GU Pathology Flashcards
what are the types of non-neoplastic renal disease?
obstruction/hydronephrosis
infection
congenital abnormalities
reflux
what are the causes of hydronephrosis?
extrinsic; enlarged lymph nodes retroperitoneal fibrosis inflammatory conditions within the retroperitoneum endometriosis
intramural;
tumour (transitional cell carcinoma)
within the lumen;
stones
renal colic blood clots
describe nephrolithiasis
the entire calyceal system and pelvis is occupied by a single calculus
moulded by the luminal cavity of the pelvis and calyces (stag horn)
found in middle-aged to elderly females
infection with proteus and sometimes E. coli
can cause hydronephrosis
describe hydronephrosis and its causes
requires surgical removal
markedly reduced renal function
nephrolithiasis
vesicoureteric reflux; causes massive dilatation of the upper part of the ureter, renal pelvis and much of the kidney
describe acute pyelonephritis
ascending infection
common in young children
may be blood borne; E. coli is the most common organism
usually responds well to antibiotic treatment
rarely require surgical removal
what are the clinical features of acute pyelonephritis?
loin pain
fever
can be complicated by infectious element; septicaemia, abscess, mycotic abscess elsewhere
what are the anatomical features of acute pyelonephritis?
histology; collections of neutrophil polymorphs
gross; small, studded abscesses right through the renal parenchyma
describe chronic pyelonephritis
repeated infections leading to chronic damage
specific pathological features; polar scars, related to the underlying calyx
causes; obstructive or reflux
what are the anatomical features of chronic pyelonephritis?
histology; inflammation fibrosis, glomerular sclerosis, thyroidisation of the tubules
dilated tubules containing pink cast-like material that resembles thyroid follicles
gross; marked cystic dilatation of the calyx and renal pelvis, small area of normal kidney remaining
what are the non-neoplastic congenital kidney disorders?
polycystic kidney disease
horseshoe kidney
duplex ureteres
agenesis; 1%
describe adult polycystic kidney disease
AD condition
only presents in adulthood; 3rd decade
can present with hypertension and uni/bilateral renal masses
numerous large cysts; can rupture or bleed
10% risk of a renal carcinoma; cystic clear cell carcinoma
associated with cysts in the liver and pancreas
berry aneurysms in the arteries of the circle of willis
describe infantile polycystic kidney disease
AR condition
presents at birth or shortly afterwards
very poor prognosis
renal function severely impaired; dialysis dependent from birth/shortly after
describe duplex ureter
reasonably common
complications; obstruction, increased risk of stones, dilated ureters
can form strictures; hydronephrosis, dilatation of calyxes and renal pelvis
describe benign renal tumours
relatively uncommon in clinical manifestation
small; adenomas
larger; oncocytomas, impossible to differentiate from a renal cancer so are often removed
metanephric adenoma; often found incidentally
what are the types of malignant renal tumours?
clear cell; 75%
papillary; 10%
chromophobe; 5%
collecting duct
renal carcinoma unspecified; cannot be put into a category, usually poorly differentiated
urothelial tumours; involve the kidney, usually spread from the renal pelvis or ureter
what are the risk factors of renal tumours?
male
age; 5th decade or beyond
smoking
tuberous sclerosis
von hippel-lindau disease; clear cell carcinoma
brain transplants
dialysis; particularly papillary renal carcinoma due to scarring in the native kidneys
what are the genetic/chromosomal anomalies of renal tumours?
clear cell; 3p deletion, most often in those associated with syndromes
papillary carcinoma; trisomy 7 or 17
chromophobe; multiple trisomy
newer variants; specific 11p deletion
what is the clinical triad of renal tumours?
renal mass
haematuria
flank pain
much worse prognosis if present with all of the components of the triad
what investigations are required to diagnose renal tumours?
USS; can identify the renal mass, tell if it is cystic or solid, attempt at telling whether it is TCC or renal cell carcinoma
IV urogram
MRI; gives a better anatomical description
metastases; classical cannonball secondary within the lungs or pleural tract
describe the histological appearance of clear cell carcinoma
sheets of clear cells
vacuolated cytoplasms
polycystic nuclei; pyknotic looking, vascular component
cystic in 15%
describe the histological appearance of a papillary carcinoma
an exophytic-type tumour
soft
very friable
sometimes multifocal or bilateral; must check the other kidney
describe the anatomy of a chromophobe carcinoma
gross; brown colour
histology; very thick cell membrane, perinuclear halo
very good prognosis compared to others
describe a collecting duct carcinoma
one of the worst prognoses; very very aggressive
forms glands
tend to find it in the renal medulla
associated with lymph node and other visceral metastases
describe a sarcomatous carcinoma
a type of collecting duct carcinoma spindle pattern lots of mitotic figures associated with a very poor prognosis usually has spread beyond the kidney
describe the steps of pathological staging of a kidney tumour
pT1a; <4cm, confined to kidney
pT1b; 4-7cm, confined to kidney
pT2; >7cm, confined to kidney
pT3; involves the renal vein or vena cava
pT4; spread to adjacent organs, gerota’s fascia, liver, adrenal gland
describe furham grading
based exclusively on nuclear size
1; very small nuclei
4; quite big nuclei, lots, prominent nucleoli
what is the treatment of renal cell carcinomas?
radical nephrectomy; removal of the kidney, ureter, adrenal gland, higher lymph nodes
partial nephrectomy; tumours <4cm, peripheral, not involving the collecting system
radio frequency ablation; tumours <3cm
cryotherapy; freezing of the tumour
chemotherapy; offered in distant metastasis
interferon; marginal benefit in distant metastasis, poorly tolerated
describe transitional cell carcinoma of the kidney
common tumour of the urinary tract
more so involves the bladder and ureter
sometimes seen in the renal pelvis
classically presents as a cauliflower tumour involving the renal pelvis and extending down the ureter
can be hard to distinguish from a renal cell carcinoma
must take out the ureter as far as the bladder
describe Wilms’ tumour/nephroblastoma
most common paediatric tumour
affects children age 2-4
present with an abdominal mass
prognosis; improved considerably, improved surgical technique and chemotherapy
describe the anatomy of wilms’ tumour
gross; very variegated, haemorrhagic, pale, fleshy
histologically; small blue tumour cells with poorly formed glomerular and tubular structure
has blastema
stromal component that sometimes can form muscle and cartilage
what is the types of clinical presentation of glomerulonephritis?
nephrotic syndrome; significant protein loss in the urine nephritic syndrome; renal impairment acute renal failure chronic renal failure incidental
describe nephrotic syndrome
proteinuria >3.5g/24hrs
oedema; can be massive depending on the protein loss
hypercholesterolaemia
hypoalbuminaemia
causes; minimal change disease in children, membranous glomerulonephritis or drug induced in adults
describe the electron microscopy of membranous glomerulonephritis
lots of sub-epithelial deposits along the basement membrane
what are the clinical and urinary findings in nephritic syndrome?
blood in the urine
renal impairment
hypertension
active urine sediment
urinary;
hyaline casts
red blood cell casts
inflammatory cells; acute or chronic
what are the histological features of nephritic syndrome?
proliferation; lots of cells within the glomeruli
neutrophil polymorphs within the capillary loops
what is the clinical presentation of acute renal failure?
failing urinary output or total anuria
elevated creatinine
hypertension
describe chronic renal failure
slow onset
elevated creatinine
irreversible
usually leads to end stage renal disease; requiring dialysis and hopeful transplantation
what are the types of primary glomerulonephritis?
IgA nephropathy; younger adults with chronic renal failure, younger males with nephrotic syndrome
minimal change disease
membranous glomerulonephritis
post streptococcal GN; common, rarely pathological, good outcome
ANCA associated vasculitis; anti-GBM/goodpasture’s disease, occurs at springtime
membranoproliferazive GN; caused by lupus nephritis, hepatitis C, cryoglobulinaemia
describe renal biopsy
diagnostic gold standard
invasive procedure
under US guidance by the nephrologists/radiologists
take 2 or 3 cores; light microscopy, immunofluorescence, electron microscopy
useful in looking at the ultrastructure of the glomerulus
what are the stains used to look for in renal biopsy?
haematoxylin eosin stain; morphology
masson’s trichrome; connective tissue
silver stain; basement membrane
PAS stain
describe immunofluorescence of renal biopsy
frozen tissue apply antibodies to it; immunoglobulins G, A and M complement factors C3, C4, C1q and fibrinogen deposits of antigen antibody complexes along the basement membrane
describe electron microscopy of renal biopsy
identifies;
deposits and structural anomalies in the basement membrane
hereditary renal disease
conditions with a splitting of the basement membrane
what conditions can cause chronic renal failure?
vascular disease
diabetes
chronic tubulointerstitial nephritis
what are the types of tumour in the bladder and ureters?
transitional cell carcinoma; most common, they are lined by transitional epithelium
squamous carcinoma; more common in Egypt due to endemic infection with schistosomiasis
adenocarcinomas; uncommon
miscellaneous; include sarcomas of the bladder
describe the pathology of transitional cell carcinoma
most are not invasive
huge proportion recur
20-30% recur as invasive carcinomas; metastatic potential and require thorough treatment
what are the risk factors for bladder cancer?
smoking; rare to get a bladder tumour in a non-smoker
occupational exposure to aniline dye; rubber industry
male
hydrocarbon exposure
what is the clinical presentation of bladder cancer?
sometimes asymptomatic
LOTS;
micro/haematuria; detected in dipstick testing
mass lesion; palpable mass indicates a very advanced tumour
what investigations are required to diagnose bladder cancer?
cystoscopy CT MRI IVU; usually incidentally biopsy; can only tell exactly what it is cold cup biopsies; small lesion TURBT; large lesion
describe the potential findings of a cystoscopy
carcinoma in situ; red patches, requires a biopsy to confirm
superficial TCC
invasive TCC; very pale, flat, ulceration and necrosis in part of the tumour, requires resection
describe the histology of a bladder grade 1 TCC
multi layered; usually more than 7
loss of orientation
occasional cells slightly enlarged
describe the histology of a bladder grade 2 TCC
loss of orientation
more marked cellular pleomorphism
describe the histology of a bladder grade 3 TCC
lots of cells coming off the surface
lots of cellular pleomorphism; mitotic figures throughout
describe the histology of a bladder adenocarcinoma
forms papillary structures and glandular structures
more common in the dome of the bladder
sometimes in associated with persistent urachus or brachial remnants
describe the staging of bladder TCC
pTa; superficial, non-invasive
pT1; in the submucosa
pT2; in the muscle coat
pT3; beyond the muscle coat or muscularis propria
pT4; gone into adjacent organs, prostate, uterine cavity, uterine cervix, advanced disease, rarely operable
what is the treatment of bladder cancer?
mostly superficial; resection
grade 3 or associated carcinoma in situ; adjuvant BCCG therapy
mitomycin C; more cytotoxic
small or in the dome; may be amenable to partial cystectomy
>T2; cystectomy, offered ileal conduit
advanced; chemotherapy and radiotherapy, do not respond well
describe carcinoma in situ of the bladder
full thickness dysplasia
often seen as a red patch in the bladder
often found along with TCC
what is the treatment of carcinoma in situ of the bladder?
on its own; BCG therapy
may require numerous courses
what are the types of renal, pelvic and ureteric tumours?
transitional cell; almost 90%
squamous cell carcinoma; occasionally
adenocarcinoma; less common
describe ureteric cancer
multifocal and bilateral in >10%
investigate the rest of the ureter and renal pelvis on both sides
>50% of ureteric TCC develop bladder TCC; field change
require extended follow-up
sometimes synchronous
what are the types of penile cancer?
squamous cell carcinoma; majority
malignant melanoma
spindle cell carcinoma; arise in the glans penis
adenosquamous carcinoma; mixture of glandular and squamous patterns in the carcinoma
what are the risk factors for penile cancer?
poor hygiene uncircumcised phimosis HPV; younger males smoking
what are the pre-neoplastic conditions associated with penile cancer?
Bowenoid papulosis; HPV related change
erythroplasia de queyrat; elderly males, basically CIS in the foreskin or glans penis
Bowen’s disease; dysplastic condition which can affect anywhere in the body
describe the histology of the testes
seminiferous tubules and interjacent stroma
contain leydig cells; produce testosterone
Sertoli cells present; provide nutritional support
germ cells; form spermatozoa
what can be seen in a biopsy of the testes?
spermatogenesis; normal, absent
pre-neoplastic change
intratubular germ cell neoplasia
what are the non-neoplastic conditions of the testes?
epididmyo-orchitis; common, usually following a UTI, often related to E. coli UTI
torsion; young males, usually an acute surgical emergency, intense pain
hydrocele; older males, can follow trauma or lower UTI
describe testicular torsion
dark congested sometimes haemorrhage causes infarction fairly uncommon acute medical/surgical emergency treatment; untwist the testicular vessels and suture it to the scrotal sac
describe testicular cancer
incidence is rising
affects younger males
18-55yrs
most have a good prognosis
what are the types of testicular cancer?
germ cell; 90%, always malignant sex cord stromal tumour leydig tumour Sertoli cell tumour lymphomas; elderly males leukaemia; younger males mostly benign, some of them have a malignant potential
what are the subtypes of germ cell testicular tumours?
seminomas; 50%
non-seminomatous/teratomas; 15%
mixed germ cell tumours; 33%
describe seminomas
mid 30-40s most common individual testicular tumour very amenable to treatment very radiosensitive good prognosis fleshy, pale tumours
describe the histology of seminomas
sheets of quite large cells
look anaplastic
always have lymphoid stroma
sometimes contains granulomas
intratubular germ cell neoplasia in the tubules; abnormal tubules
virtually no spermatogenesis in tubules close to the tumours
describe non-seminomatous germ cell tumours
4 groups; MTD; mature, can mimic normal structure MTI; some primitive epithelium in it MTU; purely anaplastic teratoma MTT; a trophoblastic or choriocarcinoma arising in the testis
motley MTI or MTU
usually large, with haemorrhage, necrosis, cystic change, sometimes can see cartilage
what are the patterns of differentiation of malignant teratomas?
embryonal carcinoma
yolk sac tumour
choriocarcinoma
mixed form; polyembryoma
describe the histology of embryonal carcinoma teratomas
forms glands
poorly differentiated
associated with spindle primitive stroma
describe the histology of yolk sac teratomas
schiller-duval body
central vessel
rim of epithelial cells
second rim; almost glomerular type structure
describe the histology of choriocarcinoma teratomas
often associated with haemorrhage
lots of giant cells and cytotrophoblasts
describe primitive teratomas
very primitive neural tissue
worst kind to have
does not respond to chemotherapy if seen in the lymph nodes
how is a testicular tumour diagnosed?
usually present with a painless lump
test for markers
test for lymphatic spread
what testicular tumours will respond to which type of markers?
seminoma; only raised LDH
teratomas; raised AFP and HCG, particularly in choriocarcinoma and some mixed germ cell tumours
what is the treatment of testicular tumours?
radical orchidectomy; 1st line, done through the inguinal canal
adjuvant radiotherapy; large seminomas that can spread to the retroperitoneal lymph nodes
chemotherapy; all teratomas are given this after the initial surgery
what is the MRC criteria for testicular tumours?
presence of embryonal carcinoma (1)
absence of yolk sac tumour (1)
lymphatic invasion (1)
vascular invasion (1)
> 2; give chemotherapy after surgery
what is the 5-year survival of testicular tumours?
seminomas; 95%
teratomas; 90%
what are the common benign conditions of the prostate?
benign nodular hyperplasia
prostatitis; polymorphs extending into the prostatic glands, often follows lower UTI
describe benign nodular hyperplasia
proliferation of glands and stroma form a nodule; androgen-oestrogen imbalance
usually int he transitional/central zone
blocks off the prostatic urethra
distension of the bladder and outflow obstruction
common with increasing age
what is the treatment of benign nodular hyperplasia?
drugs
transurethral resection of the prostate (TURP)
describe prostatic carcinoma
most common tumour in males
incidence increasing; increased detection of serum PSA
what are the types of prostatic carcinoma?
acinar; 90%, can see prostatic acini in the periphery of the gland
ductal; 5%, seen in the periurethral zone of the prostate
other types; lymphomas, sarcomas
what is the presentation of prostatic carcinoma?
usually asymptomatic outflow obstruction; BNP haematuria abnormal PR examination abnormal PSA
what investigations are required to diagnose a prostatic carcinoma?
TRUS biopsies; US of the rectum and prostate gland to detect areas of abnormality to biopsy
MRI or CT
bone scan
what is the treatment of prostatic carcinoma?
hormone radiotherapy combination; offered to the majority
radical prostatectomy; only offered to some
hormone therapy; poorly differentiated, high Gleason score
radiotherapy
brachytherapy; use radio isotopes
describe the Gleason score
1-5; well - poorly differentiated
two most common patterns graded and combined
total score / 10
describe the scores of the Gleason score
2; round glands, lots of stroma in between
3; smaller glanders, starting to infiltrate widely
4; back to back and all together
5; total lag of glands, poorly differentiated
describe radical prostatectomy
most realistic hope for cure
usually performed in males <65yrs
only performed if PSA <15 and if Gleason score <7 on biopsy
describe the staging of prostatic carcinoma on core biopsies
pT1; reflect what the stage is on biopsy or TURP
T2; confined to the lobes
T3; spread outside the lobes or into the seminal vesicle
T4; involved the rectum or the bladder
what does the prognosis of prostatic carcinoma depend on?
PSA
stage
Gleason score
