FGT Flashcards
Describe the urothelium
- Lines the entire conducting passage of the urinary tract, from pelvicalyceal area down the ureter, lining the bladder and urethra
- Constitutes an impermeable barrier.
- Stratified (3-7 cells)/multi-layered
- Umbrella cells (U) at the surface.
- Lower layers have cells with cuboidal morphology
- Able to distend.
- thickness of urothelium depends on how distended bladder is (i.e. thinner if bladder is full)
- Rests on a basement membrane and lamina propria (LP).
B1 revision
Recall the approach to a lesion of mass
-
Non-Neoplastic
- Congenital
- Hamartomatous
- Infection
- Inflammation
- Deposits
-
Neoplastic
- Benign
- Primary
- Secondary
- Malignant
- Epithelial
- Mesenchymal
- Benign
Describe non-neoplastic lesions of the ureter
Congenital:
- Duplication/Bifid
- Diverticuli
Infection:
- Secondary to vesicoureteric reflux
Inflammation:
- Ureteritis Cystica
Deposits leading to obstruction:
- Calculi
- Blood clot
- Fibrosis
List non-neoplastic lesions of urinary bladder
Congenital
- Exstrophy: skin over lower abdominal wall does not close properly, so bladder is exposed on outer side of abdomen
- Hypoplasia: underdevelopment of tissue
- Diverticuli
#### Infection
- Schistosomiasis esp. in Africa and Asia
#### Inflammation
- eosinophilic
- drugs e.g. cyclophosphamide
- radiation
- idiopathic
#### Deposits
- lithiasis within the lumen
- amyloid within the wall
List non-neoplastic lesions of the urethra
two
Congenital
- Accompanies bladder anomalies: Hypospadias
#### Infection
- Gonococcal, Chlamydia, E. coli
List the two types of urothelial neoplasms
- flat
- papillary
Describe urothelial CIS (a flat urothelial malignancy)
- Presentation: Asymptomatic or symptoms of urinary tract infection not responding to treatment.
- Cystoscopy: Flat red inflamed-looking mucosa.
- Histology: Features of malignancy (NC ratio, hyperchromasia, mitotic activity etc): full thickness, urothelium replaced by large pleomorphic atypical cells. No breach in the basement membrane. Haemorrhagic change to urothelium.
- Macroscopy: haemorrhagic, multifocal flat lesions
Note:
- it may be a diffuse process involving the entire bladder
- important to rule out invasive areas, and any associated papillary lesions
Some risk factors include:
- genetic: HNPCC: inherited genetic mutations in mismatch repair genes– tend to get colon carcinoma but can get different malignancies in other parts of body
- acquired: smoking
Treatment:
- BCG - placed in bladder: causes chronic hypersensitivity inflammatory reaction so entire urothelium becomes inflamed, drops off, dies and falls out
Describe another type of flat malignant neoplasm
Urothelial carcinoma
- Invasive carcinoma
- High grade: invasion muscularis propria, low prognosis
- Low grade: invasion into lamina propria
- surface epithelium contains malignant cells that have invaded past BM, which them forms a tumour seen macroscopically by cystoscopy
- Treatment: cystoscopy and replacement with neo-bladder made of ileum
What is the value in differentiating between different levels of invasion?
- Different Treatments
- Urothelial Carcinoma in situ: Transurethral resection & intravesical BCG
AND
Tumor invading through the muscularis propria: Cystectomy
Describe general features of papillary neoplasms
Papillary architecture:
It is present in normal tissues e.g. choroid plexus as well as several tumours.
- Architectural Pattern: Finger-like projection - can be seen with cystoscopy: may hypertrophy if bladder chronically obstructed by multiple papillae
- Covering epithelium.
- Microscopy: Core of blood vessels and connective tissue in the center i.e. fibrovascular core.
- Presentation: - Delicate papillae break due to stresses leading to bleeding from the central core of blood vessels.
- This leads to patients present with microscopic or macroscopic hematuria.
- **Hematuria outside of the setting of a UTI is abnormal and must be investigated
Describe benign papillary urothelial neoplasms
- Papilloma
- Lined by essentially normal urothelium
- Normal thickness
- Orderly and organised architecture
- No mitoses
List the two types of malignant papillary neoplasms
Papillary urothelial neoplasm of low
malignant potential/unknown potential
AND
Papillary urothelial carcinoma
Describe papillary urothelial neoplasms of low
malignant potential
- Lined by cytologically troublesome urothelium
- Increased thickness of urothelium
- Mild disarray
- Occasional mitoses
Describe the features of papillary urothelial carcinoma
- Papillary urothelial carcinoma (may be non-invasive or invasive)
- Lined by cytologically malignant urothelium
- Very increased thickness of urothelium
- Complete loss of organisation
- Several mitoses
Cystoscopic Appearance
- Fronds like a sea anemone, floating in the urine.
#### Macroscopic Appearance
- Finger-like papillary projections.
Cytological Classification (Grade)
- The nuclear appearance gives the grade.
- Low grade
- Non-invasive
- Cells are bland.
- Non-invasive
- High grade
- Invasive
- Cells are very pleomorphic and large.
- Invasive
Invasion (Stage)
- The depth of invasion gives the stage.
- Muscularis propria invasion is a poor prognosis.
- Low grade
- Non-invasive
- The cells are limited to the urothelium, and there has been no breach of the basement membrane.
- Invasive
- The cells have invaded beyond the basement membrane into the submucosa and muscle.
Describe the fallopian tube
- Muscular (Smooth) tube connecting the ovary with the uterus.
- Tubular structure with smooth muscle coat
- Ciliated columnar cells: motilit
- Non-ciliated columnar cells with apical granules: secrete fluid
- Intercalated/Peg cells: non-ciliated, may act as stem cells
- Distal parts have fimbriae (finger-like projections that catch egg in ovulation)
- Centre of tube has plicae (complicated folds) - large SA to grab egg and move along the tube
- Movement along the tube due to smooth muscle peristalsis and cilia
List some problems that can occur in the fallopian tube
- infection or inflammation known as salpingitis - acute, chronic, granulomatous, foreign body type
- obstructive causes: mainly ectopic pregnancy, endometriosis, paratubal cyst
- benign tumour: adenomatoid
- malignant neoplasm: primary carcinoma or secondary metastasis from ovary or other abdominal organs
Describe salpingitis
Aetiology: Infection
- STI (Neisseria gonorrheae, Chlamydia, Mycoplasma).
- Post instrumentation / IUD / post-pregnancy or abortion.
#### Macro
- Adhesion and fusion of fimbria.
- Dilated tube.
- Filled with pus.
- Often asymptomatic or very mild symptoms e.g. low-grade abdominal pain
#### Micro
- Acute (neutrophils) or chronic inflammation (plasma cells).
- Plicae fused.
#### Complications
- Abscess formation.
- Ectopic pregnancy.
- Infertility
- Systemic sepsis and death
Describe ectopic pregnancy
Aetiology
- Chronic salpingitis: Inflammation fuses the plicae and can, therefore, trap the ovum.
- Congenital abnormalities.
- Functional tubal disturbances.
- Endometriosis.
Macro
- Dilated.
- Hemorrhagic.
- +/- fetus.
Micro
- Chorionic villi.
Treatment
- Salpingectomy - with implications for ferility
Appearance: - Fallopian tubes are distended with ruptured wall exuding hemorrhagic material and fetal tissue.
Describe the uterus briefly
- endometrium comprised of glands and stroma
- myometrium: smooth muscle, lined by endometrium
Describe the endometrium
Endometrium: tubular glands lined by simple columnar epithelium
- Endometrial stroma: small sesame seed-like specialised fibroblasts closely packed
- Endometriosis: endometrium outside the uterus (can occur anywhere)
- Adenomyosis: endometrium within myometrium
- Look similar microscopically, but are distinct diseases with different prognoses - thickened uterine wall because smooth muscle hypertrophies
- Deposits look like endometrium - have glands with stroma and signs of haemorrhage
- Complications: chronic pain (bleed on cyclical basis causing inflammation and pain), infertility
Describe changes to endometrium within menstrual cycle
Proliferative Phase to secretory phase over ovulation
Describe diseases of endometrium ‘in the wrong location’
-
Adenomyosis
- Endometrium within the myometrium.
-
Endometriosis
- Endometrium outside the uterus.
- Complications: Pain, Infertility.
Note that both disease look similar under the microscope, they are distinct diseases, with distinct pathogenesis.
Describe endometrial carcinoma
- Endometrial carcinoma
- Complex glandular and papillary architecture
- Glands arranged back-to-back without intervening normal stroma
- Oestrogen-driven disease ∴ cases increasing with obesity (more aromatisation in peripheral fat = ↑ oestrogen levels) and may improve after menopause when oestrogen is driven down
- Glands and papillae are lined by multiple layers of cells
- Cells show large nuclei with nucleoli, altered nuclear/cytoplasmic ratio and pleomorphism
- Malignant glands start to invade myometrium
- Presentation: PV bleeding intermenstrual, heavy, prolonged or post-menopausal
Describe leiomyoma
- Smooth muscle proliferation, homogenous whorled appearance.
- Complications: Pain, Menorrhagia, Infertility, Compressive symptoms.
- Leiomyoma: smooth muscle proliferation (fibroids)
- Microscopy: homogenous, whorled appearance, fascicles of smooth muscle, circumscribed, abundant pink cytoplasm and spindled nuclei
- Complications: pain (if large/heavy or necrotising), menorrhagia and dysmenorrhoea (uterus so large causing increased endometrial surface area ∴ heavy bleeding), infertility or pregnancy loss as leimyomas interfere with implantation, compressive symptoms
List the three parts of the cervix
- endocervix: glandular
- squamocolumnar junction: transformation zone of squamous to columnar - site where CST taken from
- ectocervix: squamous
Discuss pathology of cervix
Cervix - Infection
- Trichomonas.
- Candida.
- HPV.
Cervix - Benign Neoplasm
- Polyps.
Cervix - Malignant Neoplasm
- Squamous cell carcinoma.
- Adenocarcinoma.
Describe the vagina and pathology of vagina
Vagina
- Fibromuscular canal.
- Mucosal layer – squamous epithelium.
- Lamina propria – elastic fibers.
- Smooth muscle with rugae
- Adventitial layer.
Vagina - Pathology
- Congenital
- Atresia, septate vagina, Gartner duct cysts.
- Infection
- Candida, HPV.
- Benign Neoplasm
- Squamous papilloma.
- Malignant Neoplasm
- Squamous cell carcinoma, Clear cell carcinoma, Embryonal rhabdomyosarcoma.
- Vaginal pathology except for infection is rare.
Describe vulva
- normal vulva has stratified non-keratinising squamous epithelium
- highly vascularised beneath epithelium due to erectile tissue
List vulval pathology
-
Congenital
- Ectopic mammary tissue.
-
Inflammation
- Dermatitis, lichen sclerosus, lichen planus.
-
Infection
- HPV, candida.
-
Benign Neoplasm
- Fibroepithelial polyp, nevi, hidradenoma papilliferum.
-
Malignant Neoplasm
- VIN/Squamous carcinoma, melanoma, Paget’s disease.
Describe lichen sclerosis
- Lichen sclerosus
- Post-menopausal women
- Pathogenesis: autoimmune, genetic or hormonal
- Macro: area of leukoplakia (white thickened layer of keratin on mucosal surface -
hyperkeratosis) - Micro: hyperkeratosis, thickening of epidermis, loss of rete pegs, dermal collagen altered
- Not a pre-malignant condition, but associated with increased risk of SCCNote also:
- Lichen planus: immune system mistakenly attacking cells of skin/mucous membranes
Describe benign neoplasms of the vulva
Vulval intraepithelial neoplasia
- Squamous epithelial neoplasia without invasion beyond the basement membrane (pre-invasive).
- Risk factors: HPV, cigarette smoking, lichen sclerosis.
#### Macro
- Leukoplakia.
#### Micro
- Hyperkeratosis, thick epithelium (acanthosis), elongation of rete pegs, nuclear atypia, mitoses.
Describe malignant neoplasms of vulva
Vulval SCC:
- Age: >60, rare in women younger than 30.
- Risk factors: HPV, cigarette smoking, immunodeficiency.
- Site: Labia majora, also labia minora, clitoris.
- Prognosis: 5-year survival 50-75%.
extra
Describe the ovary
- Peripheral darkly staining cortex with follicles
- Vascular and fibrous central hilar region containing groups of Leydig cells
-
Corpus luteum: very convoluted with steroid secreting cells (large w abundant cytoplasm - appear swollen
microscopically) - Corpus albicans: pale fibrotic structures
-
Primordial follicles: sit within cellular ovarian stroma comprising specialised hormone-responsive
fibroblast-like cells arranged like shag rug
