm.
Immunohistochemical staining is positive for chromogranin,
neuron-specific enolase, and keratin. Variable positivity for
serotonin, pancreatic polypeptide, prostatic acid phosphatase, and vasoactive intestinal polypeptide has been
reported.126
Most patients present with an asymptomatic mass but they
can also present with abdominal pain, mass, or hematuria.
Workup for alternate origin is indicated when a lesion is discovered in the kidney, because of the rarity of primary carcinoid of the kidney.123 Carcinoid symptoms are present in less
than 10% of patients on presentation.4,126,127 The median age
at diagnosis is 50 years, with no sex predilection. On CT scan
it appears as a circumscribed solid mass with occasional
calcification or cystic changes.127 Some authorities have suggested that an octreotide scan can contribute to accurate staging and diagnosis.128,129
Because of the rarity of the disease, the clinical outcome is difficult to predict. This is also complicated by the fact that a
significant proportion of patients with metastatic disease have
a prolonged survival. No standard treatment has been approved
for locally advanced or metastatic disease.130 Localized disease
has been treated surgically. In one of the largest reviews, with
56 patients, Romero et al. reported that nonmetastatic disease
was associated with cure and survival rates of 86% and 96%,
respectively, at 48-month follow-up.131,132
Carcinoid tumors that arise in horseshoe kidneys tend to
have a more indolent course.123
Three main prognostic factors have been acknowledged for
patients with renal carcinoids.131
• Age above 40 years has been associated with a more rapid
progression, thus more severe early presentation.
• Tumors measuring less than 4 cm or limited to the renal
parenchyma have fewer tendencies to metastasize and hence
have a better prognosis.
• Purely solid tumors and those with a mitotic rate higher than
1/10 high-power field (HPF) have also been reported to have a
worse prognosis.
Carcinoid crisis secondary to release of vasoactive substances
can occur with biopsy or surgical resection of the tumor and
can be managed with somatostatin. In patients with a solitary
metastasis, especially in the liver, it is appropriate to consider
resection of the primary tumor with the metastatic lesions,
because of the lack of effective systemic treatment options.
Radiation is effective for short-term palliation.
Limited information on the therapy for metastatic renal
carcinoid is available. In patients with carcinoid syndrome,
symptom control with somatostatin or its analogs such as
octreotide is reasonable.133 For individuals with metastatic
disease, systemic treatment options are based on clinical trials in patients with gastrointestinal carcinoids. The need to
start systemic therapy is based on tumor anatomy and/or the
11
presence of symptoms and is not indicated immediately for
many patients. Interferon produces tumor regression (15%)
and biochemical responses in patients with metastatic disease.134 Combination chemotherapy is of limited value. In an
Eastern Cooperative Oncology Group (ECOG) trial, 118
patients with metastatic carcinoid tumor were randomized
for treatment with streptozotocin combined with cyclophosphamide or with 5-fluorouracil (5-FU). Objective response
rates among the evaluable patients treated with the 5-FU
combination were 33% and with the cyclophosphamide
combination 26%, with substantial toxicity in both regimens.135 There are no data supporting other chemotherapy
regimens specifically for renal carcinoid and in general the
same management approach as for other carcinoid tumors is
undertaken.
Advanced neuroendocrine tumor (NET) has demonstrated
increased activation of mTOR pathway components plus
mTOR inhibitors have shown efficacy in animal models and
cell lines and human tumors. This was the rationale for mTORtargeted therapy for treating advanced NET.136
In 2008, Yao et al.137 published the first phase 2 trial of
everolimus in patients with low-grade to intermediate-grade
NET. The study enrolled 60 patients with advanced, lowgrade to intermediate-grade NET (30 pancreatic NET and 30
lung NET or gastrointestinal NET [carcinoid]). Patients
received daily everolimus 5 mg (n = 30) or 10 mg (n = 30)
orally in combination with octreotide long-acting release
(LAR). The overall response rate was 23% in the per-protocol
population, in which 13 patients (22%) achieved a partial
response (PR), 42 (70%) maintained stable disease, and five
(22%) had disease progression. PRs were more frequent in
patients with pancreatic NET than in patients with nonpancreatic NET (27% versus 17%). Concerning the different dosages,
everolimus 10 mg produced a higher PR rate than 5 mg (30%
versus 13%). Median PFS was 60 weeks overall, longer in
patients with nonpancreatic NET (63 weeks) than in patients
with pancreatic NET (50 weeks). In terms of tumor shrinkage,
the majority of patients showed some degree of tumor reduction. This study revealed that everolimus was effective and tolerated in the treatment of low-grade to intermediate-grade
NET. Currently there are clinical trials of everolimus ongoing
across various types of NET.136 Even though these studies were
not specifically in renal carcinoids, application to these tumors
is reasonable.
Lymphoma
Background
Lymphomatous involvement of the kidney occurs in three
distinct clinical scenarios. Most commonly, lymphoma
of advanced stage involves the kidney secondarily.
Posttransplantation lymphoproliferative disease (PTLD) can
also involve the kidney secondary to iatrogenic immunosuppression (see Chapters 44 and 48). Primary renal lymphoma
(PRL) is the least common. The incidence of PTLD arising in
transplant kidneys has been rising in the last couple of decades
because of the increasing frequency of transplantations.
12
Secondary renal involvement tends to be bilateral and is seen
with a high incidence (37–47%) in advanced disease. Whether
PRL truly exists is still a controversial issue because of its rarity; about 60 cases have been reported and only about 30 cases
truly fulfill the diagnostic criteria as PRL.138,139
Pathology
Nephrectomy specimens in PRL can have a homogeneous,
firm, pale appearance with occasional tumor thrombus or renal
vein involvement. The most common pattern is a diffuse
involvement with lymphoma cells permeating between the
nephrons, a so-called “interstitial pattern.” However, nodular
involvement with discrete masses and intravascular lymphoma
has also been described. Diffuse large B cell is the most common histological type, although Burkitt, lymphoblastic lymphoma, and other histologies have been described. The origin
of these tumors is still controversial, since renal parenchyma
does not contain any lymphoid tissue. PTLD in transplant
kidneys is related to the degree of immunosuppression
and Epstein–Barr virus (EBV) infection and can present as a
monoclonal or polyclonal process.4
Due to the silent course of the disease, patients usually present
as late manifestations of a systemic disease, although it was
found in 34% of autopsies of patients dying of progressive
lymphoma or leukemia.140–142 Patients can present with flank/
abdominal pain, fever, cachexia, renal insufficiency, or hematuria. Renal failure was believed to be secondary to general
replacement of the functioning parenchyma or bilateral urethral obstruction secondary to enlarged retroperitoneal lymph
nodes.142 However, the diagnosis of renal failure secondary to
parenchymal replacement by lymphoma requires exclusion of
other causes of renal failure and demonstration of improvement in renal function after starting systemic chemotherapy or
radiation therapy.143,144
Computed tomography scan is known to be the most sensitive and efficient imaging used for diagnosis and monitoring
response to treatment in renal lymphoma.141,145–147 In a review
by Urban et al.,147 the typical patterns of involvement are single and multiple masses, renal invasion from retroperitoneal
disease, perirenal disease, and diffuse renal infiltration. Renal
lymphoma should always be kept in mind in patients with
immense retroperitoneal lymphadenopathy, splenomegaly, or
lymphadenopathy in other parts of the body or uncommon
areas within the retroperitoneum.147,148
Patients with PRL are usually treated by nephrectomy,
because PRL is regarded clinically as a renal epithelial tumor.
Once the renal involvement of lymphoma is confirmed, a
thorough search for extrarenal disease and staging studies,
such as CT scans and bone marrow biopsy, are warranted to
rule out a secondary lymphoma, as the latter is much more
common (30 times more common). Stallone et al.138 have
proposed that the diagnosis of PRL be made only when the
following criteria are fulfilled:
• lymphomatous renal infiltration
• nonobstructive kidney enlargement
• no extrarenal localization at the time of diagnosis.
If renal lymphoma is expected, consideration should be given
to percutaneous biopsy to achieve a pathological diagnosis.
Where exploratory surgery is required, intraoperative biopsy
and frozen-section analysis will take priority.
Although there have been reports of modest disease-free
survival after nephrectomy of PRL, the prognosis is generally
poor due to dissemination to secondary sites. Early detection
and systemic combination chemotherapy may reverse the
renal failure and improve survival by preventing dissemination.138,148–150 Secondary renal lymphomas are usually seen in
the setting of advanced lymphoma and have a dismal prognosis. Nephrectomy is hardly ever indicated for these advanced
patients except with severe symptoms, for instance uncontrollable hemorrhage. Patients with advanced lymphoma
involving the kidney are treated with conventional therapy
(e.g. R-CHOP). PTLD is treated by reducing the immunosuppression if possible; Oertel et al. reported a multicenter phase
2 trial investigating rituximab (anti-CD20 monoclonal antibody) as single agent in 17 patients with PTLD. Transplanted
organs were heart (n = 5), kidney (n = 4), lung (n = 4), and
liver (n = 4). Patients were treated with a weekly dose of
rituximab for 4 weeks on days 1, 8, 15 and 22. The mean
follow-up time is 24.2 months. The mean overall survival
period is approximately 3 years with 11 patients that were
still alive. In total, nine patients (52.9%) achieved a complete
remission, with a mean duration of 17.8 months. Partial
remission was observed in one patient, minor remission in
two patients, no change in three patients and one patient
experienced progressive disease. Two patients relapsed, at
intervals 3 and 5 months after obtaining complete remission.
Although the kidney was never one of the affected sites in
this study, this study proved the feasibility and efficacy of the
monoclonal antibody rituximab in the setting of patients with
PTLD subsequent to solid organ transplantation.151
Renal sarcomas
Background
Primary renal sarcoma in adults is rare, representing approximately 1% of all primary tumors of the kidney.152–154 Renal sarcomas are less common but more fatal than any other sarcoma
in the genitourinary tract, counting the prostate, bladder, and
paratesticular area.155,156 Sarcomatoid components can be seen
in approximately 5% of RCC, including clear cell, papillary,
chromophobe, and CDCs. It should not be confused with primary renal sarcomas, as the two entities have entirely different
biology, pathology, and clinical features.4,157
Pathology
Any sarcomas that arise in other parts of the body can occur
in the kidney, including leiomyosarcoma, osteosarcoma,
malignant fibrous histiocytoma (MFH), angiosarcoma,
rhabdomyosarcoma and synovial sarcoma. As in other parts
of the body, the diagnosis and classification are traditionally
based on H&E histology and immunohistochemistry.158
However, molecular studies have been increasingly used in
the classification of sarcomas. For example, synovial sarcoma of the kidney has a characteristic chromosomal translocation t (X;18) between the SYT gene on chromosome 18 and
a member of the SSX gene family on chromosome X.159,160
A wide variety of histological subtypes has been described;
as mentioned earlier,leiomyosarcoma is the most common histological subtype of renal sarcoma, representing 50–60% of
such tumors.161,162 Liposarcoma is fairly distinguished from
RCC due to the presence of adipose tissue, but it is often confused with angiomyolipoma (AML) or with large, benign renal
lipomas.163 Osteogenic sarcoma is a rare but unique form of
renal sarcoma that contains calcium and is usually stony
hard.164,165 Tumor grade, which is recognized as an important
prognostic factor in soft tissue sarcomas, is also believed to be
prognostic in primary renal sarcomas.
The common signs and symptoms that are seen with renal sarcoma in adults include palpable mass, abdominal or flank
pain, and hematuria and are like those seen with large, fastgrowing RCCs,166 with a climax incidence in the fifth decade
of life.152,155,163,167 They can spread along tissue spaces and
attain a large size before becoming symptomatic, similar to
retroperitoneal sarcomas. Systemic symptoms are less commonly reported. Metastasis is generally hematogenous; Saitoh
and colleagues reported the common sites of metastases of
renal sarcomas where lung was the most common followed by
lymph nodes and the liver.168
Abdominal CT classically demonstrates a large soft tissue
mass connecting or derived from the kidney, a result that is
again comparable to that associated with various sarcomatoid
RCCs.152,155,169 Clues that might be indicative of sarcoma rather
than of RCC include clear origin from the capsule or perisinuous region, growth to large size, lack of lymphadenopathy,
presence of fat or bone suggestive of liposarcoma or osteosarcoma, and hypovascular pattern on angiography, while one
notable exception is the hemangiopericytoma, which is highly
vascular.169,170
Renal liposarcomas in general develop in the fifth and sixth
decades of life and frequently grow to enormous size.166
Preoperative radiographic imaging of the chest should also be
performed since this is one of the most common sites of
metastatic disease.
Complete surgical excision is the mainstay of treatment of soft
tissue sarcomas at any location with intraoperative screening
of margin status. On the basis of case reports in renal sarcomas,
complete surgical extirpation of the organ-confined tumor
appears to offer patients the only reasonable chance for prolonged survival.152–154,167 The best outcome is seen with small
13
tumors (<5 cm) of low histological grade that are confined to
the kidneys. Surgical resection of locally recurrent or oligometastatic disease may be beneficial in selected patients as
seen with nonrenal metastatic sarcomas.171 In most case series,
leiomyosarcoma has been the most common histological subtype. Karakousis et al.172 reported early disease progression
and indicated that most patients die within months regardless
of treatment received. However, Vogelzang demonstrated that
low-grade sarcomas have a tendency to a more indolent
course.154 In renal liposarcoma, Economou et al. reported
response to radiation and cisplatin-based chemotherapy in an
adjuvant setting.166 Adjuvant radiation therapy, although commonly used in locally extensive disease, has not been proven to
prevent local recurrence or increase survival. Likewise, the use
of adjuvant chemotherapy has been described only in case
report and case series form for renal sarcoma. Therefore, adjuvant radiation and/or systemic chemotherapy (with sarcoma
regimens such as adriamycin and ifosfamide) can be considered for high-risk patients, while appreciating the balance of
definite risks and unknown benefits. The benefit of adjuvant
chemotherapy in more typical sarcomas is limited, and it is
unlikely that the benefit for renal sarcomas is greater.
Metanephric neoplasms
Background
These tumors were first described by Bove et al. in1979,173 and
are also known as nephrogenic nephroma.174 Several reports
of similar lesions described under a variety of names then
emerged and confirmed them as a distinct entity. They include
metanephric adenoma (predominantly epithelial), metanephric
adenofibroma, and metanephric stromal tumor (stromal tumor)
which is a pediatric tumor identical to the stromal component
of metanephric adenofibroma.175
Most of the clinical and pathological characteristics of
metanephric adenoma were outlined around the mid-1990s in
two large series.176,177 Metanephric adenofibroma was then
identified as a biphasic tumor with both epithelial and stromal
elements and presented mostly in children and young adults.
Metanephric tumors as a group are highly cellular benign
epithelial tumors but in two cases metastasis has been reported.
They are also known for their close relationship to WT and are
conceptualized by some as being the benign, well-differentiated end of a spectrum of tumors that also includes WT as its
malignant counterpart.175,178–180
Pathology
These tumors are usually unilateral and seldom multifocal.181
They tend to grow large, to 0.3–20 cm in their greatest dimension.182 They are usually unicentric, sharply circumscribed
without a capsule (Fig. 1.5a). The cut surface is gray to yellow,
with foci of hemorrhage, cystic changes and necrosis being
uncommonly present. Histologically, they are composed of
tightly packed, small, round acini. Half the tumors contain
papillary structures, which resemble primitive glomeruli.
Psammoma bodies are frequently present but no blastemal
14
(a)
(b)
Figure 1.5 Metanephric adenoma is sharply demarcated from the adjacent renal parenchyma (a). The tumor cells are closely packed to form tubules with
inconspicuous lumens. They have a strikingly uniform appearance with scant cytoplasm and smooth chromatin (b).
elements. The stroma can be inconspicuous or edematous. The
cells are generally cuboid with monotonous appearance, scanty
cytoplasm, and small, uniform nuclei with inconspicuous
nucleoli4,175–177 (Fig. 1.5b).
Metanephric adenofibroma is composed of nests of epithelial elements similar to metanephric adenoma embedded in
bands and sheets of fibroblast-like spindle cells. The proportion of spindle cells and epithelial components in these tumors
varies.183,184 Metanephric stromal tumor, as the name implies,
is very similar to the stromal component of metanephric
adenofibroma.
Metanephric adenoma can occur in children and adults; however, it is predominantly seen in the fifth and sixth decades of
life, with a female preponderance (female-to-male ratio 2:1).
Metanephric adenofibroma is generally seen in children and
young adults from 5 months to 36 years, with a male preponderance. Metanephric stromal tumors are seen mostly in children, with rare adult cases reported. These tumors as a group
comprise less than 1% of renal cell neoplasms. Most of these
cases are discovered incidentally during radiological studies
and workup for incidental hematuria. Radiologically,
metanephric adenoma presents as a hypovascular tumor
protruding extrarenally. When symptomatic, they can cause
abdominal pain and hematuria. Erythrocytosis has also been
reported in patients at presentation.176,185–187
Yoshioka et al.188 provided evidence that metanephric adenoma cells generate erythropoietin and other cytokines. A
number of reports support that the diagnosis of metanephric
adenoma can be achieved by percutaneous fine needle aspiration biopsy.189,190 As using cytological features to make a distinction between metanephric adenoma and Wilms tumor can
be challenging, immunocytochemical analysis in this context
might be helpful.189
These tumors are benign, with the exception of a few case
reports.179,180 If metanephric adenoma is suspected from the
clinical findings, it is important to obtain an intraoperative
diagnosis in order to avoid excessive resection. Erythrocytosis
associated with these tumors resolve following complete resection. There have been a number of reports supporting partial
nephrectomy for metanephric adenoma, mainly in adults.191–193
A conservative approach to metanephric adenoma, with no
surgery, has been described in a few case reports.6,194 No local
recurrence or distant metastasis has been reported for
metanephric stromal tumors. Wilms tumor has been reported
to have arisen in metanephric adenofibroma and metanephric
stromal tumor, pointing to the possible common origin of these
entities.184 Renal angiodysplasia associated with these lesions
can cause morbidity secondary to vascular complications.
Resection without adjuvant chemotherapy is the preferred
modality of treatment. There are no reliable reports of metastatic metanephric adenoma, and therefore no literature supporting any systemic therapy for unresectable disease. Presence
of distant metastases should cause one to question the
histological diagnosis.
Adult Wilms tumor (nephroblastoma)
Background
Wilms tumor (WT) is the most common malignant renal tumor
in children. It affects approximately one in every 8000 children
without a significant sex predilection, and about 450 new cases
are reported yearly in the United States. Ninety-eight percent
of all cases occur in children below the age of 10 years, and
less than 300 cases of adult WT have been reported in the literature. It tends to occur with almost the same incidence across
the globe, suggesting the absence of an environmental factor.
However, the incidence in the United States is highest in
African-Americans and lowest in Asians, indicating a possible
genetic predisposition.4,195 Its true incidence in adults is difficult to ascertain because it is included with renal cell carcinoma in epidemiological reports, and varying diagnostic
criteria are utilized in case reports.
Most experts use the following criteria to define adult WT:
(i) primary renal neoplasm, (ii) primitive blastematous spindle
or round cell component, (iii) formation of abortive or embryonal tubular or glomeruloid structure, (iv) no area of tumor
diagnostic of RCC, (v) pictorial confirmation of histology, and
(vi) age >15 years.196,197
Kilton et al. reported 35 cases of adult Wilms tumor which
met the terms of all the above criteria.198 Approximately 1–2%
of pediatric WT cases have a familial origin.
Pathology
In contrast with childhood WTs, which are often multicentric
and bilateral, most of the adult WT cases are unicentric, with
multicentric and bilateral disease reported in 7% and 5% of
patients, respectively. Horseshoe kidneys are associated with a
two-fold higher incidence of WT. The gross and microscopic
appearance of adult WT otherwise tends to resemble pediatric
WT. The gross appearance of WT varies and reflects the proportion of stromal and nonstromal components. Generally WT
is pale gray or tan and has a soft consistency; however, tumors
with predominant stroma may be white and firm. Cyst formation may be prominent in certain cases.
Wilms tumor contains varying proportions of undifferentiated blastemal cells and differentiated cells of epithelial and
stromal lineage. Blastemal cells are undifferentiated, small,
mitotically active, rounded or oval, and densely packed with
scant cytoplasm. They can occur in several distinctive growth
patterns within individual tumors, including diffuse, nodular,
serpentine, and basaloid. The epithelial component of WT can
manifest as primitive tubules with rosette-like forms and occasionally as glomeruloid structures. Heterologous epithelial differentiation with squamous, mucinous, or ciliated epithelial
components can be detected. The stromal component can
exhibit significant diversity but is usually composed of spindle
cells with a myxoid background. Heterologous elements
including skeletal muscle, cartilage, bone, adipose tissue, and
neural tissue can be present.
The histological diversity of WT is a hallmark.
Characteristically, it has a so-called triphasic pattern with blastemal, epithelial, and stromal components, although monophasic patterns with only one component, and biphasic pattern
with two components, are also seen often. Chemotherapy can
alter the morphology by inducing maturation of blastemal, epithelial, and stromal elements, leading to a disproportionate
reduction of actively proliferating cells as compared to the prechemotherapy specimen. Metastatic WT may comprise a single element or a combination of what is present in the primary
tumor. WT-1 antigen is usually identified in the blastemal
and epithelial elements, but not in differentiated epithelial or
stromal components.199,200
Nuclear anaplasia associated with an adverse outcome has
been recognized in 5% of pediatric cases and increases in
15
prevalence with age and in certain populations (e.g. AfricanAmericans). Anaplasia requires the presence of multipolar
mitotic figures, marked nuclear enlargement (three times that
of nonanaplastic nuclei), and nuclear hyperchromasia. The
prognostic significance is more profound in diffuse anaplasia
compared to focal anaplasia. Extensive blastemal cells have
also been identified as an adverse prognostic factor.
Nephrogenic rests are foci of abnormally persistent embryonal renal tissue that are capable of developing into WT. The
presence of diffuse or multifocal nephrogenic rests is defined
as nephroblastomatosis. There are two variants of nephrogenic
rests called perilobar nephrogenic rests (PLNR) and intralobar nephrogenic rests (ILNR). They can be seen in 25–45% of
pediatric WT and have also been seen in adult WT patients, as
well as in several ectopic sites outside the kidney.
Pediatric WT has been associated with a number of wellknown syndromes and genetic mutations. WAGR (Wilms
tumor, aniridia, genitourinary anomalies, mental retardation)
and Denys–Drash (gonadal dysgenesis, early-onset nephropathy) syndromes are associated with deletion or mutations of
the WT1 gene (11p13), a gene critical for renal and gonadal
development. Beckwith–Wiedemann syndrome (hemihypertrophy, macroglossia, omphalocele, and visceromegaly) is
associated with loss of imprinting on WT2 (11p15). Because of
the lack of sufficient cases, the genetics and syndromic associations have not been well elucidated in adults. Recently, a
high-resolution genomic analysis of adult WT in a 71-year-old
Swedish woman, using a SNP array, displayed a complex
genetic profile highly diverse from those observed in pediatrics WT, which indicates that WT in adults may represent a
distinct biological entity compared to WT in pediatric
patients.201
The most common clinical presentation of an adult WT is flank
pain, hematuria, abdominal mass, or constitutional symptoms.
Hypertension, which is commonly presented in pediatric WT,
has not been commonly reported in adult WT. While Kilton
et al.198 had described 42% of their patients being symptomatic
for more than a year prior to diagnosis, this has not been seen
in other adult case series.196,199,202–205 The tumors are usually
fairly large on initial presentation and a varicocele may signal
obstruction of the spermatic vein secondary to tumor thrombus
in the renal vein or inferior vena cava. Acquired von Willebrand
disease has been associated with pediatric WT and testing for
this is warranted in adult patients with clinical bleeding tendency. CT findings typically present as a heterogeneous intrarenal mass with a moderately hypovascular outline, but
discrimination from RCC can be challenging if not impossible
in many cases.205–207
Computed tomography scan of the chest and abdomen
should be done preoperatively to evaluate for metastases and
extrarenal WT. Intravascular extension involving the renal
vein and IVC can be seen.
The most common sites for metastasis of WT are the lung,
lymph nodes, and the liver. Metastasis to the bone is unusual
and a bone scan or skeletal survey is warranted only in the
16
Table 1.1 Wilms tumor staging system.
Stage
Findings and treatment
I
II
III
Tumor limited to the kidney and is resected completely
Tumor extends beyond kidney but is resected completely
Gross or microscopic residual tumor present and confined to
the abdomen
Hematogenous metastasis or lymph node metastasis outside
the abdomen and pelvis
Bilateral renal involvement at diagnosis; tumor in each
kidney should be separately substaged
IV
V
presence of symptoms. The staging system used by the
Children’s Oncology Group (COG), Societé Internationale
d’Oncologie Pédiatrique (SIOP) (International Society of
Pediatric Oncology) and National Wilms Tumor Study Group
(NWTSG) has been accepted by most adult WT authorities in
the staging of WT (Table 1.1). The staging is based on both
radiological and surgical pathology data.
The prognosis of adults with WT is poor compared to children,
who have an 85% chance of cure. This success in pediatric WT
represents a paradigm change to multimodality treatment.208
However, it was also thought that adults are more likely to
present with advanced disease and a decline in performance
status.206,209 In the 1980s, most adult case series had reported a
long-term survival of about 25%. Even though prior studies
have shown comparable results between adult and pediatric
WT patient populations when adults are treated on protocols,
a recent analysis of the Surveillance, Epidemiology and End
Results (SEER) database has demonstrated that adults have a
significantly worse overall survival than the pediatric patient
populations, which was attributed to inaccurate diagnosis,
inadequate staging, and undertreatment.210
Prior to the report by Arrigo et al. of 27 patients reported to the
NWTSG from 1979–87 with a 3-year overall survival of 67%, it
was believed that this high rate of cure could not be achieved in
adults.203 This series included six stage I, five stage II, four stage
III, 11 stage IV, one stage V patients and four patients with
anaplastic histology. In this series, 26 patients underwent
nephrectomy, 25 received chemotherapy, and 20 received radiation treatment. This led to the authors’ recommendations that
patients with stage I disease and favorable histology should be
treated with surgery followed by 6 months of postoperative
chemotherapy using actinomycin-D and vincristine without
postoperative radiation therapy; and for stage II, III, and IV with
favourable histology, vincristine, actinomycin-D and doxorubicin for 15 months along with radiation of 2000 cGy to the
tumor bed, 1200–1500 cGy to the lungs, 2000 cGy to the liver,
and 3000 cGy to other sites as appropriate in patients with metastases at diagnosis.
Kattan et al. reported the French experience in 22 adult
patients from 1973 to 1992.204 Their series included four stage
I, eight stage II, three stage III and seven stage IV patients. All
patients underwent nephrectomy followed by single-modality
adjuvant treatment in seven patients (radiotherapy in one and
chemotherapy in six) and combined modality in 15 patients.
The chemotherapeutic agents used most often were actinomycin-D, vincristine, and doxorubicin. Two of seven (29%) and
7/15 (47%) patients were disease free after first-line treatment.
Salvage chemotherapy had to be given in 13 patients. After a
mean follow-up of 100 months, 12/22 patients (55%) were
alive, including 10 who were disease free (45%). These authors
recommended aggressive treatment including a three-drug
regimen (actinomycin-D + vincristine + doxorubicin), regardless of stage, and irradiation starting from stage II.
Terenziani et al. reviewed the Italian experience with 17
adult patients between 1983 and 2001 who were treated with
an Italian protocol and followed for a median of 131 months.208
This included eight patients with stage II, four patients with
stage III and five patients with stage IV and included one
patient with anaplasia. Sixteen patients underwent nephrectomy, 15 received chemotherapy (10 with two drugs and five
with three drugs) and seven patients received radiation. The
5-year disease-free survival was 45% with an overall survival
of 62%. Reinhard et al. reviewed the German experience
which included 30 adult patients on the SIOP 93–01 study.205
Ten patients (33%) had metastatic disease at presentation.
There was a predominance of higher stage (stage I, 8; stage II,
7; stage III, 15 patients), with histology revealing intermediate
risk in 23 patients and high risk in two patients. Twenty-six
patients underwent primary radical nephrectomy and the other
four patients received neoadjuvant chemotherapy prior to
surgery. Nineteen patients received the intermediate-risk
chemotherapy and 11 patients received the high-risk chemotherapy as per protocol. Intermediate-risk chemotherapy
included vincristine, actinomycin-D ± doxorubicin for 18–27
weeks, and the high-risk regimen was etoposide, carboplatin,
ifosfamide, and doxorubicin for 34 weeks. Fourteen patients
received local radiation from 15–35 Gy and three patients
received radiation to metastatic sites. Complete remission was
obtained in 24 patients (80%) with an event-free survival of
57% and an overall survival of 83% with a median observation
time of 4 years.
In an earlier series by Byrd et al., it was noted that adults are
at risk for relapse for a greater period of time compared with
children.202 This has not been supported by more recent
series.203,205 Recurrent disease in children has been treated successfully with radiation, multiagent salvage chemotherapy
regimens (etoposide, carboplatin, and ifosfamide), or highdose chemotherapy with stem cell support leading to long-term
remissions (30–60%).211,212
All existing modern series have lain to rest the skepticism
regarding multimodality treatment of WT in adults. A riskadapted multimodality treatment approach similar to pediatric
WT protocols is the current standard of care. In contrast with the
pediatric population, where the opinion differs as to whether
nephrectomy should be done primarily or after neoadjuvant
treatment, there is a consensus opinion that primary surgery is
advisable for adult WT because of the difficulty in establishing
this rare diagnosis preoperatively. Only in cases of primarily
inoperable patients should diagnosis be established by biopsy
and neoadjuvant treatment initiated to attempt regression of the
tumor and enhance operability. In the absence of bilateral disease,
which is rare in adults, the primary surgery should include a
radical nephrectomy with lymph node sampling. Although
a complete resection of all viable tumor is desirable, surgical
effort that may endanger vital organs is not advisable, because
local control can be achieved by adjuvant treatment.
Because of the rarity of the disease, there are no established
treatment guidelines in adult WT. Treatment should preferably
be done in a tertiary center with experience in this disease.
Since pathological staging is similar to pediatric Wilms tumor,
we propose treating adult patients with similar therapeutic
protocols that have been investigated and verified in children.213 The most recent recommendations available in the literature were based on discussions held with representatives of
the renal tumor committees of the SIOP and COG and have
been updated with a review of more recently published institutional and trial experiences of adults treated on pediatric protocols as follows.214
17
• Radiation treatment should be given to all patients unless
they have a stage I nonanaplastic (favorable histology) WT,
when they are treated with a combination chemotherapy
regimen such as vincristine and actinomycin-D. Radiation
should be used in the adjuvant setting in stage III and IV postoperatively. Pulmonary irradiation is indicated when patients
present with lung metastases, regardless of whether complete
remission is achieved after chemotherapy or surgery.
Abdominal radiotherapy is advised when there is diffuse tumor
rupture either before or after surgery.
• Chemotherapy in WT as a general rule needs to be risk
adapted based on the histology and should be used in the
adjuvant setting in all stages in patients with adequate organ
function and performance status. In stage I, chemotherapy
based on histology (favorable histology) can be used with a 2–3
drug regimen for 22–25 weeks while unfavorable histology will
Adult WT
Metastalic disease/surgically ‘inoperable’ tumor
Immediate nephrectomy
UH
FH
Stage 1†
VP16/CARBO +
Stage 1‡/ stage II/
CYCLO/DOX¶ = ‘high risk’
stage III
+
ActD/VCR
ActD/VCR/DOX
RTs
FH
Act/VCR/DOX
UH
VP16/CARBO + CYCLO/DOX¶ = ‘high risk’
+
Response assessment#
+
Response assessment#
RT
Complete resolution
metastases
ActD/VCR/DOX
+
RT lungs + flank/abd
+
##
Complete resolution
Incomplete resolution
metastases
metastases
or
Surgically ‘inoperable’ tumor
‘High-risk’ schedule
+
RT lungs + flank abd
+
Consider surgical
resection lung metastases
+
##
Continue ‘high risk’
+
+
##
Incomplete resolution
metastases
or
Surgically ‘inoperable’ tumor
‘High-risk’ schedule
+
+
Consider surgical
resection lung metastases
+
##
Figure 1.6 Therapeutic guidelines for adult Wilms tumor patients.
†
Only stage I favorable histology if all four criteria are met, that is:
1. Stage and histology have been reviewed by a pediatric pathologist experienced in Wilms’ tumor;
2. Histological examination and review has included at least one lymph node;
3. CT scan of the chest has excluded the presence of lung metastases;
4. Chemotherapy can be started within 30 days if date of nephrectomy.
‡
All other stage I Wilms’ tumor cases.
¶
‘High risk’ chemotherapy schedule.
#
Response assessment of metastases and operability of the primary tumor after 6 weeks by abdominal/pulmonary CT scan.
##
Delayed nephrectomy should be considered after 6 weeks of preoperative chemotherapy if a nephrectomy has not been performed at initial diagnosis. If the
original diagnosis was made on biopsy only, then in the care of nonresponse or inadequate response to preoperative chemotherapy, the histological diagnosis
should be reviewed again and a further biopsy may be warranted if there is any uncertainty. Then in these cases where the Wilms’ tumor (histologically
confirmed again) remains surgically ‘inoperable’, we advise to consider changing to the ‘high-risk’ schedule or go on with this schedule and assess operability
again after two to three courses of chemotherapy.
abd, abdominal; ActD, actinomycin D; CARBO, carboplatin; CT, computed tomography; CYCLO, cyclofosfamide; DOX, doxorubicin; FH, favorable histology;
VCR, vincristine; VP16, etoposide; RT, radiotherapy; UH, unfavorable histology; WT, Wilms’ tumor.
18
need the four-drug regimen for 25–36 weeks. Chemotherapy
for stages II, III and IV (metastatic) is also based on histology
and can vary from three- to four-drug regimens for 25–36
weeks. The chemotherapy regimens utilized were based on the
existing pediatric experiences. The two-drug regimen was
vincristine and actinomycin-D for 22 weeks; the three-drug
regimen was vincristine, actinomycin-D, and doxorubicin for
25 weeks; and the four-drug regimen was etoposide, doxorubicin,
cyclophosphamide, and carboplatin for 36 weeks. Figure 1.6
describes how to proceed with management.
• Patients with bilateral tumors (stage V disease) should be
given primary chemotherapy for about 6–8 weeks followed by
nephron-sparing bilateral partial nephrectomy in an attempt to
preserve normal renal tissue. Additional chemotherapy and
radiation treatment may be needed after the surgery.215
Conclusion
Several different tumor types can affect the kidney, ranging
from very indolent tumors treated primarily with surgery to
more aggressive entities which require multimodal therapy.
Close consultation with an expert renal pathologist is critical
to ensure a proper diagnosis of these less common entities.
More common tumors such as AML and Wilms tumor have
established treatment guidelines which should be followed.
More rare entities will by definition have only case series and
case reports. Such data should be viewed cautiously as lowlevel evidence when assessing the risk:benefit ratio of a given
approach for an individual patient. Future directions include
more complete and specific molecular testing of these tumors
to identify specific alterations which can be therapeutically
targeted.
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