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
