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Table of Content-Volume 12 Issue 2 - November 2019


 

 

Histopathological analysis of nephrectomy specimens: A  year study in a tertiary care center in Telangana

 

Aruna Tekumalla1, Sreedhar Ragi2*, Ravinder Thota3, Sucharitha Kakuturu4

 

1Associate Professor, 3Professor, 4Post Graduate Student, Department of Pathology, Chalmeda Ananda Rao Institute of Medical Sciences, Karimnagar, Telangana, INDIA.

2Associate Professor, Department of Pharmacology, Surabhi Medical College, Siddipet, Telangana, INDIA.

Email: drsreedharkrnr@gmail.com

 

Abstract               Background: Nephrectomy is not an uncommon procedure in surgical practice. It is indicated in various non-neoplastic and neoplastic diseases of kidney. Aim and objectives: This study is undertaken to analyse all nephrectomy specimens and to see the histomorphological spectrum of all renal diseases. Materials and Methods: This is an observational retrospective study including all nephrectomy specimens which are received in the Dept. of Pathology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar. A total of 86 cases have been studied over a period of 4 and ½ years from Jan 2015 to June 2019.After collecting all relevant clinical data from requisition forms, specimens were examined grossly and microscopically after routine histopathological processing and staining. Clinicopathological correlation was done. Results: 70 cases were non-neoplastic and 16 were neoplastic.Chronic pyelonephritis is the most common lesion among non-neoplastic diseases followed by hydronephrosis. Xanthogranulomatous pyelonephritis is the third most common non-neoplastic disease and constitutes a significant proportion in this study. Renal cell carcinoma clear cell type is the most common malignancy followed by papillary renal cell carcinoma. Conclusion: This study provides far insight into histopathological spectrum of renal diseases that are indicated for nephrectomy in a rural tertiary health care centre in Telangana.

Key Words: Nephrectomy, chronic pyelonephritis, xanthogranulomatous pyelonephritis, renal cell carcinoma

 

 

INTRODUCTION

Kidney is an important vital organ which plays an important role in excretion of waste products in the body, water and electrolyte balance, acid base balance, regulation of blood pressure by secreting renin angiotensin and regulation of erythropoiesis by secreting erythropoietin1. Kidney is affected by various non neoplastic and neoplastic diseases. Indications for nephrectomy include malignant diseases of kidney, severe trauma to the kidney and benign diseases like symptomatic hydronephrosis, chronic infection, poly cystic kidney disease, small contracted kidney, hypertention or renal calculous. First successful nephrectomy was performed by Germon surgeon Gustav Simon on Aug 2, 1869 in Heidelberg.2 Post operative complications include infection, bleeding and post operative pneumonia, failure in remaining kidney. Radical nephrectomy is the treatment of choice in malignant kidney diseases like renal cell carcinoma in adults and Wilm’s tumor in children2,3. In last few decades there has been growing interest in nephron sparing surgery in selected cases of localised renal cell carcinoma by open or laparoscopic approach.4,5

 

AIM AND OBJECTIVES

  1. To analyse and to see the histopathological spectrum of all nephrectomy specimens.
  2. To see the incidence of renal malignancies in this region.
  3. To compare with previous studies.

 

MATERIALS AND METHODS

All nephrectomy specimens received in the Dept of Pathology, CAIMS, Karimnagar during the period of Jan 2015 to Jun 2019 were studied. Relevant clinical details regarding age, gender, presenting symptoms, laterality have been noted from the requisition forms. Specimens received in 10% neutral buffered Formalin. The gross features of the specimens such as size, external surface and cut surface, size of the tumor and other features were noted. Tissue bits were taken from appropriate sites and subjected for automated tissue processing and section cutting. 3-4 micron thick sections were taken and stained with routine HandE stains.

Inclusion and exclusion criteria

All nephrectomy specimens are included in the study and needle core biopsies were excluded from the study.


 

OBSERVATIONS / RESULTS

A total of 86 nephrectomy cases have been studied over a period of 4 and ½ years. 41 were males and 45were females with a male to female ratio1:1.09. 70 were non-neoplastic and 16 were malignant with 81.40% and 18.60% respectively.(Table:1)

Table 1: Non neoplastic and neoplastic kidney lesions with percentage

Lesion

Male

Female

Total

Percentage

Non-neoplastic

34

36

70

81.40

Neoplastic

7

9

16

18.60

Right sided involvement is more common than left sided involvement, 51 vs 35 with 59.30% and 40.70% respectively.(Table:2).

Table 2: Laterality of specimens

Laterality

Non-neoplastic

Neoplastic

percentage

right

43

8

59.30

left

27

8

40.70

Total

70

16

100

Age group ranging from 8 years to 85years with most common age group is between 31-70 years.(Table:3).

 

Table 3: Age range of non-neoplastic and neoplastic diseases

Age in years

Non-neoplastic

Neoplastic

0-10

0

1

11-20

5

0

21-30

4

0

31-40

11

0

41-50

15

5

51-60

20

4

61-70

10

4

71-80

4

2

81-90

1

0

Chronic pyelonephritis is relatively most common among non-neoplastic lesions 24 out of 70 cases with 34.28%.This is followed by hydronephrosis 20 out of 70 cases with28.57%.Xanthogranulomatous pyelonephritis constituted a significant proportion 13 out of 70 with 18.57% in this study. Calculous disease was found in 12 cases out of 70 with 17.14%. A single case of polycystic kidney disease PCKD) was also encountered in the present study. (Table:4)

Table 4: Spectrum of non-neoplastic lesions

Histological type

Number

Male

Female

Percentage

Chronic Pyelonephritis

24

14

10

34.38

Hydronephrosis

20

12

8

28.57

Xanthogranulolmatous Pyelonephritis

13

3

10

18.57

Calculous Disease

12

5

7

17.14

PCKD

1

-

1

1.42

Malignant diseases of kidney in this study constituted 18.60%(n=16). Renal cell carcinoma is most frequent tumor accounting for 13 cases with 81.25%, others being 1 case of papillary urothelial carcinoma with 6.25%, 1 case of Wilm’s tumor with 6.25% and 1 case of squamous cell carcinoma of renal pelvis with 6.25%. (Table:5)

Table 5: Spectrum of neoplastic diseases

Histological type

Number

Male

Female

Percentage

Wilm’s tumor

1

--

1

6.25

RCC Clear cell

7

3

4

43.75

RCC papillary

5

2

3

31.25

RCC chromophobe

1

1

-

6.25

Papillary urothelial carcinoma

1

-

1

6.25

Squamous cell carcinoma of renal pelvis.

1

1

-

6.25


DISCUSSION

Kidney is affected by various pathological conditions. Simple nephrectomy is indicated in end stage renal disease of various causes and radical nephrectomy is the treatment of choice for malignant diseases of kidney. In the present study a total of 86 nephrectomy specimens have been included which were received over a period of 4 and ½ years, that is from Jan2015 to June 2019.Out of these 70 were non-neoplastic and 16 were neoplastic lesions constituting 81.40% and 18.60%. Similar results were found in Ghalayini et al6, Rafique et al7 and Aiman et al8 whereas a reverse ratio was found in Suma M T et al2with 61% neoplastic and 39% non-neoplastic lesions. (Table:6)

 

Table 6: Comparison of Non-neoplastic and Neoplastic lesions among other studies

Study

Non-Neoplastic( %)

Neoplastic (%)

Ghalayini et al6[2002]

70.44

29.66

Rafique et al7[2007]

76.6

23.4

Aiman et al8[2013]

77.2

22.8

Suma MT et al2[2017]

39

61

Present study

81.40

18.60

 

Table 7: M:F ratio in various studies

Study

M:F Ratio

Ghalayini et al6(2002)

1.29:1

Rafique et al7(2007)

1:1.05

Aiman et al8(2013)

1:1.05

E I Malik et al9(1997)

1.9:1

Present study

1:1.09


In the present study males were 41 and females were 45 with M:F ratio 1:1.09 .This is similar to Rafique et al7 with 1:1.05 and Aiman et al8 with1:1.05 but in contrast to EI Malik et al9 and Ghalayini et al6in which reverse ratio was seen with M:F 1.9 :1 and 1.29:1 respectively (Table:7). In this study we found right sided involvement is more common than left sided involvement 51 and 35 with 59.30% and 40.70%respectively. Chronic pyelonephritis is the most common among non neoplastic lesions which is similar to Aiman et al8. Popat et al10,EI Malik et al9 and Ghalayini et al6. Second most common non neoplastic disease is hydronephrosis. In contrast Biswajit Dutta et al4 found that neglected pelviureteric junction obstruction was the most common disease. Age range of chronic pyelonephritis is between11years and 85 years, maximum number of patients are between 41-60 years with mean age is50.8 years. Xanthogranulomatous pyelonephritis constituted a significant proportion in the present study with 18.57%.which is much higher than the previous studies, D’Costa et al 11with 10% and Ghalayini et al6 with 8.1% and Vinay KS et al12 with 14.08%.(Table:8)shows comparative incidence of xanthogranulomatous pyelonepritis.

 

Table 8: Xanthogranulomatous Pyelonephritis, comparison with other studies

Study

Percentage

Ghalayini et al6

8

De Costa et al11

10

Vinay K S et al12

14.08

Present study

18.57

1

            Figure 1                     Figure 2

Figure 1: Gross appearance of Xanthogranulomatous Pyelonephritis; Figure 2: Microscopy of Xanthogranulomatous Pyelonephritis (H and E 400X)


Age range is between 15 and 60 years with majority in 31- 40 years followed by 41-50years. Mean age is 39.8 years. Similar observation was seen in Aiman et al8 with majority found in 41-60 years. In Popat et al10 all cases found in 20-40 years range and in Ranadive et al13 between 20-60 years. In present study female predeliction was noted with 10 cases in females and 3 cases in males. Similar observation was noted in Aiman et al8 , Parsons et al14 and KB Koh et al15. Xanthogranulomatous pyelonephrits is an uncommon inflammatory condition which can be mistaken grossly and microscopically with renal cell carcinoma.Grossly it presents with irregular yellow masses around the renal calyses(Fig.1). Microscopy shows replacement of renal parenchyma with sheets of foamy histiocytes, occational multinucleated giant cells and chronic inflammatory cells(Fig.2). Hydronephrosis may be due to obstructed pelvi ureteric junction due congenital valves or due to calculi. Age range of hydronephrosis in this study is between 14 and 70 years with peak incidence in 61 -70 years followed by 41-50 years. Mean age is 48.7 years. Neglected PUJ obstruction was the predominant non neoplastic lesion found in Biswajit Dutta et al4.Renal calculous disease accounted for 12 cases with 17.14%.Age range is from 26 to 70 years with maximum number of cases are in between 31 to 50 years. Mean age is 49.2 years.Neglected PUJ obstruction with extensive stone disease causing loss of renal function was very common in a study conducted by Biswajit Dutta et al4. In this study we have also come across one case of polycystic kidney disease presented in 33 year old female patient with right sided involvement. Grossly kidney was measuring 8.5x5x2.8 cms with 150 grams weight. Cut section showed solid and cystic areas, largest cyst measuring 2.8x2.5cms. Microscopy showed cystic lesions lined by cuboidal to flattened epithelium. Intervening tissue showed fibrosis and associated pyelonephritis. Malignant diseases of kidney in this study constituted 18.60%. Renal cell carcinoma(RCC) is most frequent tumor accounting for 13 cases with 81.25%, others being 1 case of papillary urothelial carcinoma 6.25% , 1 case of Wilm’s tumor 6.25% and 1 case of squamous cell carcinoma of renal pelvis 6.25%. This is in concordance with all of the previous studies. Anitha Padmanabhan et al16 in their study found similar results with 78.33% of renal cell carcinoma. Among histologic types clear cell RCC is most common constituting 7 cases with 53.8% followed by papillary RCC, 5 cases with 38.46% and 1 case of chromophrobe RCC with 7.69%. Similar results were found in Anitha Padmanabhan et al16. In the present study papillary RCC constituted a significant percentage of renal cell carcinoma which is much higher than in previous studies. (Table: 9) shows the relative percentage of papillary RCC in other studies.

Table 9: Papillary RCC among other studies

Study

Number

%

Aiman et al8[2013]

2

8

Anitha Padmanbhan et al16[2016]

8

13.33

Sheikh Bilal172017]

3

6.66

Suma M T et al2[2017]

3

10

Present study

5

38.46

Age range of neoplastic lesions is ranging from 8 years to75 years with peak incidence in between 41-50 years with mean age of 53.35 years. This is in concordance with Anitha Padmanabhan et al16 in which mean age was 46.2 years. Latif et al18and Hashmi et al19 also got the similar results. In our study among neoplastic lesions 9 cases were females and 7 were males with M:F ratio being 1:1.28. In contrast male preponderance was noted in other studies like Anitha Padmanabhan et al16 Latif et al18 and Hashmi et al19. Right and left sided involvement were equal in our study, 8 cases with 50% each. Similar results were found in Anitha Padmanabhan et al16 53.1%, Siddharth et al2052% and FreitasAMS et al2151% with slight right sided preponderance. Clear cell RCC and papillary RCC also showed slight female preponderance in our study in contrast to other studies. Clear cell RCC presented in the age range of 41 -75 years with mean age of 47.5 years. This is coinciding with many other studies. Right side involvement is more common with clear cell RCC, and slight left preponderance is seen in papillary RCC. Chromophobe RCC presented in a 73 year old male patient with right sided involvement. Papillary urothelial carcinoma presented in a 69year old female patient with right sided involvement. Wilm’s tumour presented in an eight year old female child with left sided involvement. Squamous cell carcinoma of renal pelvis presented in a 62 year old male patient with left sided involvement. There was associated long standing renal stone disease and hydronephrosis in our case. Size of the tumour in RCC ranged from 3.5 -12 centimeters with mean of 6.55 cms. Similar observation was found in Anitha Padmanabhan et al16 (6.56cms),Latif et al18 and Sidharth et al20. Upper pole is involved in majority of cases. All tumors showed a well circumscribed lesion with variegated appearance on cut section showing gray white to dark brown friable areas and cystic areas(Fig.3).Microscopy showed sheets of clear cells with intervening network of small blood vessels(Fig.4). One of the cases showed extension into renal vein, renal pelvis and ureter. Two of them showed extension into capsule and perinephric fat. According to Fuhrman nuclear grading majority were falling into grade 3in our study 5 out of 7 cases,1 in grade 1 and 1 in grade 2. No case was showing grade 4 nuclear features in our study. Nuclear grading is one of the prognostic indicators for renal cell carcinoma along with histological differentiation (presence of rhabdoid or sarcomatoid differentiation) and presence of coagulative necrosis.

2

               Figure 3                                                  Figure 4                                                        Figure 5                           

3

Figure 6

                  Figure 7                                              Figure 8                                                    Figure 9                                  

 

 

  Figure 10

4

         Figure 11                                  Figure 12                                               Figure 13

Figure 3: Gross appearance of Clear cell RCC; Figure 4: Microscopy of Clear cell RCC. ( H and E 400X ); Figure 5: Gross of Papillary RCC; Figure 6: Microscopy of Papillary RCC. (H and E 400X); Figure 7: Gross of Chromophobe RCC; Figure 8: Microscopy of Chromophobe RCC ( H and E 400X ); Figure 9: Microscopy of Papillary helial Carcinoma. (H and E 100X); Figure 10: Gross of Wilm’s tumour; Figure 11: Microscopy of Wilm’s tumour (H and E 400X); Figure 12: Gross appearance of Squamous cell carcinoma of Renal Pelvis; Figure 13: Microscopic appearance of Squamous cell carcinoma of Renal Pelvis ( H and E 400X )

 

 

Papillary RCC grossly presented with gray white to gray brown lesion, irregular cut surface with friable necrotic and haemorrhagic areas(Fig 5). Microscopy showed papillary architecture with fibrovascular cores and lined by pleomorphic epithelial cells with areas of coagulative necrosis and cystic change(Fig 6).

Papillary urothelial carcinoma presented grossly with papillary growth seen in renal pelvis measuring 7x5x5 cms. Microscopy showed papillary fronds with central fibrovascular cores and lined by atypical urothelium(Fig 9).

Wilms tumour presented with a well circumscribed lesion measuring 7x6 cms with grey white to gray brown and yellowish areas(Fig 10). Microscopy showed triphasic pattern with blastemal, mesenchymal and epithelial components(Fig 11).

Squamous cell carcinoma of renal pelvis is a rare tumour which was encountered in our present study, grossly presenting with gray white irregular lesion at the pevic region and extending towards cortex. There were associated renal calculi and hydronephrosis.(Fig 12). Microscopically the tumour was showing inltrating sheets of atypical squamous cells with intercellular bridges, keratin pearls and keratinous cellular debris(Fig 13).Primary renal squamous cell carcinoma is one of the rarest neoplasms constituting less than 1% of all urinary tract neoplasms. Clinically this tumour shows aggressive behavior and very poor prognosis22.

 

CONCLUSION

The present study enables us to know the histopathological spectrum of various non neoplastic and neoplastic diseases of kidney which are indicated for nephrectomy in our institution. The clinicopathological correlation in this study is comparable with all other studies world wide. Xanthogranulomatous pyelonephritis and Papillary RCC are significantly higher in proportion than in other studies. Squamous cell carcinoma of renal pelvis one of the rarest malignancies which was encountered in present study. Thus histopathological examination is essential for every nephrectomy specimen for correct diagnosis and accurate management of the patient.

 

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