|Year : 2013 | Volume
| Issue : 3 | Page : 148-154
Histopathological spectrum of lesions in nephrectomy specimens: A five-year experience in a tertiary care hospital
Aiffa Aiman1, Kuldeep Singh1, Mir Yasir2
1 Department of Pathology, Government Medical College, Jammu, Jammu and Kashmir, India
2 Department of Surgery, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, India
|Date of Web Publication||19-Oct-2013|
H. NO. W-13, Shah Faisal Colony, Upper Soura, Srinagar, Kashmir - 1990020
Source of Support: None, Conflict of Interest: None
Context: Nephrectomy is a common procedure in surgical practice. It is indicated in patients presenting with a wide range of clinical conditions ranging from symptomatic chronic infections, obstruction, calculus disease, and severe traumatic injury to renal cell carcinomas. It is performed increasingly in the context of end-stage renal disease and to treat renovascular hypertension from non-correctable renal artery disease, or for severe unilateral parenchymal damage resulting from nephrosclerosis, pyelonephritis, vesicoureteric reflux, and congenital dysplasia. Objective: This study aimed to assess the patterns and morphology of lesions in nephrectomy specimens in a tertiary care hospital, observe variations if any from the conventional pattern, and clinico-morphological correlation for proper postoperative management. Materials and Methods: A hospital-based five-year study included all nephrectomy specimens received in the department over a period of five years (November 1, 2005 to October 31, 2010). Results: A total of 140 cases over a period of five years were studied. A wide range of lesions were found on histopathological examination. The histopathological analysis correlated well with the clinical diagnosis; however, few benign lesions like xanthogranulomatous pyelonephritis may be misdiagnosed clinically as malignant. Similarly, cases of cystic diseases of kidney, renal sarcomas, renal squamous cell carcinomas, and angiomyolipomas were confirmed on histopathological analysis only. Conclusions: The present study provides a fair insight into the histological patterns of lesions in nephrectomy specimens at our institution. In conclusion, a wide range of lesions are encountered on histopathology of nephrectomy specimens, many of which may be misdiagnosed clinically and radiologically; therefore, it is mandatory that every nephrectomy specimen be subjected to detailed histopathological examination for a clinico-morphological correlation to ensure proper management.
Keywords: Nephrectomy, renal cell carcinoma, renal tumors
|How to cite this article:|
Aiman A, Singh K, Yasir M. Histopathological spectrum of lesions in nephrectomy specimens: A five-year experience in a tertiary care hospital. J Sci Soc 2013;40:148-54
|How to cite this URL:|
Aiman A, Singh K, Yasir M. Histopathological spectrum of lesions in nephrectomy specimens: A five-year experience in a tertiary care hospital. J Sci Soc [serial online] 2013 [cited 2020 Apr 8];40:148-54. Available from: http://www.jscisociety.com/text.asp?2013/40/3/148/120058
| Introduction|| |
Kidney can be involved in various pathological processes, some of which may require its surgical removal. Nephrectomy is a common procedure in surgical practice. Simple nephrectomy is indicated in patients with irreversibly damaged kidney resulting from symptomatic chronic infections, obstruction, calculus disease, or severe traumatic injury.
Nephrectomy may also be indicated for the treatment of renovascular hypertension from non-correctable renal artery disease, or in severe unilateral parenchymal damage resulting from nephrosclerosis, pyelonephritis, vesicoureteric reflux, and congenital dysplasia. It is the treatment of choice in renal cell carcinomas. 
Both benign and malignant tumors occur in the kidney. The kidneys are affected by different malignant tumors: 99 percent of renal neoplasms are malignant, with renal cell carcinoma and Wilms' tumor being the most common.  Radical or partial nephrectomy is the treatment of choice for a great proportion of patients with renal tumors. 
Renal cell carcinoma accounts for approximately 2 percent of adult malignancies and 80-85 percent of malignant kidney tumors.  Renal cell carcinoma occurs twice as commonly in men than in women, it is primarily a disease of elderly patients, typically presenting in the fifth to seventh decades of life; however, it has been reported in much younger patients as well. 
Wilms' tumor, though ranked fifth in frequency among childhood solid tumors, is the most common childhood abdominal malignancy; however, less than 1 percent of Wilms' tumor occurs in adults.  Kidneys with end-stage renal disease can give rise to major complications such as massive bleeding for which nephrectomy may be indicated.  Other less frequent indications for nephrectomy intractable hypertension, pain, and repeated infections.
Kidney removed for one of the distinct but related conditions such as obstructive nephropathy, hydronephrosis, and chronic pyelonephritis is the most frequent type of nephrectomy specimen for non-neoplastic renal diseases in both adults and children. 
Xanthogranulomatous pyelonephritis is also an indication for nephrectomy. Grossly, mass occupying nature of this lesion often mimics renal cell carcinoma.  Nephrectomy is the treatment modality in cystic renal dysplasia.  Angiomyolipoma kidney demands nephrectomy.  Almost any non-neoplastic kidney disease can be present in tumor nephrectomy specimens by sheer chance, but diabetic nephropathy and arterionephrosclerosis comprise most of these renal lesions. Surgical pathologists should be aware of the importance of both - correctly classifying the underlying renal or urothelial neoplasm and the concomitant non-neoplastic kidney that is likely to be present in these specimens. 
The objective of this study was to assess the patterns and morphology of lesions in nephrectomy specimens in a tertiary care hospital, observe variations if any from the conventional pattern, and clinico-morphological correlation for appropriate postoperative management.
| Materials and Methods|| |
The present study was conducted in the Department of Pathology in collaboration with the Department of Surgery, Government Medical College, Jammu, and included all nephrectomy specimens received in the department over a period of five years (November 1, 2005 to October 31, 2010). The study included a retrospective four years and a prospective one year. A total of 140 cases of nephrectomy specimen were studied during this period. For the retrospective period (November 1, 2005 to October 31, 2009), all nephrectomy cases were taken out from the records of the department and slides were reviewed. In the prospective period (November 1, 2009 to October 30, 2010), all resected nephrectomy specimens received were followed up. Patient particulars were recorded in detail on proformas, which included age, sex, and clinical findings; investigations such as CT scan, USG, and other relevant investigations were also noted. Nephrectomy specimens were examined in detail grossly and a minimum of three sections were taken from the tumors. The tissue was processed as per standard procedure; 4- to 5-μm-thick sections were cut on a rotary microtome. Special stains and immunohistochemistry was also done where needed.
| Results|| |
In our study, males constituted 48.57 percent (68 cases) and females, 51.43 per cent (72 cases), of 140 patients who underwent nephrectomy; hence, the male to female ratio was 0.94:1 [Table 1]. The highest percentage of patients belonged to the age group of 21-30 years. The youngest patient was 10 months old and the oldest patient was 80 years old. A majority of cases of chronic pyelonephritis were seen in the age group of 21-40 years. Maximum number of renal cell carcinomas fell into the age group of 61-70 years [Table 2]. All cases of Wilms' tumor were in patients below the age of five years. Majority of the cases of xanthogranulomatous pyelonephritis belonged to the age group of 41-60 years [Table 3].
Maximum number of cases were of chronic pyelonephritis [Figure 1] (62.8%), followed by renal cell carcinoma [Figure 2], [Figure 3], [Figure 4] (22.8%). Majority of the cases (77.2%) were benign in nature. A greater percentage of benign lesions (87.5%) was observed in females, while a greater percentage of malignant lesions (33%) was observed in males [Table 4]. Other pathologies encountered were xanthogranulomatous pyelonephritis, pyonephrosis, Wilms' tumor, traumatic damage to the kidney, cystic dysplastic kidney, multicystic nephroma, squamous cell carcinoma, angiomyolipoma, and renal sarcoma [Table 5].
|Table 5: Distribution of nephrectomy specimens according to histopathological lesions|
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The most common clinical presentation of patients who underwent nephrectomy was flank pain seen in 92 patients. Least common clinical presentations were bone pain and epigastric pain [Table 6].
Renal cell carcinoma
A total of 25 cases of renal cell carcinoma were seen, of which 72% were male and 28% were female. The age of patients was in the range of 40-80 years, with a maximum incidence after 60 years of age. Grossly, growth in size was in the range of 4-12 cm. The growths were solid having variegated appearance with necrosis, hemorrhagic, and yellowish areas. In the maximum number of cases (52%), the upper pole of the kidney was involved grossly [Table 7]. Microscopically, majority of the cases (80%) were of clear cell type of renal cell carcinoma [Table 8]. Fuhrman nuclear grading revealed maximum number of renal cell carcinomas (52%) showing Grade 2 nuclear features, while 8% showed Grade 4 nuclear features [Table 9].
All five cases of Wilms' tumor were characterized by a grossly enlarged kidney with hemorrhagic and nodular appearance. Microscopically, two of the cases were of biphasic Wilms' tumor, two were of triphasic Wilms', while one was of rhabdoid differentiation [Figure 5] and [Figure 6].
| Discussion|| |
In the present study, out of the 140 Nephrectomy specimens studied, 77.2% had benign lesions and 22.8% had malignant lesions. Thus, benign lesions comprised the vast majority of the cases in our study. A similar predominance of benign lesions was observed in other studies [Table 10]. Among nephrectomy specimens, 51.4% were of females and 48.5% of males, with M:F = 1:1.05. This ratio is in concordance with the M:F ratio of 1:1.05 observed by Mohammad Rafique.  However, El Malik et al. reported 61% nephrectomy specimens in males and 39% in females with M:F = 1.9:1.
|Table 10: Various studies comparing incidence of benign and malignant lesions|
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In the present study, the most common clinical feature that the patients presented with was flank pain (92 patients). This was followed by hematuria (30 patients), fever (25 patients), and lump abdomen (22 patients). A majority of patients who presented with hematuria had malignant lesions. These observations were comparable to those in the study conducted by Popat et al. and El Malik et al. 
In the present study, the most common indication for nephrectomy was chronic pyelonephritis (62.8%), followed by renal cell carcinoma (17.8%). Chronic pyelonephritis has been reported as the most common clinical indication in the studies by Popal et al.,  Adamson et al.,  El Malik et al.,  and Ibrahim Ghalayeni.  Five cases of pyonephrosis were observed to comprise 3.5% of nephrectomy specimens. Three of these cases were in the age group of 21-40 years and two were seen in the age group of 41-60 years; thus, the age of patients was in the range of 21-60 years. This was comparable to the study conducted by Popat et al. 
In the present study, 8 (5.7%) cases of xanthogranulomatous pyelonephritis were seen. Popat et al. observed 2 cases (2.5%), El Malik et al.,  6 cases (1.1%), and D'Costa et al.  found 10% cases of xanthogranulomatous pyelonephritis in 188 nephrectomy specimens. Among the cases of xanthogranulomatous pyelonephritis in the present study, 3 (37.5%) were male and 5 (62.5%) female. Thus, a female predilection was noted. A similar female predilection was observed by Parsons et al. and KB Koh.  A majority of patients, i.e., 5 cases (62.5%), belonged to the age group of 41-60 years, followed by 2 cases (25%) in the age group of 21-40 years. In the study conducted by Popat et al., all cases were in the age group of 20-40 years. Ranadive et al.  reported the age of cases in the range of 20-60 years. In the current study, the majority of patients (75%) presented with flank pain, followed by burning micturition (50%), which is similar to the observations made by KB Koh  who reported 80% patients of xanthogranulomatous pyelonephritis presenting with flank pain and 50% of patients presenting with recurrent urinary tract infections.
In the present study, a total of 32 (22.8%) malignant lesions were observed; of these, a vast majority comprised renal cell carcinomas, i.e., 25 cases (53.1%). This was similar to the findings of Mohammad Rafique  who observed that the majority of malignant neoplasms (97%) of the kidney were renal cell carcinomas. Popat et al.,  in their study, found that 70% of malignant lesions were accounted for by renal cell carcinomas. Among renal cell carcinomas, a majority of cases (72%) were seen in males and 28% in females. Grossly, majority of tumors (52%) involved the upper pole, followed by 40% tumors that involved the whole of the kidney. This was similar to the results by Popat et al., who found majority of the tumors (57%) involving the upper pole of the kidney. In our study, microscopically, the clear cell type of renal cell carcinomas was the predominant type of tumor observed, involving 20 (80%) cases. This was followed by granular cell type in 3 (12%) cases and papillary type in 2 (80%) cases. Fuhrman nuclear grading revealed 13 (52%) cases showing Grade 2 nuclear features and 6 (24%) cases depicting Grade 3 nuclear features. Thus, majority of cases (76%) showed Grades 2 and 3 nuclear features. This is similar to the findings of Popat et al.,  who observed that all cases of conventional renal cell carcinomas showed Grades 2 and 3 nuclear features.
Primary squamous cell carcinoma of the kidney is a very rare entity. The incidence of renal squamous cell carcinomas among malignant renal tumors is in the range of 0.5-0.8%, as reported by Li et al.  and Blacher et al.  In the present study, one case of squamous cell carcinoma was seen in a 33-year-old man.
One case (0.07%) of angiomyolipoma was seen in our study. The patient was a 50-year-old woman presenting with pain and lump in the right lumbar region. No evidence of tuberous sclerosis was found in the patient. Popat et al.  reported two cases (2.5%) of angiomyolipoma falling in the age group of 40-60 years. None of the patients showed features of tuberous sclerosis. El Malik et al.  reported one case (1.1%) of angiomyolipoma in a female patient with tuberous sclerosis.
Primary sarcomas constitute only 1-2% of malignant renal tumors in adult hood and are usually found as incidental tumors.  In the current study, one case of renal sarcoma was observed in a 60-year-old man presenting with hydronephrosis.
A wide range of lesions is encountered when nephrectomy specimens are subjected to histopathological examination. The pre-operative diagnosis was confirmed histopathologically in 91.6% cases of chronic pyelonephritis, 78.1% cases of renal cell carcinoma, and 100% cases of Wilms' tumor, renal trauma, and angiomyolipoma kidney. Cystic renal dysplasia and multicystic nephroma were diagnosed histopathologically in the specimens sent as multicystic kidney disease. The histopathological diagnosis correlated well with the clinical diagnosis; however, few benign lesions like xanthogranulomatous pyelonephritis were misdiagnosed clinically as malignant. Similarly, cases of cystic renal dysplasia, multicystic nephroma, renal sarcoma, and renal squamous cell carcinomas were confirmed on histopathological analysis only [Table 11]. Thus, it is mandatory that every nephrectomy specimen be subjected to a detailed histopathological examination to ensure proper postoperative management.
|Table 11: Correlation of clinical diagnosis with histopathological diagnosis|
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The present study provides a fair insight into the histological patterns of lesions in nephrectomy specimens in our institution and its correlation with studies conducted across the world. A wide range of lesions are encountered on histopathology of nephrectomy specimens, many of which may be misdiagnosed clinically and radiologically; therefore, it is mandatory that every nephrectomy specimen be subjected to a detailed histopathological examination for a clinico-morphological correlation to ensure proper management. Since Government Medical College Jammu caters, in addition to Jammu province, to adjacent parts of Kashmir and Himachal Pradesh, the results can be safely considered as a reflection of the disease pattern in this region of the country.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]