The most common mesenchymal tumor in a medical renal biopsy is an angiomyolipoma (Table 10).103–105 This is not surprising as 8% to 12% of unselected autopsy kidneys thoroughly examined have one or more angiomyolipomas.104 An incidental angiomyolipoma may be lipid cell predominant, myoid cell predominant or triphasic with abnormal arteries (Figs. 22A, B). They are usually easily recognized although the uncommon oncocytic and epithelioid types can be diagnostically challenging. Melanocytic markers may be employed in uncertain cases. Sarcomas of renal or perirenal origin occur but are extremely rare in medical renal biopsy. Liposarcoma is the most common type but any sarcoma may arise in, or secondarily involve the kidney (Fig. 2B).
The kidney is affected by the most diverse collection of diseases of any organ system. This includes developmental abnormalities, neoplastic diseases, injury from the most common systemic diseases, hypertension and diabetes, and injury resulting from its filtration and tubular secretory/absorptive functions and its external environmental connection. It is the only organ in which two pathology subspecialties, renal and urologic pathology, and 2 clinical specialties, nephrology and urology, engage in diagnosis and treatment.
A surgical or urologic pathologist focuses on macroscopic kidney diseases although the recent emphasis on medical renal diseases in the non-neoplastic kidney has expanded their diagnostic responsibilities. Conversely, the renal pathologist has a more microscopic focus but macroscopic renal anatomic issues and urologic diseases such as cysts and cystic kidney diseases and neoplastic diseases, periodically enter their diagnostic domain.
Renal neoplasia is a rapidly expanding field with new entities appearing on a regular basis. This coupled with the often limited quantity of tumor when incidentally detected on a medical renal biopsy create great challenges for a renal pathologist. In the final analysis it is most important to simply recognize a lesion as a neoplasm on a medical renal biopsy. This may be particularly difficult if the only tumor present is in the tissue for immunofluorescence or electron microscopy. The issue of contaminate, metastasis versus renal primary, and benign versus malignant tumor must be considered but in conjunction with consultation with a hematopathologist, surgical pathologist or urologic pathologist. The latter consultation is required for all cases in which a diagnosis of malignancy is entertained since Standard of Care requires a new diagnosis of cancer be reviewed by a second pathologist.
Most renal and urologic pathology fellowships have limited, or entirely lack, exposure to their kindred discipline. A significant segment of renal diseases are not, therefore, a formal part of their training programs. However, all fellows will be confronted with the full spectrum of kidney diseases in their clinical practice. This review attempts to bridge this diagnostic divide by first pointing out important anatomic features of the normal kidney, its local environment and its lymphovascular connections that may influence understanding of the findings in a medical renal biopsy. This was followed by review of some of the more common and important urologic diseases that may surface in a medical renal biopsy with general diagnostic strategies provided. It is hoped this may compliment previous publications of medical renal diseases encountered in a nephrectomy specimen. It is also hoped that this may also encourage integration of, or exposure to, urologic pathology in renal pathology fellowship programs, and vice versa, in order to optimize fellowship training.
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