renal anatomy & renal cell cancers
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KIDNEY & RENAL PELVIS
Presented by: Dr. Isha Jaiswal
Moderator: Dr. Madhup Rastogi
Date:20th august 2014
KIDNEY : location
• pair of organs located in the abdominal cavity on either side of the spine in a retroperitoneal position.
• Approx. at vertebral level T12 to L3,• right kidney being slightly lower than the left.• Left kidney is little nearer to median plane
than right
• Long axis of kidney is directed downward and laterally &runs parallel to the lateral margin of the psoas muscle
• The kidneys are mobile organs that move vertically within the retroperitoneum on average 0.9 cm to 1.3 cm and as much as 4 cm during normal respiration
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KIDNEYS :external features
• Shape :Bean shaped
• poles: upper & lower• Border: medial & lateral• Surface: anterior & posterior
• Size: approx. 11–14 cm in length, 6 cm wide and 3cm thick
• Weight: around 150 gm. in males & 135 gm. in females
External Features
• Hilum of the kidney,• Concave medial border of
the kidney• Structures enter / leave
through the hilum (from anterior to posterior),
» Renal vein» Renal artery» Pelvis» Ureter» Renal nerves» Lymphatics.
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Relations of kidney Upper pole: adrenal gland
Lower pole: about 2.5 cm above iliac creast
Posterior relations: Diaphragm Muscles: psoas major,
quadratus lumborum,
transv.abdominis Ribs: 11th &12th ribs on left ,
only 12th on right side
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Anterior relationsRight kidney: Rt. adrenal gland
Liver 2nd part duodenum Hepatic flexure colon jejunum
Left kidney Lt. adrenal gland Spleen Stomach Pancreas splenic flexure colon jejunum
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Coverings of kidney
fibrous tissue, the renal capsule,
perinephric fat, renal fascia (of Gerota
) paranephric fat.
Internal features
parenchyma, of the kidney is divided into two major structures: Renal cortex: lobules & column
medulla: pyramid,papilla,calyx
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Functional unit of kidney: nephron
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URINARY DRAINAGE
Pyramids
Papillae
Renal pelvis
Major calyces
Minor calyces
Blood supply of kidney
Arterial supply: renal artery Venous drainage: renal vein
• Lymph Drainage :
• Nerve Supply: • Through sympathetic plexus (T10 – L1) fibres• Afferent nerves T10 to T12 thoracic nerves.
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The right kidney drains predominantly into the paracaval and interaortocaval lymph nodes
left kidney drains exclusively to the para-aortic lymph nodes
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CANCERS OF KIDNEY
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Renal Tumors: incidenceIn U.S in 2011 (ref:parez)
• 60,920 cases diagnosed(4 % of all new cancers)
• 13,120 deaths (2% of cancer related death)
• Approx 88% of solid renal masses are malignant• RCC comprise 80-85%of primary kidney tumors• Transitional cell carcinoma acoount for 7 % of kidney tumors• Rest are lymphoma, sarcomas, oncocytoma
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Renal Cell Carcinoma• First described by Konig in 1826.
• In 1883 Grawitz, noted the fatty content of cancer cells similar to that of adrenal cells. (Also called as Grawitz’s tumor)
• All these tumors arise from Renal proximal tubular epithelium
• The incidence of RCC is increasing & the size decreasing because of increased use of abdominal CT scans
• Male predominance (1.6:1.0 M:F)
• Highest incidence between age 50-70-Median age of diagnosis is 66 years
-Median age of death 70 years
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Risk Factors • Tobacco smoking contributes to 24-30% of RCC cases
Tobacco results in a 2-fold increased risk
• Environmental:Cadmium, thorium-di-oxide,
petroleum
aresenic
phenacetin analgesics.
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• Occupational:
leather tanners, shoe workers, asbestos workers, petroleum,
blast furnace, iron & steel industry
• Hormonal: diethylistillbestrol,
• Dietary: fried meats,(vegetables, fruits & alcohol are protective)
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• Obesity,
• HTN,
• DM
• ACKD:• 50% Pt. on long term dialysis(>3 yrs)
develop Acquired polycystic kidney disease, out of which 5.8% develops RCC
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A sarcomatoid variant represents1% to 6% of renal cell carcinoma and these tumors are associated with a significantly poorer prognosis. BHD=Birt-Hogg-Dubé; FH=fumarate hydratase; VHL=von Hippel-Lindau.
RCC variant
Clear cell
75%
Type
Incidence (%)
Associated mutations
VHL
Papillary type 1
5%
c-Met
Papillary type 2
10%
FH
Chromophobe
5%
BHD
Oncocytoma
5%
BHD
It is made up of no. of different types of cancers with different histology, different clinical courses and caused by different gene.
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Hereditary Renal Cancer SyndromesSyndrome Chromosome
Location (Gene)Renal
ManifestationsOther Manifestations
Von Hippel-Lindau (VHL)
3p25 VHL
Clear cell renal carcinoma: solid and/or cystic, multiple and bilateral28%-45%
Retinal and central nervous system hemangioblastomas; pheochromocytomas; pancreatic cysts and neuroendocrine tumors; endolymphatic sac tumors; epididymal and broad ligament cystadenomas
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Syndrome ChromosomeLocation (Gene)
Renal Manifestations Other Manifestations
Hereditary papillary renal carcinoma type1(HPRC)
7q31 MET
Papillary renal carcinoma type 1: solid, multiple and bilateral
None
Hereditary leiomyomatosis and renal cell carcinoma (HLRCC)
1q42-43 FH
Papillary renal carcinoma type 2, collecting duct carcinoma: solitary, aggressive
Uterine leiomyomas and leiomyosarcomas; cutaneous leiomyomas
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Syndrome ChromosomeLocation (Gene)
Renal Manifestations Other Manifestations
Birt-Hogg-Dubé syndrome (BHD)
17p11.2BHD
Hybrid oncocytic renal tumors, chromophobe and clear cell renal carcinomas, oncocytomas: multiple, bilateral
Benign tumors of hair follicle (fibrofolliculomas); lung cysts, spontaneous pneumothoraces
Constitutional chromosome 3 translocation
3p; Not known; VHL somatic mutations 84% - 98%
Clear cell renal carcinoma: multiple, bilateral
None
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Spread of renal cancer
Local Infiltration :through the renal capsule to involve the
perinephric fat and Gerota's fascia.
Venous: The tumor may grow directly along the venous channels to
the renal vein or vena cava.
Lymph node metastases :involve the renal hilar, para-aortic, and paracaval lymph nodes
Distant metastasis: lung, bone, bone, liver ,adrenal
Natural History7% diagnosed incidentally45% present with localized disease at time of diagnosis 25% with locally advanced disease at diagnosis30% with metastatic disease at diagnosisLymph node metastases- 9% to 27% (renal hilar, para-
aortic and paracaval)Renal vein – 21% & IVC 4%Distant metastases- lung (75%), soft tissue (36%), bone
(20%), liver (18%), skin (8%) and CNS (8%)
Ref: DeVita
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• CLINICAL FEATURES
50 % of RCC are now detected incidentally: Radiologist's tumor’
Triad of presentation: seen in only 10% pt., poor prognosis Pain (80%),
Hematuria (45%)
palpable mass (15%)
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Other signs and symptoms
Weight loss (33%)
Fever (20%) Hypertension (20%) Hypercalcemia (5%) Night sweats Malaise Varicocele usually left sided, due to obstruction of the testicular
vein (2% of males)
Stauffer’s syndrome: Non metastatic hepatic dysfunction reported in 3-20% of cases Hepatic function normalizes in 60 to 70% of cases after nephrectomy.
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Paraneoplastic syndromes are found in 20% of patients with RCC
Elevated E.S.R.HypertensionAnemiaCachexiaPyrexiaAbnormal liver functionHyper calcemiaPolycythemiaNeuromyopathy
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Clinical presentation• History taking:
• age, Sex,Occupation
• Chief coimplains:
Pain :onset, duration, progress, nature, radiation, relation with micturition
Renal pain: painless or dull ache, at renal angle radiating along subcoastal area towards umbilicus along with fever loss of weight malaise
Ureteric pain: colic, start at renal angle radiate downward along course of ureter,referred to groin inner part of thigh, penis etc
Bladder pain is midline suprapubic dull,
Urethral pain: during or at end of micturition
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Haemeturia:
• Amount,• Relation to micturition
• Association with pain
Beginning: urethralToward end: vesicalThroughout: prerenal,renal,vesical
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Renal lump
• History:site onset duration progression• Examination• Inspection,• Palpation• Percussion• auscultation
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Inspection
in recumbent position fulleness in lumbar regionmoves slightly with respiration
palpation
murphy’s punch testpatient sits up press over the renal angle to see for tenderness
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Palpation of kidney: bimanual method
• Features of a renal lump• Lies in loin• Can be moved in loin• Reniform shape• Ballotable• slightly move with respiration • fingers can be insinuated between coastal margin and swelling
• To palpate the left kidney,• reach across the client • place your left hand under the client’s left flank with your palm upward.• Elevate the left flank with your fingers, displacing the kidney upward.• Ask the client to take a deep breath • use the palmer surface of your right hand to palpate the kidney • Repeat the technique for the right kidney
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Percussion
features of a renal lump
resonant anteriorly due to bowel loopsdull posteriorly: enlarged kidney displaces colon
Auscultation: bruit may be heard
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Diagnostic Work-Up • Laboratory studies
– CBC, LFT's, alkaline phosphatase, BUN, creatinine, urinalysis
• Radiographic studies- Increased use of imaging has increased the detection of renal lesions most of which are simple cysts.– X-Ray KUB region– Ultrasonography- Excellent in distinguishing cystic from solid masses– Intravenous Urography - Starting point for hematuria evaluations and
function of contralateral kidney– Computed tomography- Provides an excellent assessment of the parenchyma
and nodal status.– Magnetic Resonance Imaging - excellent demonstration of solid renal masses
and is image test of choice to demonstrate extent of vena caval involvement with tumor. Useful in patients with renal insufficiency
– MRI has no advantage compared with contrast enhanced CT for the diagnosis of RCC but it is better for staging of locally advanced cases
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Metastatic Work-Up
• Chest X-ray or Chest CT • CT/MRI scan of abdomen or pelvis • Bone scan with plan films (for elevated alkaline
phosphatase or bone pain).
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Radiological anatomy
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Figure : Computed tomography demonstrates a right renal carcinoma (m) with a large contralateral adrenal metastasis (a).
Figure: CT scan shows large left renal mass with calcification (m) invading the left renal vein (arrow).
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Figure: T1-weighted magnetic resonance image demonstrates tumor (m) and vascular invasion (arrow). Flowing blood (v) in the left renal vein is black on this scan.
Figure A: Axial T1-weighted image demonstrates a large left renal carcinoma with extension into the left renal vein (m) with protrusion into the IVC (v). B: Sagittal T1-weighted image shows the relation of the tumor thrombus (m) to the IVC (v) in the lateral projection.
Renal Cell Carcinoma• 3D CT scan showing a left lower pole RCC extending into the
renal hilum
Renal Cell Carcinoma• Multifocal renal cell carcinoma in a patient with Von Hippel Lindau disease.
Patient had already undergone a right nephrectomy. Contrast-enhanced CT
scan
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Renal cell carcinoma of left kidney involving renal vein & inferior vena cava
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Thank you !
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