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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 3  |  Page : 586-590
The pathological evaluation of nonneoplastic kidney disorder in tumor nephrectomy specimens


1 Department of Pathology, Urmia University of Medical Sciences, Urmia, Iran
2 Department of Nephrology, Urmia University of Medical Sciences, Urmia, Iran
3 Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran
4 Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran

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Date of Submission25-Apr-2017
Date of Decision18-Jun-2017
Date of Acceptance24-Jun-2017
Date of Web Publication28-Jun-2018
 

   Abstract 

Renal cell carcinoma (RCC) comprises 2%-3% of all visceral and 80%-85% of all adult kidney malignancies. Nephrectomy is the treatment of choice for renal tumors. The accurate pathological evaluation of nonneoplastic renal parenchyma in nephrectomy specimens is important for subsequent management. Eighty-two patients with RCC who underwent surgery at Imam Khomeini Hospital, Urmia, Iran, from April 2006 to February 2015 were studied. Paraffin blocks of the hospital archives were stained by hematoxylin and eosin (H and E) and periodic acid-Schiff staining. Microscopic examination was performed on nontumoral portions that were in the farthest possible distance from the tumor. Out of total 82 cases, 24 (29.3%) had normal renal parenchyma and 58 (70.7%) had pathological changes in renal parenchyma. The most frequent pathological findings were vascular sclerosis with parenchymal scarring and pyelonephritis. Other findings include focal and diffuse mesangial hypercellularity, eight; focal segmental glome-rulonephritis, five; membranoproliferative glomerulonephritis, three; and membranous glome-rulonephritis, two. Parenchymal scarring and vascular change included 36% of clear cell type, 41% of papillary type, and 53.8% of chromophobe type. Although there is not any statistical relation between the gender of patients and pathological findings, there was an obvious correlation between age and pathological findings. Before the age of 55 years, vascular sclerosis with parenchymal scarring and glomerular diseases and then chronic pyelonephritis are more prevalent.Evaluation of pathological changes in nonneo-plastic renal parenchyma is an essential step in recognizing patients at risk of accelerated functional failure of the single remaining kidney, particularly in patients with a background of chronic vascular injury associated with diabetes or hypertension.

How to cite this article:
Noroozinia F, Makhdoomi K, Behnamfard H, Mohammadi S, Dindarian S, Bagheri M, Mohammadi H. The pathological evaluation of nonneoplastic kidney disorder in tumor nephrectomy specimens. Saudi J Kidney Dis Transpl 2018;29:586-90

How to cite this URL:
Noroozinia F, Makhdoomi K, Behnamfard H, Mohammadi S, Dindarian S, Bagheri M, Mohammadi H. The pathological evaluation of nonneoplastic kidney disorder in tumor nephrectomy specimens. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Dec 6];29:586-90. Available from: http://www.sjkdt.org/text.asp?2018/29/3/586/235170

   Introduction Top


Kidney cancer accounts for 2%–3% of all human cancers[1] and renal cell carcinoma (RCC) is the most common type of renal tumor which is responsible for 80%–85% of all primary renal neoplasms.[2] Incidence rate of RCC is different in various parts of the world. In the United States, almost 63,000 new cases and approximately 14,000 deaths are reported per year.[3] African and Southeast Asian countries have a lower incidence rate of cancer in comparison with Europe, Australia, and North America. In the European Union, 84,000 RCC cases and 35,000 deaths occurred in 2012. The RCC occurs mainly in older individuals, especially at the age of sixty and above.[4] Among 6944 patients with RCC reported between 2003 and 2009, there is a 2:1 male preponderance in Iran.[5] A slow increasing trend of incidence rate was observed. There were 595 patients in 2003, while the number of patients increased to 1387 in 2009.[5] The treatment of choice for patients with RCC is partial or total nephrectomy. The long-term complications of this procedure include elevation in glomerular filtration rate, hypertension (HTN), and pro-teinuria that are associated with developing chronic kidney disease in adults.[3],[6],[7],[8] The pathological changes in renal parenchyma of patients with kidney cancer who had undergone total or partial nephrectomy can accelerate single remaining kidney function failure. The purpose of this study is: (1) to perform a diagnostic examination that includes periodic acid-Schiff (PAS) and hematoxylin and eosin (H and E) staining and microscopic examination on nonneoplastic area in tumor nephrectomy specimens to describe the incidence of pathological changes in neoplastic renal parenchyma and (2) to assess the correlation between nonneoplastic pathological findings in renal parenchyma and age and sex of the patients.


   Subjects and Methods Top


Patient data collection

We looked for the patients with RCC admitted from April 2006 to February 2015 in the files of the Department of Pathology, Imam Khomeini Hospital, Urmia, Iran and identified 82 adult patients with total nephrectomy specimens. The computerized patients' records of the cases were searched for relevant information including age, sex, and histologic type of the tumors (clear cell, papillary, chromophobe, and sarcomatoid).

Histopathological analysis

We cut 4 μm sections from the original paraffin blocks and sampled nonneoplastic tissue sections from the nontumoral portions that were in farthest possible distance from the tumor. Then, H and E staining was performed and all samples were reviewed by light microscopy. The specifically evaluated histopathological features were mesangial sclerosis (nodular and/or diffuse), focal glomerular basement membrane (GBM) thickening, and mesangial hypercellularity (defined as more than four mesangial cells in any mesangial area of a glomerulus).[9]

We further assessed these sections by PAS stains. The evaluation of tubulointerstitial changes such as tubular fibrosis, tubular necrosis, tubular casts, and renal inflammation was performed on all of the sections. Vascular sclerosis was classified as mild, moderate, and severe. The study was approved by Ethics Committee, Urmia University of Medical Sciences, Urmia, Iran.


   Results Top


From April 2006 to February 2015, 82 patients with RCC who had undergone renal nephrectomy were enrolled. The patients' age ranged from 25 to 86 and the mean age of the patients was 56.62 ± 14.64. Among 82 patients, 45 patients (54.9%) were male and 37 patients (45.1%) were female. Among all cases, 50 patients (61.0%) had clear cell RCC with mean age of 59.90 ± 13.79 and male-to-female ratio of 1.86. Papillary RCC accounts for 17 patients (20.7%) with a mean age of 54.00 ± 13.75 and male-to-female ratio of 0.89. Chromophobe RCC also includes 13 patients (15.9%) with a mean age of 46.00 ± 14.99 and male-to-female ratio of 0.86. Finally, two patients (2.4%) had sarcomatoid RCC with mean age of 66.00 ± 5.66 and both of the patients with sarcomatoid RCC were male. These findings are summarized in [Table 1]. In 24 cases (29.3%), normal renal parenchyma was observed and the mean age of this group was 52.92 ± 14.95. We also detected varying degrees of pathological changes in renal parenchyma of 58 cases (70.7%). Among 24 patients with normal parenchyma, 11 cases (13.4%) had mild vascular sclerosis and three cases (3.7%) had moderate-to-severe vascular sclerosis. The remaining 10 cases (12.2%) had unremarkable parenchyma. Of 58 cases with pathological parenchymal changes, vascular sclerosis was the most common finding which was found in 26 patients (31.7%). Patients in this group had also parenchymal scarring to some degrees. Chronic pyelonephritis was the second most common pathological finding that was detected in 14 cases (17.1%). Other pathological findings include diffuse and/or focal mesangial hypercellularity in eight cases (9.8%) cases, focal segmental glomerulonephritis (FSGN) in five cases (6.1%) cases, membranoproliferative glomerulonephritis (MPGN) in three cases (3.7%) cases, and membranous glomerulonephritis (MGN) in 2 (2.4%) cases. Pathological findings are detailed in [Table 2]. The most common pathologic finding in clear cell RCC and papillary RCC was vascular sclerosis. While, in chromophobe RCC, mesangial hypercellularity and in sarcomatoid RCC, chronic pyelonephritis were the most common findings. Clear cell RCC has the most and papillary RCC has the least number of normal parenchymas [Table 3].
Table 1: Frequency of renal cell carcinomas according to gender.

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Table 2: Frequency of nonneoplastic renal diseases and the mean age of the patients,

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Table 3: Comparison of histopathological findings in peritumor parenchyma of various types of renal cell carcinoma.

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We did not observe any correlation between pathological findings and sex of the patients (P = 0.820). There was also no statistically considerable correlation between pathological findings and age of the patients (P = 0.919) but chronic pyelonephritis, FSGN, and MPGN occur at older ages in comparison with vascular sclerosis, mesangial hypercellularity, and MGN which are mostly seen at younger ages.


   Discussion Top


Several studies report the presence of non-neoplastic renal diseases in renal parenchyma in renal biopsies of tumor nephrectomy. In our study, we reviewed 82 tumor nephrectomy specimens and we detected vascular sclerosis with parenchymal scar, chronic pyelonephritis, mesangial hypercellularity, FSGN, MPGN, and MGN as nonneoplastic pathological findings in patients with RCC. Vascular sclerosis and chronic pyelonephritis were the most common findings but MGN and MPGN were noted. Henriksen et al[3] also carried out a study to check nonneoplastic renal parenchyma in 246 adults' tumor nephrectomy specimens. The specimens were prepared using H and E staining. According to results of their study, diffuse and/or nodular mesangial sclerosis, mesangial hypercellularity, or GBM thickening were the most remarkable morphologic abnormalities in 41 (16.7%) cases. In our study, mesangial hypercellularity was the third most common finding accounting for 9.8% of the patients.

In the current study, normal parenchyma was detected in about 29.3% of the cases. Among these cases, 12.2% had unremarkable renal parenchyma without vascular sclerosis, but the remaining 17.1% had some degrees of vascular sclerosis. Furthermore, 70.7% of our cases had varying degrees of pathological changes in renal parenchyma. The study of Bijol et al[6] on tumor nephrectomy specimens of nonneoplastic renal parenchyma showed that six months later than nephrectomy, patients with severe histologic status had a remarkable increase of serum creatinine in comparison with patients with insignificant renal parenchyma. More than 60% of 110 cases checked in their study showed pathological abnormalities such as remarkable vascular alterations, parenchymal scaring, and alterations similar to diabetes mellitus. Furthermore, 10% of the cases had Unremarkable renal parenchyma and vasculature and 28% of them had normal parenchyma with some degrees of vascular sclerosis. These findings are in agreement with the results of our study.

In our series, chronic pyelonephritis was the second most common pathological findings including 17.1% of the cases, but in previous studies, it was less reported.

In the study of Bijol et al,[6] diabetic glome-rulosclerosis is reported in 23.6% of cases as the second most common nonneoplastic disease, but we did not see any cases of diabetic glomerulosclerosis in our study.

According to US Renal Data System statistics, ESRD has a worse prognosis than RCC in patients suffering from both Stage 3 RCC and ESRD. Hence, patient's outcome should be evaluated considering the nonneoplastic renal parenchyma situation.[10],[11],[12] College of American Pathologists checklist protocol suggests that an additional stain such as PAS or Jones methenamine silver is better to be used for all cases on nonneoplastic renal parenchymal section.[13] According to above-mentioned advantages, we used PAS staining for the sections along with H and E staining and we also recommend this method for future studies.

This is the first study which assesses the correlation between nonneoplastic pathological findings in renal parenchyma and age and sex of the patients. Although we could not find any considerable correlation between patients' age and pathological findings, we observed that chronic pyelonephritis and FSGN are mostly seen in older patients and MGN is significantly seen in lower ages. Differences in dietary habits, physical activity, and differing prevalence of HTN or diabetes mellitus in Iran might be the main reason of this finding. Furthermore, we did not detect any correlation between patients' sex and pathological findings. Complimentary studies in the future might help to clarify this issue.

In conclusion, the risk of decline in renal function after operation is higher in patients with a history of nephrectomy. This is possibly because of preexisting renal parenchymal changes that are secondary to age-related changes. It might also be along with medical diseases or irrelevant conditions. Hence, evaluation of pathological changes in nonneo-plastic renal parenchyma is an essential step in recognizing patients at risk of accelerated function failure of the single remaining kidney, particularly in patients with a background of chronic vascular injury associated with diabetes or HTN.


   Acknowledgment Top


This study was supported by Research Council of Urmia University of Medical Sciences as a student thesis.

Conflict of interest: None declared.

 
   References Top

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Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin 2015; 65:87-108.  Back to cited text no. 1
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2.
Guo G, Gui Y, Gao S, et al. Frequent mutations of genes encoding ubiquitin-mediated proteolysis pathway components in clear cell renal cell carcinoma. Nat Genet 2011;44:17-9.  Back to cited text no. 2
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Henriksen KJ, Meehan SM, Chang A. Nonneoplastic renal diseases are often unrecognized in adult tumor nephrectomy specimens: A review of 246 cases. Am J Surg Pathol 2007; 31:1703-8.  Back to cited text no. 3
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Bijol V, Mendez GP, Hurwitz S, Rennke HG, Nosé V. Evaluation of the nonneoplastic pathology in tumor nephrectomy specimens: Predicting the risk of progressive renal failure. Am J Surg Pathol 2006;30:575-84.  Back to cited text no. 6
    
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Bonsib SM, Pei Y. The non-neoplastic kidney in tumor nephrectomy specimens: What can it show and what is important? Adv Anat Pathol 2010;17:235-50.  Back to cited text no. 8
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Roberts IS. Pathology of IgA nephropathy. Nat Rev Nephrol 2014;10:445-54.  Back to cited text no. 9
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Peces R, Alvarez-Navascués R. Unilateral renal cell carcinoma with coexistent renal disease: A rare cause of end-stage renal disease. Nephrol Dial Transplant 2001;16:291-4.  Back to cited text no. 10
    
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Budin RE, McDonnell PJ. Renal cell neoplasms. Their relationship to arteriolonephro-sclerosis. Arch Pathol Lab Med 1984;108:138-40.  Back to cited text no. 11
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Ahmed M, Solangi K, Abbi R, Adler S. Nephrotic syndrome, renal failure, and renal malignancy: An unusual tumor-associated glomerulonephritis. J Am Soc Nephrol 1997;8: 848-52.  Back to cited text no. 12
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Higgins JP, McKenney JK, Brooks JD, Argani P, Epstein JI; Association of Directors of Anatomic and Surgical Pathology. Recommendations for the reporting of surgically resected specimens of renal cell carcinoma: The association of directors of anatomic and surgical pathology. Hum Pathol 2009;40:456-63.  Back to cited text no. 13
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Correspondence Address:
Mr. Sina Dindarian
Student Research Committee, Urmia University of Medical Sciences, Urmia
Iran
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DOI: 10.4103/1319-2442.235170

PMID: 29970734

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    Abstract
   Introduction
   Subjects and Methods
   Results
   Discussion
   Acknowledgment
    References
    Article Tables
 

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