el carcinoma renal en revisiÓn nuevas directrices y ... · xxvi el carcinoma renal en revisiÓn...
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XXVI
EL CARCINOMA RENAL EN REVISIÓNNuevas directrices y propuestas de la ISUP
Comentario crítico
F. AlgabaUnidad de Patología Universitat Autónoma de Barcelona
Am J Surg Pathol Volume 29, Number 9, September 2005
2013 International Society of Urologic Pathology Baltimore Conference on
Best Practices : Recommendations in the Applicationof Immunohistochemistry in Diagnostic Urologic Pathology.
2012 International Society of Urologic Pathology Vancouver Conference on
Renal cell carcinoma.
XXVIEL CARCINOMA RENAL EN REVISIÓN
Nuevas directrices y propuestas de la ISUP
SUBTIPOS HISTOLÓGICOSClásicosNuevos y Emergentes
RELECTURA DE LA GRADACIÓN
VALORACIÓN EXTENSIÓN
PANEL INMUNOHISTOQUÍMICA
XXVISUBTIPOS CARCINOMA RENAL
OMS 2004
• DE CÉLULAS CLARAS• Tipo multilocular
• PAPILAR• CROMÓFOBO• DE DUCTOS COLECTORES (BELLINI)• MEDULAR • MUCINOSO TUBULAR Y FUSOCELULAR• ASOCIADO CON NEUROBLASTOMA • DE TRANSLOCACIÓN Xp11.2 (gen TFE3)
• INCLASIFICABLE
1 2 3 4 5
34%
64%
1%0%1%
1. Multilocular cystic renal cell carcinoma
2. Multilocular cystic renal cell neoplasm of low malignant potential
3. Renal cell carcinoma with extensive cystic change
4. Multicystic renal epithelial neoplasm with focal clear cell change
5. None of the above or Uncertain
Carcinoma renal células claras tipo multilocular
Carcinoma renal papilar
TIPO I TIPO II
TIPO I TIPO IIONCOCITOIDE
Should Oncocytic Papillary-RCC be recognized as a separate entity at this time?
1 2 3 4
14%
2%4%
80%
1. Yes2. No3. Uncertain even with personal
experience/ knowledge4. Not enough personal
experience/knowledge
How do you subtype papillary renal cell carcinoma?
1 2 3 4 5
14%
2%
75%
8%
0%
1. type1 vs type 22. type 1 vs type 2 vs type 3
[oncocytic]3. type 1 vs type 2a vs type 2b vs
type 2c (based on molecular classification)
4. Fuhrman grading5. Other GRADO S
EGÚN EL N
UCLEOLO
Carcinoma renal papilar
Translocación t(6;11)(p21;q12)Translocación Xp11
• MiTF, TFE3, TFEB, TFEC
Subfamilia de factores de transcripción MiT
• Marcadores melanocíticos: HMB45, MELAN A• Cathepsina K
Martignoni G et al. Mod Pathol 2009;22: 1016-1022
CARCINOMA RENAL DE TRANSLOCACIÓNFamilia MiT
Carcinoma renal híbrido
1 2 3 4 5
20%
73%
1%0%6%
1.Subcategory of oncocytoma2. Subcategory of chromophobe3. As a distinctive entity4. Should not be recognized5. I’m not sure
?
XXVINUEVOS SUBTIPOS CARCINOMA RENAL
NO INCLUIDOS EN LA OMS 2004
• EN LEIOMIOMATOSIS HEREDITARIA
• TÚBULO-QUÍSTICO
• EN ENFERMEDAD QUÍSTICA ADQUIRIDA• (TÚBULO) PAPILAR DE CÉLULAS CLARAS
Dra. Merino
Carcinoma renal en leiomiomatosis hereditaria
1 2 3 4
79%
14%
2%5%
1. Yes2. No3. Uncertain even with personal
experience/ knowledge4. Not enough personal
experience/knowledge
?
Should HLRCC be Recognized as a Distinctive Entity at this time?
AMACR
Carcinoma renal túbulo-quístico
Carcinoma renal en enfermedad quística adquirida
Carcinoma renal (túbulo) papilar de células claras
1 2 3 4
80%
13%
3%5%
Asociado a enfermedadquística adquirida
1 2 3 4
85%
3%2%10%
Túbulo-papilar deCélulas claras
1 2 3 4
73%
14%7%5%
Túbulo-quístico
1. Yes2. No3. Uncertain even with
personal experience 4. Not personal
experience
• CARCINOMA RENAL FOLICULAR (TIROIDEO)
• CARCINOMA RENAL ASOCIADO A LA MUTACIÓN GERMINAL SUCCINATO DESHIDROGENASA B
• CARCINOMA RENAL CON TRANSLOCACIÓN ALK
XXVISUBTIPOS EMERGENTES CARCINOMA
RENAL, NO INCLUIDOS EN LA OMS 2004
Carcinoma folicular Carcinoma translocacion ALK
Carcinoma renal mutación SDHB
1 2 3 4
25%
14%13%
48%
1. Yes2. No3. Uncertain even with
personal experience 4. Not personal
experience
Foliculartiroideo
SDHB
1 2 3 4
35%31%
6%
28%
1 2 3 4
9%
42%
3%
46%
Translocación ALK
RENAL EPITHELIAL NEOPLASMS 2012 ISUP modification of WHO classification
Benign
• papillary adenoma• oncocytoma
Malignant
• clear cell carcinoma– multicystic renal cell neoplasm
of low malignant potential
• papillary carcinoma
• chromophobe cell carcinoma– hybrid oncocytoma chromophobe
tumor
• collecting duct carcinoma• renal medullary carcinoma
Malignant (continued)
• mucinous, tubular and spindle cell carcinoma
• carcinoma in neuroblastoma survivors
• MiT family translocation carcinomas• Xp11 translocation carcinoma• t(6,11) translocation carcinoma
• tubulocystic carcinoma• acquired cystic disease carcinoma• clear cell tubulopapillary carcinoma• hereditary leiomyomatosis
carcinoma
• Emerging/provisional carcinomas
– Thyroid-like follicular RCC– SDHB RCC– ALK translocation RCC
• unclassified renal cell carcinoma
XXVIRELECTURA DE LA GRADACIÓN
DEL CARCINOMA RENAL
1 2
78%
22%
1. Fuhrman
2. Nucleolar
Células claras
1 2 3
9% 8%
84%
1. Fuhrman
2. Nucleolar
3. Other
Papilar
1 2 3 4
78%
14%8%
0%
1. None
2. Fuhrman
3. Chromophobe grade (Paner et al)4. Nucleolar
Cromófobo
CRITERIOS PARA LA DETERMINACIÓN DE LOS GRADOS DE FUHRMAN
TAMANO NUCLEARIRREGULARIDADPROMINENCIA NUCLEOLAR
Am. J. Surg. Pathol 1982 ;6:655-63
EVOLUCIÓN DE LA GRADACIÓN DE FUHRMAN
Grade 1 Small (approximately 10 mm) Round Absent inconspicuousGrade 2 Larger (approximately 15 mm) Irregularities Visible at 400Grade 3 Even larger (approximately 20 mm) Obvious irregular Visible at 100Grade 4 As for grade 3 Bizarre multilobed nuclei±spindle cells
Nuclear diameter Shape Nucleoli
100x
1 2
3 4
400x
1 2
3 4
Grade 1 tumors were defined as having inconspicuousor absent nucleoli at 100x magnification;
Grade 2 tumors, nucleoli should be distinctly visible at 400x,but inconspicuous or invisible at 100x magnification;
Grade 3 tumors, nucleoli should be distinctly visible at 100x magnification.
Grade 4 tumors should encompassed tumors withrhabdoid, sarcomatoid differentiationor extreme nuclear pleomorphism
PROPUESTA DE LA ISUP PARA LA GRADACIÓN DEL CARCINOMA RENAL
Fuhrman nucleolar
HACIA UN GRADO COMPUESTOPARA EL CARCINOMA RENAL
All histological subtypes (841 patients 30% with necrosis)
No necrosis
Necrosis ≥ 50%
Disease specific survival
Katz MD et al. J. Urol. 2010; 183: 909-914
Multivariate analysis independent prognostic significance disease specific survival
Grado nucleolar+necrosis tumoral
1 2 3
2%
72%
27%
Should the presence or absenceof tumor necrosis be routinely
included as a componentof a RCC pathology report evaluation?
1 2
14%
86%
1. Yes
2. No
1. MACROSCOPIC
2. MICROSCOPIC3. BOTH
Should any assessment of amount(percentage) of necrosis be derived by:
A PESAR D
EL CONSENSO
SE DECID
IÓESPERAR U
NA
AMPLIA V
ALIDACIÓ
N
XXVIVALORACIÓN DE LA EXTENSIÓN
EN EL CARCINOMA RENAL
EL SIGNIFICADO DE LA INVASIÓN DE
LOS OTROS VASOS
Dall´Oglio BJI. 2007; 100: 552
Invasión microvascular
10-year Cancer Specific SurvivalMVI (+) 85.1% MVI (-) 96.5%
Shindo et al BJI. 2013; Jan 25.
Should reporting of MVIin RCC be obligatory?
1 2
41%
59% 1. Yes
2. No
Should MVI be includedin the TNM staging of RCC?
1 2
87%
13%
1. Yes
2. No
?
19% 30%25.9%Sinus.
7% 28%50.9%Perinephric
LN Met Met5y survivalSite fat tissueinvasion
J. Urol 2005; 174: 1218-1221 AJSP 2004; 28: 1594-16001 2
10%
90%
1. Yes
2. No
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