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Scientific Basis of Clinical Practice > GU Pathology > Flashcards

GU Pathology Flashcards

1
Q

what are the types of non-neoplastic renal disease?

A

obstruction/hydronephrosis
infection
congenital abnormalities
reflux

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2
Q

what are the causes of hydronephrosis?

A 
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

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3
Q

describe nephrolithiasis

A

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

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4
Q

describe hydronephrosis and its causes

A

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

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5
Q

describe acute pyelonephritis

A

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

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6
Q

what are the clinical features of acute pyelonephritis?

A

loin pain
fever
can be complicated by infectious element; septicaemia, abscess, mycotic abscess elsewhere

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7
Q

what are the anatomical features of acute pyelonephritis?

A

histology; collections of neutrophil polymorphs

gross; small, studded abscesses right through the renal parenchyma

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8
Q

describe chronic pyelonephritis

A

repeated infections leading to chronic damage
specific pathological features; polar scars, related to the underlying calyx
causes; obstructive or reflux

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9
Q

what are the anatomical features of chronic pyelonephritis?

A

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

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10
Q

what are the non-neoplastic congenital kidney disorders?

A

polycystic kidney disease
horseshoe kidney
duplex ureteres
agenesis; 1%

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11
Q

describe adult polycystic kidney disease

A

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

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12
Q

describe infantile polycystic kidney disease

A

AR condition
presents at birth or shortly afterwards
very poor prognosis
renal function severely impaired; dialysis dependent from birth/shortly after

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13
Q

describe duplex ureter

A

reasonably common
complications; obstruction, increased risk of stones, dilated ureters
can form strictures; hydronephrosis, dilatation of calyxes and renal pelvis

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14
Q

describe benign renal tumours

A

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

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15
Q

what are the types of malignant renal tumours?

A

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

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16
Q

what are the risk factors of renal tumours?

A

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

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17
Q

what are the genetic/chromosomal anomalies of renal tumours?

A

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

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18
Q

what is the clinical triad of renal tumours?

A

renal mass
haematuria
flank pain

much worse prognosis if present with all of the components of the triad

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19
Q

what investigations are required to diagnose renal tumours?

A

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

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20
Q

describe the histological appearance of clear cell carcinoma

A

sheets of clear cells
vacuolated cytoplasms
polycystic nuclei; pyknotic looking, vascular component
cystic in 15%

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21
Q

describe the histological appearance of a papillary carcinoma

A

an exophytic-type tumour
soft
very friable
sometimes multifocal or bilateral; must check the other kidney

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22
Q

describe the anatomy of a chromophobe carcinoma

A

gross; brown colour
histology; very thick cell membrane, perinuclear halo

very good prognosis compared to others

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23
Q

describe a collecting duct carcinoma

A

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

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24
Q

describe a sarcomatous carcinoma

A 
a type of collecting duct carcinoma
spindle pattern
lots of mitotic figures
associated with a very poor prognosis
usually has spread beyond the kidney
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25
Q

describe the steps of pathological staging of a kidney tumour

A

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

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26
Q

describe furham grading

A

based exclusively on nuclear size
1; very small nuclei
4; quite big nuclei, lots, prominent nucleoli

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27
Q

what is the treatment of renal cell carcinomas?

A

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

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28
Q

describe transitional cell carcinoma of the kidney

A

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

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29
Q

describe Wilms’ tumour/nephroblastoma

A

most common paediatric tumour
affects children age 2-4
present with an abdominal mass
prognosis; improved considerably, improved surgical technique and chemotherapy

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30
Q

describe the anatomy of wilms’ tumour

A

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

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31
Q

what is the types of clinical presentation of glomerulonephritis?

A 
nephrotic syndrome; significant protein loss in the urine
nephritic syndrome; renal impairment
acute renal failure
chronic renal failure
incidental
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32
Q

describe nephrotic syndrome

A

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

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33
Q

describe the electron microscopy of membranous glomerulonephritis

A

lots of sub-epithelial deposits along the basement membrane

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34
Q

what are the clinical and urinary findings in nephritic syndrome?

A

blood in the urine
renal impairment
hypertension
active urine sediment

urinary;
hyaline casts
red blood cell casts
inflammatory cells; acute or chronic

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35
Q

what are the histological features of nephritic syndrome?

A

proliferation; lots of cells within the glomeruli

neutrophil polymorphs within the capillary loops

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36
Q

what is the clinical presentation of acute renal failure?

A

failing urinary output or total anuria
elevated creatinine
hypertension

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37
Q

describe chronic renal failure

A

slow onset
elevated creatinine
irreversible
usually leads to end stage renal disease; requiring dialysis and hopeful transplantation

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38
Q

what are the types of primary glomerulonephritis?

A

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

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39
Q

describe renal biopsy

A

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

40
Q

what are the stains used to look for in renal biopsy?

A

haematoxylin eosin stain; morphology
masson’s trichrome; connective tissue
silver stain; basement membrane
PAS stain

41
Q

describe immunofluorescence of renal biopsy

A 
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
42
Q

describe electron microscopy of renal biopsy

A

identifies;
deposits and structural anomalies in the basement membrane
hereditary renal disease
conditions with a splitting of the basement membrane

43
Q

what conditions can cause chronic renal failure?

A

vascular disease
diabetes
chronic tubulointerstitial nephritis

44
Q

what are the types of tumour in the bladder and ureters?

A

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

45
Q

describe the pathology of transitional cell carcinoma

A

most are not invasive
huge proportion recur
20-30% recur as invasive carcinomas; metastatic potential and require thorough treatment

46
Q

what are the risk factors for bladder cancer?

A

smoking; rare to get a bladder tumour in a non-smoker
occupational exposure to aniline dye; rubber industry
male
hydrocarbon exposure

47
Q

what is the clinical presentation of bladder cancer?

A

sometimes asymptomatic
LOTS;
micro/haematuria; detected in dipstick testing
mass lesion; palpable mass indicates a very advanced tumour

48
Q

what investigations are required to diagnose bladder cancer?

A 
cystoscopy
CT
MRI
IVU; usually incidentally
biopsy; can only tell exactly what it is
cold cup biopsies; small lesion
TURBT; large lesion
49
Q

describe the potential findings of a cystoscopy

A

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

50
Q

describe the histology of a bladder grade 1 TCC

A

multi layered; usually more than 7
loss of orientation
occasional cells slightly enlarged

51
Q

describe the histology of a bladder grade 2 TCC

A

loss of orientation

more marked cellular pleomorphism

52
Q

describe the histology of a bladder grade 3 TCC

A

lots of cells coming off the surface

lots of cellular pleomorphism; mitotic figures throughout

53
Q

describe the histology of a bladder adenocarcinoma

A

forms papillary structures and glandular structures
more common in the dome of the bladder
sometimes in associated with persistent urachus or brachial remnants

54
Q

describe the staging of bladder TCC

A

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

55
Q

what is the treatment of bladder cancer?

A

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

56
Q

describe carcinoma in situ of the bladder

A

full thickness dysplasia
often seen as a red patch in the bladder
often found along with TCC

57
Q

what is the treatment of carcinoma in situ of the bladder?

A

on its own; BCG therapy

may require numerous courses

58
Q

what are the types of renal, pelvic and ureteric tumours?

A

transitional cell; almost 90%
squamous cell carcinoma; occasionally
adenocarcinoma; less common

59
Q

describe ureteric cancer

A

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

60
Q

what are the types of penile cancer?

A

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

61
Q

what are the risk factors for penile cancer?

A 
poor hygiene
uncircumcised
phimosis
HPV; younger males
smoking
62
Q

what are the pre-neoplastic conditions associated with penile cancer?

A

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

63
Q

describe the histology of the testes

A

seminiferous tubules and interjacent stroma
contain leydig cells; produce testosterone
Sertoli cells present; provide nutritional support
germ cells; form spermatozoa

64
Q

what can be seen in a biopsy of the testes?

A

spermatogenesis; normal, absent
pre-neoplastic change
intratubular germ cell neoplasia

65
Q

what are the non-neoplastic conditions of the testes?

A

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

66
Q

describe testicular torsion

A 
dark
congested
sometimes haemorrhage causes infarction
fairly uncommon
acute medical/surgical emergency
treatment; untwist the testicular vessels and suture it to the scrotal sac
67
Q

describe testicular cancer

A

incidence is rising
affects younger males
18-55yrs
most have a good prognosis

68
Q

what are the types of testicular cancer?

A 
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
69
Q

what are the subtypes of germ cell testicular tumours?

A

seminomas; 50%
non-seminomatous/teratomas; 15%
mixed germ cell tumours; 33%

70
Q

describe seminomas

A 
mid 30-40s
most common individual testicular tumour
very amenable to treatment
very radiosensitive
good prognosis
fleshy, pale tumours
71
Q

describe the histology of seminomas

A

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

72
Q

describe non-seminomatous germ cell tumours

A 
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

73
Q

what are the patterns of differentiation of malignant teratomas?

A

embryonal carcinoma
yolk sac tumour
choriocarcinoma
mixed form; polyembryoma

74
Q

describe the histology of embryonal carcinoma teratomas

A

forms glands
poorly differentiated
associated with spindle primitive stroma

75
Q

describe the histology of yolk sac teratomas

A

schiller-duval body
central vessel
rim of epithelial cells
second rim; almost glomerular type structure

76
Q

describe the histology of choriocarcinoma teratomas

A

often associated with haemorrhage

lots of giant cells and cytotrophoblasts

77
Q

describe primitive teratomas

A

very primitive neural tissue
worst kind to have
does not respond to chemotherapy if seen in the lymph nodes

78
Q

how is a testicular tumour diagnosed?

A

usually present with a painless lump
test for markers
test for lymphatic spread

79
Q

what testicular tumours will respond to which type of markers?

A

seminoma; only raised LDH

teratomas; raised AFP and HCG, particularly in choriocarcinoma and some mixed germ cell tumours

80
Q

what is the treatment of testicular tumours?

A

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

81
Q

what is the MRC criteria for testicular tumours?

A

presence of embryonal carcinoma (1)
absence of yolk sac tumour (1)
lymphatic invasion (1)
vascular invasion (1)

> 2; give chemotherapy after surgery

82
Q

what is the 5-year survival of testicular tumours?

A

seminomas; 95%

teratomas; 90%

83
Q

what are the common benign conditions of the prostate?

A

benign nodular hyperplasia

prostatitis; polymorphs extending into the prostatic glands, often follows lower UTI

84
Q

describe benign nodular hyperplasia

A

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

85
Q

what is the treatment of benign nodular hyperplasia?

A

drugs

transurethral resection of the prostate (TURP)

86
Q

describe prostatic carcinoma

A

most common tumour in males

incidence increasing; increased detection of serum PSA

87
Q

what are the types of prostatic carcinoma?

A

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

88
Q

what is the presentation of prostatic carcinoma?

A 
usually asymptomatic
outflow obstruction; BNP
haematuria
abnormal PR examination
abnormal PSA
89
Q

what investigations are required to diagnose a prostatic carcinoma?

A

TRUS biopsies; US of the rectum and prostate gland to detect areas of abnormality to biopsy
MRI or CT
bone scan

90
Q

what is the treatment of prostatic carcinoma?

A

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

91
Q

describe the Gleason score

A

1-5; well - poorly differentiated
two most common patterns graded and combined
total score / 10

92
Q

describe the scores of the Gleason score

A

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

93
Q

describe radical prostatectomy

A

most realistic hope for cure
usually performed in males <65yrs
only performed if PSA <15 and if Gleason score <7 on biopsy

94
Q

describe the staging of prostatic carcinoma on core biopsies

A

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

95
Q

what does the prognosis of prostatic carcinoma depend on?

A

PSA
stage
Gleason score

Scientific Basis of Clinical Practice (10 decks)

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