Cytogenetic characterization of renal cell carcinoma in von Hippel-Lindau syndrome

Immunohistochemistry for the diagnosis of renal epithelial neoplasms

Despite the increasing number of newly identified renal neoplasms, the diagnosis of renal cell carcinoma (RCC) can usually be reached with careful histologic examination and a limited immunohistochemical (IHC) panel. Clear cell, papillary, chromophobe RCC and oncocytoma account for more than 90% of renal neoplasia in adults, and sophisticated ancillary tools are usually unnecessary. Renal tumors with entity-defining genetic alterations may ultimately require molecular confirmation via cytogenetics or sequencing technologies, such as RCC with TFE3, TFEB, or ALK gene rearrangements, or TFEB amplified RCC. In fumarate hydratase-deficient and succinate dehydrogenase-deficient RCC, highly specific IHC markers can strongly suggest the diagnosis. In the metastatic setting, PAX8 and carbonic anhydrase 9 are among the most helpful markers for confirming RCC and clear cell type, respectively; however, caution should be exercised in the absence of a current or historical renal mass. In diagnostically challenging cases, such as renal eosinophilic tumors with low-grade nuclear features, or infiltrative high-grade tumors, careful examination coupled with a judicious panel of IHC markers usually resolves the diagnosis. This review offers concise algorithms for diagnosis of kidney neoplasia with the latest recognized, provisional, and emerging entities to daily pathology practice.

Five decades of urologic pathology: the accelerating expansion of knowledge in renal cell neoplasia

Those who are knowledgeable in cosmology inform us that the expansion of the universe is such that the velocity at which a distant galaxy is receding from the observer is continually increasing with time. We humbly paraphrase that as "The bigger the universe gets, the faster it gets bigger." This is an interesting analogy for the expansion of knowledge in the field of renal tumor pathology over the past 30 to 50 years. It is clear that a multitude of dedicated investigators have devoted incalculable amounts of time and effort to the pursuit of knowledge about renal epithelial neoplasms. As a consequence of the contributions of numerous investigators over many decades, the most recent World Health Organization classification of renal neoplasms includes about 50 well defined and distinctive renal tumors, as well as various miscellaneous and metastatic tumors. In addition, a number of emerging or provisional new entities are under active investigation and may be included in future classifications. In this review, we will focus on a number of these tumors, tracing as accurately as we can the origins of their discovery, relating relevant additions to the overall knowledge base surrounding them, and in some instances addressing changes in nomenclature.

Pathologic Features of Adult Renal Cortical Tumors

In the past few years, a much better understanding of the morphologic spectrum of renal cortical tumors has resulted in a clinically highly relevant contemporary classification system of these tumors. The current and still evolving era of targeted therapies in kidney cancer further highlights the importance of the appropriate pathologic classification. The recently gained knowledge about molecular-driven antigen expression almost certainly will have a major role to play in the characterization, development, and evaluation of targeted therapies in kidney cancer in the future.

Genetic evaluation of von Hippel-Lindau disease for early diagnosis and improved prognosis

von Hippel-Lindau disease (VHL) is a rare autosomal-dominant disorder in which affected individuals develop tumors in a number of locations. It occurs at a frequency of one per 36,000 population. Metastatic renal cell carcinoma (RCC) remains the leading cause of mortality in patients with clear cell RCC arising from mutations in the VHL tumor suppressor. RCC is the presenting feature in only 10% of VHL patients. VHL patients can present with a number of other renal lesions, such as hemangiomas and benign adenomas, in addition to simple cysts and RCC. We have investigated VHL gene mutations in familial RCC. The study cohort consisted of four patients with synchronous VHL and RCC and 31 kindreds. Analysis of the chromosomes was performed by the Moorehead method. Although none of the kindreds investigated had clinical evidence of VHL disease, 22 were found to have a VHL gene mutation consisting of deletions on the short arm of chromosomes 3, 17, and 19. Detailed clinical examination of the 22 kindreds with a VHL mutation revealed cerebellar hemangioblastoma (three kindreds), meningioma (two) and renal cell carcinoma (five). No VHL gene mutation was detected in nine kindreds. The prevalence of VHL gene mutations was 70.9% in the familial RCC kindreds. As a result of this study, the kindreds of patients with synchronous VHL and RCC have undergone molecular genetic testing and should be investigated for associated disorders.

Clear cell renal cell carcinoma

Clear cell RCC is the most common type of RCC that occurs in adults. It has the worst prognosis among the common epithelial tumors of the kidney. Histologically, a wide range of morphologic patterns can be encountered. Those cases with a multi-locular cystic architecture are considered to be a distinct subtype because of the clinicopathologic features.

The expression of insulin-like growth factor-I receptor correlates with Fuhrman grading of renal cell carcinomas

Recent reports have shown significant correlation between Fuhrman nuclear grade of renal cell carcinoma (RCC) and patient survival. However, no one specific gene alteration has yet been described to account for this correlation. This study investigated the expression of the insulin-like growth factor-I receptor (IGF-IR) in RCC and correlated the results to the tumor Fuhrman nuclear grade. Formalin-fixed, paraffin-embedded sections from 68 cases of RCC were stained using the immunohistochemical avidin-biotin-peroxidase method. An anti-human IGF-IR rabbit polyclonal antibody was used. The stains were semiquantitatively evaluated using the Allred score system, assessing intensity of stain and percentage of positive tumor cells. Statistical analysis was performed using the Kruskal-Wallis test. Strong and diffuse cytoplasmic IGF-IR stain (Allred score 7 to 8) was identified in 25 of 25 (100%) of grade 3 and 4 RCCs. Grade 2 RCCs had a median IGF-IR Allred score of 4. Ten of 10 (100%) grade 1 RCCs were negative. Even in the positive high-nuclear-grade tumors, areas of low nuclear grade, when present, were IGF-IR negative. Statistical analysis using the Kruskal-Wallis test demonstrated significant correlation between increasing Fuhrman nuclear grade and increasing IGF-IR Allred score (P <0.0001). Thus we report the novel finding of significant statistical correlation between IGF-IR protein expression and Fuhrman nuclear grade of RCC, and consequentially with patient survival.

Recurrent DNA sequence copy losses on chromosomal arm 6q in capillary hemangioblastoma

Capillary hemangioblastomas (CHB) of the central nervous system, the most common tumor in von Hippel-Lindau (VHL) disease, usually show mutations in the VHL tumor suppressor gene on chromosome 3p25-p26. Because little is known concerning the cytogenetic changes in these tumors, we studied 22 cases through comparative genomic hybridization to screen for DNA copy number changes in both sporadic and VHL-associated CHB. Our analysis revealed that 6 of 22 samples (27%) contained DNA copy number losses, whereas no gains were observed. The most recurrent finding was loss of chromosomal arm 6q, seen in five cases. In two of these cases also loss of chromosome 3 was noted. The third aberration observed was loss of chromosome 8, seen in one case. No differences were noted between VHL-associated and sporadic tumors, nor did the cytogenetic aberrations correlate with the clinical outcome. The loss of 6q, seen in this study and previously in other VHL-associated tumors (renal cell carcinomas and pheochromocytomas) and other tumors, suggest that this chromosome area may contain tumor suppressor genes involved in the early steps of tumorigenesis.

Establishment and characterization of a renal cell carcinoma line from a patient with von Hippel-Lindau syndrome

It is not known how the von Hippel-Lindau (VHL) gene and the, as yet unidentified, renal cell carcinoma (RCC) gene(s) interact to result in RCC; nor is it known if mutations in both, or all genes are necessary for this progression. The availability of a RCC cell line from a VHL patient would be useful in studies comparing sporadic RCC with RCC resulting from VHL syndrome; and for determining the relationship or interaction of the RCC gene with the VHL gene to produce a common tumor type. This paper describes the isolation and characterization of a renal cell carcinoma cell line derived from a patient with von Hippel-Lindau disease. The line is epithelial in origin and the genome contains a familial mutation in the VHL gene. Tissue culture studies indicate that this cell line, although immortalized, is not fully transformed. Chromosomal analysis performed on cells derived from disseminated primary tumor cells revealed no detectable chromosomal abnormalities. However, analysis performed on cells at passages 9, 19, 41, and 79 showed both numerical and structural chromosomal changes. The cytogenetic profile of this cell line demonstrated a number of abnormalities known to be associated with RCC from patients with and without VHL syndrome.

The von Hippel-Lindau tumor suppressor gene. A rare and intriguing disease opening new insight into basic mechanisms of carcinogenesis

The von Hippel-Lindau (VHL) disease is an inherited tumor susceptibility syndrome featuring a high variety of benign and malignant tumors. The gene has been localized and cloned at 3p25-26. Recent functional analysis defined the VHL gene product as an inhibitor of the transcription elongation process. Its possible involvement in the vascularization process may explain the histologic features of VHL tumors providing insight into basic mechanism of tumorigenesis. Direct genetic testing is available for patients affected with VHL. Seventy to eighty percent of the germline mutations expected could be detected. As first geno/phenotype correlations have been established, we are now beginning to understand the diversity of this fascinating disease at the molecular level. As mutational analysis proved to be of striking prognostic significance, gene testing became an important tool for the management of the disease. The VHL gene was also found to be responsible for tumorigenesis in the corresponding sporadic tumors, especially in the clear cell type of renal cell carcinomas. The understanding of the normal and disturbed function of the VHL gene product will enable us to develop treatment strategies based on and targeted at the molecular cause of the disease. In this review we summarize the current knowledge about genetics, clinics, and function of VHL.

Von Hippel-Lindau's disease: report of three cases and review of the literature

The authors present the autopsy findings of two related patients and the biopsy findings of a third member of the family. The oldest member was 34 years old at death and on postmortem examination he had haemangioblastomas in the retina, cerebellum, medulla and spinal cord. Other findings were renal cell carcinoma, phaechromocytoma, cysts of kidney and pancreas, hydromyelia and atypical meningiomas. His brother died when 30 years old. The autopsy revealed haemangioblastomas of cerebellum, renal cell carcinoma and a clear cell cystadenoma of epididymus. The third patient was the daughter of the first and presented with headache and dizziness. CT-scan showed a cerebellar haemangioblastoma. Epidemiological considerations on the commonest visceral and CNS lesions and a review of current diagnostic criteria are discussed.

The clinical and pathological manifestations of renal tumors in von Hippel-Lindau disease

The protean nature of renal lesions in von Hippel-Lindau disease has made surgical management difficult. To develop a sensible surgical approach the pathological and clinical manifestations of renal involvement in von Hippel-Lindau disease patients were defined. A total of 87 lesions in 9 kidneys from 6 patients with von Hippel-Lindau disease was examined for size, presence of renal cell carcinoma, cystic or solid qualities and local invasion. There was no correlation between the size of the lesion and renal cell carcinoma. All 44 benign lesions were cystic, while 35% (15 of 43) of malignant lesions were cystic and 65% (28 of 43) were solid. All 9 locally invasive tumors were solid. The distribution of lesions in our patients was compared to the findings in 138 cases we collected from the literature. The 3 patterns of clinical presentation recognized were solitary, multiple and diffuse. We recommended that all lesions, cystic or solid, be excised at the time of nephron sparing surgery, with a wider margin for solid lesions, and that nephron sparing surgery should be reserved for patients with cystic and small solid lesions, with radical nephrectomy being preferred for patients with diffuse disease.

Cytogenetic and fluorescence in situ hybridization studies on sporadic and hereditary tumors associated with von Hippel-Lindau syndrome (VHL)

We performed cytogenetic and fluorescence in situ hybridization (FISH) studies on 29 sporadic or familial tumors associated with von Hippel-Lindau [correction of Landau] disease. Four of five renal cell carcinomas with detectable alterations showed clones with chromosome 3 alterations. These changes led to loss of genetic material visible with cytogenetic resolution: either an unbalanced translocation involving 3p or loss of a whole homolog 3, resulting in monosomy of 3p. We have previously mapped the VHL gene to chromosomal region 3p25-p26. We applied FISH using the single copy probes cA233 and cA479, sequences close to the VHL gene, in a search for submicroscopic deletions of 3p. Use of FISH with differentially labeled probes indicated cA479 to be distal to cA233, but both were located within bands 3p25-26. FISH with single copy probes for interphase cytogenetics detected four subclones with deletions in the VHL region in 8/22 tumors, including four tumors which appeared cytogenetically normal. FISH proved to be a powerful tool in tumor genetic studies, especially helpful in detecting tumor subclones in benign and slowly growing tumors.

A tumor suppressor locus within 3p14-p12 mediates rapid cell death of renal cell carcinoma in vivo

High frequency loss of alleles and cytogenetic aberrations on the short arm of chromosome 3 have been documented in renal cell carcinoma (RCC). Potentially, three distinct regions on 3p could encode tumor suppressor genes involved in the genesis of this cancer. We report that the introduction of a centric fragment of 3p, encompassing 3p14-q11, into a highly malignant RCC cell line resulted in a dramatic suppression of tumor growth in athymic nude mice. Another defined deletion hybrid contained the region 3p12-q24 of the introduced human chromosome and failed to suppress tumorigenicity. These data functionally define a tumor suppressor locus, nonpapillary renal carcinoma-1 (NRC-1), within 3p14-p12, the most proximal region of high frequency allele loss in sporadic RCC as well as the region containing the translocation breakpoint in familial RCC. Furthermore, we provide functional evidence that NRC-1 controls the growth of RCC cells by inducing rapid cell death in vivo.

Von Hippel-Lindau disease and renal cell carcinoma in a 16-year-old boy

Von Hippel-Lindau disease is a rare autosomal dominant disorder. Kidney lesions occur in the majority of cases, with renal cell carcinoma noted in 40% and renal cysts in 60%. Renal cell carcinoma in von Hippel-Lindau disease is usually bilateral and occurs at an earlier age than in patients with sporadic renal cell carcinoma. We report on a 16-year-old boy who, to our knowledge, is the youngest patient to present with von Hippel-Lindau disease and renal cell carcinoma. Controversy currently exists regarding the nature of renal cysts in von Hippel-Lindau disease and the optimal therapeutic approach (that is radical versus parenchymal sparing surgery). We review the histology of renal cysts and carcinoma, and discuss the rationale for selecting parenchymal sparing surgery.

The region of common allelic losses in sporadic renal cell carcinoma is bordered by the loci D3S2 and THRB

Cytogenetic studies and DNA analysis have shown that the short arm of chromosome 3 is the region in the genome that is commonly deleted in renal cell carcinoma. By studying loss of heterozygosity in 41 matched tumor/normal kidney tissue pairs, we could delimit the commonly deleted part of 3p to the region between the loci THRB (in 3p24) and D3S2 (in 3p21). The regions on 3p suggested to be involved in the Von Hippel-Lindau syndrome and in hereditary renal cell carcinoma are both outside this smallest region of overlapping deletions. Consequently, renal cell cancer would be an illustration of the possibility that different genes cause the same type of tumor.

Renal cell carcinoma

Renal cell carcinoma accounts for 3% of all adult cancers and has many unusual features in its presentation, diagnosis, and management. It develops in a significant number of patients with acquired renal cystic disease, a disorder found almost exclusively in chronic hemodialysis patients. Abnormalities of chromosome 3 are frequently found in sporadic and familial forms. Radical nephrectomy remains the only potentially curative therapy for this tumor.

Cytogenetics of renal cell carcinomas associated with von Hippel-Lindau disease

To establish the chromosome pattern, we have analyzed short-term cultures of 24 renal cell carcinomas (RCC) from four patients with von Hippel-Lindau disease (VHL). We evaluated the results together with those for 16 RCCs from two VHL patients karyotyped previously in our laboratory and those of 6 tumors published by others. In all 46 RCCs, the cells had lost the shortest overlapping region of the 3pl3-pter chromosome segment. The rearrangement of 3p was the only karyotype change in 20 tumors. In more than 50% of the tumors, a gain of the shortest overlapping region of the 5122-qter segment was detected. Comparative analysis showed that the chromosome aberrations in RCCs associated with VHL are similar to those found in sporadic RCCs. These results indicate that non-papillary sporadic and VHL-RCCs have common genetic mechanisms that result in the loss of the 3p13-pter region containing one or more putative suppressor genes.

Clustering of features of von Hippel-Lindau syndrome: evidence for a complex genetic locus

von Hippel-Lindau syndrome (HLS), an autosomal-dominant inherited disease, was studied in 92 affected subjects from 29 kindreds. In an initial survey to identify HLS gene carriers, all patients treated at the University of Freiburg for angiomatosis retinae (22), haemangioblastoma of the central nervous system (CNS) (63), and phaeochromocytoma (54) were examined as potential HLS gene carriers. HLS was diagnosed in 86% of the patients with angiomatosis retinae, 19% of the patients with haemangioblastoma of the CNS, and 19% of the patients with phaeochromocytoma. Based on these and on an additional 49 newly diagnosed cases (24 by clinical examination and 25 by pedigree analysis), the calculated prevalence of the disease in the district of Freiburg, Germany, with a population of 1.909 million is 1/38 951. There was a striking tendency for familial clustering of HLS features in affected kindreds. Both angiomatosis retinae and haemangioblastoma of the CNS occurred in most families, whereas renal lesions and/or pancreatic cysts and phaeochromatocytoma were mutually exclusive. This finding suggests that HLS is caused by different mutations within a complex genetic locus, or additional genetic lesions, which cooperate with the HLS gene on chromosome 3p. The data point to a linear sequence of features as follows: phaeochromocytoma, angiomatosis retinae, haemangioblastoma of the CNS, renal lesions, pancreatic cysts, and epididymal cystadenoma.