Pathology Review Carousel 7

Pathology Review Carousel 7
Renal II

Case 1 - Chronic Pyelonephritis

This kidney is from an autopsy of a 65 year old man. His death was related to myocardial infarction. He had a serum creatinine of 1.5 mg/dl. Other findings were pulmonary edema and prostatic hyperplasia.

Image	Slide #	Tissue	Mag	Feature
	A-B			Dilatation of the pelvic calyceal system with extensive chronic inflammation. B shows the thinning of the cortex.
	C		HP	High power of B where you can observe severe chronic changes of the cortex with tubular atrophy and dilatation and chronic inflammation. Normal glomeruli are not seen.
	D-E-F			To show areas of affected parenchyma related to normal parenchyma
	G		HP	High power of pelvis with chronic inflammation lined by normal transitional epithelium.

The pathological process of the pelvicaliceal system is: ans=Inflammatory, notneoplastic

The pathological process of the renal parenchyma is: patchy

This pathological process is: ans=chronic

Do you think this patient had hydronephrosis and hydroureter: ans=yes

Your diagnosis is: ans=Chronic pyelonephritis

Case 2 - Renal Cell Carcinoma, clear cell type

This is a nephrectomy specimen from a 57 year old man. His initial clinical complaint was hematuria. Gross examination of the kidney showed a well circumscribed yellow mass localized in the lower pole of the kidney and measuring 4x3x3cm.

Image	Slide #	Tissue	Mag	Feature
	A			Fibrous tissue (capsule) separates the renal cell carcinoma from compressed renal parenchyma.
	B			Compressed renal parenchyma with interstitial fibrous tubular atrophy and chronic inflammation and normal renal parenchyma.
	C			Renal cell carcinoma with fribrous capsule. The neoplasm do not extend into the capsule.
	D-E-F-G		HP	Higher power. The neoplastic cells have clear cytoplasm and round small nuclei of a low grade neoplasm. The cells are often arranged in a tubular pattern.

Is this a papillary tumor? ans=no

Histological grade?ans=low grade

Cytoplasmic features? ans=clear

Diagnosis? ans=carcinoma, Renal cell carcinoma, clear cell type

Case 3 - Papillary Necrosis and Acute Pyelonephritis

This kidney is from an autopsy of a 52 year old diabetic female who died with renal failure and sepsis.

Image	Slide #	Tissue	Mag	Feature
	A-B			Renal papilla with extensive necrosis and acute inflammation.
	C		HP	High power of A and B showing the area of necrosis with acute inflammatory cells.
	D-E			Dilated tubules with acute inflammatory cells in the tubular lumens and interstitium.
	F			Renal tubules with acute inflammatory cells in area of viable renal medulla.
	G			Renal cortex with patchy area of interstitial fibrosis chronic inflammation and sclerosed glomeruli.

Your diagnosis is: ans=Acute pyelonephritis & papillary necrosis

Case 4 - Papillary Renal Cell Carcinoma (RCC)

(EM prints also available) 20 year old black male previously healthy with a solid renal mass identified by CT scan.

Image	Slide #	Tissue	Mag	Feature
	A			Papillary RCC well demarcated by fibrous tissue from the related renal parenchyma.
	B-C-D			The papillary features of this neoplasm are well demonstrated. Kodachrome D represents cross sections of the papillary projections. Note that several cells have clear cytoplasm.
	E-F		HP	The papillae are formed by few layers of cells (no more than 2-3) in contrast to transitional cell carcinoma (case 5) which has many layers of cells. The nuclei are large and irregular (nuclear grade 3) as compared to nuclear grade 1-2 of case 2. The nucleoli are prominent.
	G-H-I		EM	The cells have irregular nuclei and prominent nucleoli as observed by light microscopy. The cells are attached to each other with desmosomes (features of epithelial cells). H and I show the cells arranged toward a lumen with microvilli (features of some renal cell carcinoma and also adenocarcinomas). The cytoplasm contains large amount of glycogen granules.

Is this a papillary tumor? ans=yes

Can you identify this tumor as epithelial by the ultrastructural features? ans=yes

Ultrastructurally, does the cytoplasm of the cell show glycogen? ans=yes

What is your diagnosis? ans=Renal cell ca.

Case 5 - Transitional Cell Carcinoma, Ureter

45 year old male who presented to the physician with complaints of lumbar pain and hematuria.

Image	Slide #	Tissue	Mag	Feature
	A-B		LP	Showing a papillary neoplasm growing toward the lumen (like a cauliflower). The wall of the ureter is well identified in B.
	C		HP	Ureter wall showing normal transitional epeithelium and muscular wall.
	D-E			The transitional cell carcinoma do not extend into the muscular wall.
	F-G		HP	Neoplasm showing features of transitional cells in a papillary pattern. Note the numerous layers of cells characteristic of TCC. This neoplasm is well differentiated (histological grade I to II).

Is this a papillary neoplasm? ans=yes

From which anatomical site is the neoplasm arising? ans=ureter

What is the staging (level of invasion of the wall) of this neoplasm? ans=stage A

What is your diagnosis? ans=TCC

Case 6 - Acute Tubular Necrosis

- (Rat injected with glycerol)

Image	Slide #	Tissue	Mag	Feature
	A-B			Necrotic tubules related to normal tubules and normal glomeruli. Note that no nuclei are seen in necrotic tubules.
	C			Granular casts in the lumen of tubules.
	D			Necrotic tubules and tubules with casts and mitosis (sign of regeneration).
	E			Casts including crystals (related to glycerol) are seen in the lumen of viable tubules.

Which features can you observe?

Glomerular cellular proliferation? ans=no

Tubular necrosis? ans=yes

Interstitial nephritis? ans=no

Tubular regeneration? ans=yes

Tubular casts? ans=yes

Glomerulosclerosis? ans=no

Path diagnosis: ans= ATN

Which manifestations did this rat probably have?

Proteinuria? ans=no

Acute renal failure? ans=yes

Chronic renal failure? ans=no

Nephrotic syndrome? ans=no

Case 7 - Rejection, Acute and Chronic

35 year old female with renal transplant 2 years ago. Progressive decrease in renal function with no response to increase in immunosuppressive therapy. A transplant nephrectomy was performed.

Image	Slide #	Tissue	Mag	Feature
	A-B			Interstitial fibrosis and tubular atrophy is observed (sign of chronic rejection). There is also an extensive mononuclear cellular infiltrate (acute cellular rejection).
	C-D-E-F			Several vessels showing mild intimal fibrosis (chronic rejection) and mild intimal arteries (acute rejection).
				Prominent interstitial cellular infiltrate (acute cellular rejection). Tubulitis is observed in kodachromes H and I.

Diagnosis: (more than one can be correct):

Acute cellular rejection (acute rejection)? ans=yes

Chronic rejection (chronic allograft nephropathy)? ans=yes

Endovasculitis (intimal arteritis)? ans=yes

Parenchymal necrosis? ans=no

Interstitial hemorrhage? ans=no

Gross Images Kodachromes