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a path 3 > HISTO: Urological pathology > Flashcards

HISTO: Urological pathology Flashcards

1
Q

What are urinary calculi?

A

Crystal aggregates that form in the renal collecting ducts

May be deposited anywhere in the urinary tract

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2
Q

How common are renal calculi? Who is most affected?

A

Lifetime incidence 15%

M:F 3:1

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3
Q

What are the three most common types of urinary calculi?

A
  • Calcium Oxalate (Weddellite) – 75%
  • Magnesium Ammonium Phosphate (Struvite) – 15%
  • Uric Acid – 5%
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4
Q

What are three aetiologies of calcium oxalate calculi?

A

Absorptive hypercalciuria – excessive gut calcium absorption

Renal hypercalciuria – impaired proximal renal tubule absorption of calcium

Hypercalcaemia – primary hyperparathyroidism, rare

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5
Q

What are triple stones? Why do they form?

A

Magnesium ammonium phosphate stones = ”triple stones”

Form as a consequence of infection with urease-producing organisms e.g. Proteus sp.

Ammonia alkalinises urine –> precipitation of magnesium ammonium phosphate salts

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6
Q

What form can triple stones take?

A

Can become very large –> “Staghorn Calculi”

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7
Q

When do uric acid stones form?

A

Uric acid stones may form in patients with hyperuricaemia e.g.

  1. Gout
  2. Rapid cell turnover

BUT most patients do not actually have hyperuricaemia or increased uric acid excretion in urine so believed to occur due to (3) tendency to produce slightly acidic urine.

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8
Q

What are the complications of urinary calculi?

A

If large:

  • Obstruction,
  • risk of infection,
  • chronic renal failure
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9
Q

When do urinary calculi cause colic? What locations?

A

When small stones that drift out of the kidney may become impacted in…

  • Pelvi-ureteric junction (PUJ)
  • pelvic brim
  • vesico-ureteric junction (VUJ)
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10
Q

Name 3 benign renal neoplasms.

A
  • Papillary adenoma
  • Angiomyolipoma
  • Renal oncocytoma
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11
Q

Define renal papillary adenoma.

A

Benign epithelial kidney tumour composed of papillae and / or tubules

By definition, 15mm or less in size + well-circumscribed

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12
Q

What genetic abnormalities are renal papillary adenomas associated with?

A
  • Trisomy 7,
  • Trisomy 17,
  • Loss of Y chromosome
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13
Q

When are papillary adenomas more commonly diagnosed?

A

Frequent incidental finding in nephrectomies and at autopsy

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14
Q

What is this benign renal tumour?

A

Papillary adenoma

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15
Q

What is this benign renal tumour?

A

Renal oncotyoma

- Pink, oncocytic cells – full of mitochondria

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16
Q

What is this benign renal tumour?

A

Angiomyolipoma

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17
Q

What is renal oncocytoma?

A
  • Benign epithelial kidney tumour composed of oncocytic cells
  • Well-circumscribed
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18
Q

What is the aetiology of renal oncocytoma?

A
  • Usually sporadic
  • Can be seen in Birt-Hogg-Dubé syndrome

Birt-Hogg-Dubé syndrome (BHD) = hereditary condition associated with multiple benign skin tumors, lung cysts, and an increased risk of renal lesions (cysts, benign tumors, and kidney cancer.)

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19
Q

Which benign renal tumour is associated with BHD syndrome?

A

Renal oncocytoma

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20
Q

What are renal angiomolipomas?

A

•Benign mesenchymal kidney tumour composed of thick-walled blood vessels, smooth muscle and fat

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21
Q

What are angiomyolipomas derived from? What is their aetiology?

A

Derived from perivascular epithelioid cells

Mostly sporadic. Can be seen in tuberous sclerosis.

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22
Q

What are the complications of angiomyolipomas?

A

Usually an incidental finding but larger tumours (>4cm) can cause:

  • flank pain
  • haemorrhage
  • shock
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23
Q

Name three types of malignant renal neoplasms.

A

Renal cell carcinoma

  • Clear cell
  • Papillary
  • Chromophobe

Nephroblastoma

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24
Q

What is renal cell carcinoma? How common is it?

A

Malignant + epithelial renal tumour

2% of all cancers worldwide, more common in developed countries

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25
Q

List 4 risk factors for RCC.

A
  • Smoking
  • Hypertension
  • Obesity
  • Long-Term Dialysis
  • Genetic Syndromes – von Hippel Lindau
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26
Q

How does RCC present?

A
  • 50% present with painless haematuria
  • Detected incidentally on imaging
  • Some present with metastatic disease
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27
Q

What are the main subtypes of RCC and which is most common?

A
  1. Clear Cell Renal Cell Carcinoma (70%)
  2. Papillary Renal Cell Carcinoma (15%)
  3. Chromophobe Renal Cell Carcinoma (5%)

Remaining 10% are various rare subtypes

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28
Q

What genetic abnormality is seen in clear cell RCC?

A

loss of chromosome 3p

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29
Q

What is a clear cell RCC composed of? Describe its gross appearance.

A

Epithelial kidney tumour composed of nests of clear cells set in a delicate capillary vascular network

Golden yellow tumour with haemorrhagic areas

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30
Q

What genetic mutations are seen in papillary RCC?

A
  • trisomy 7,
  • trisomy 17
  • loss of Y chromosome
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31
Q

What is the difference between papillary adenoma and papillary RCC?

A

Main difference is size

  • Papillary aenoma <15 mm
  • Papillary RCC >15mm

Both have similar mutations.

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32
Q

What are papillary RCCs subdivided based on?

A

Morphology

Two types:

  • Type 1 = well defined, show genetic loss consistently, single layer of smaller flat cells
  • Type 2 = heterogenous , may be further subdivided in the future; worse prognosis; multilayering/stratification of cells is characteristic
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33
Q

What is the gross histology of papillary RCCs?

A

Grossly appears as a fragile, friable brown tumour

(papillary adenomas = well circumscribed)

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34
Q

What is the gross histology of chromophobe RCC?

A

Grossly appears as a well-circumscribed solid brown tumour

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35
Q

What are the histological chromophobe RCCs? What genetic abnormalities exist?

A

Epithelial kidney tumour composed of sheets of large cells that display distinct cell borders, reticular cytoplasm and a thick-walled vascular network

Shows variable genetic aberrations

“plant-like” defined cell borders

36
Q

What is the prognosis for RCC? What is the most important prognostic factor?

A

Most important prognostic factor - stage and grade (ISUP Nuclear Grade (1-4) applies to clear cell and papillary renal cell carcinoma)

5-year survival for RCC = 60%

37
Q

What is the Leibovich risk model?

A

Clear Cell Renal Cell Carcinoma risk progression index

Stratifies into low risk, intermediate risk, high risk

38
Q

What is a Wilm’s tumour? What three components does it consist of?

A

Nephroblastoma = malignant triphasic kidney tumour of childhood:

Consists of:

  1. Blastema (small round blue cells)
  2. Epithelial cells
  3. Stromal cells
39
Q

How does nephroblastoma present? What is the prognosis?

A

Second most common childhood malignancy

Typically presents as an abdominal mass in children aged 2-5 years old

95% of cases show favourable histological features with excellent prognosis

40
Q

What are urothelial carcinomas also known as?

A

TCC - transitional cell carcinoma

They are a group of malignant epithelial neoplasms arising in urothelial tract

  • Bladder
  • Renal Pelvis
  • Ureters
41
Q

What are two risk factors for TCC/urothelial carcinoma?

A
  • Smoking
  • Aromatic amines (probably from a step in their production and not the actual amines)
42
Q

How do urothelial carcinomas present?

A

Most present with haematuria

43
Q

What are the three types of urothelial carcinomas?

A
  • Non-Invasive Papillary Urothelial Carcinoma
  • Infiltrating Urothelial Carcinoma
  • Flat Urothelial Carcinoma in-situ
44
Q

Describe the appearance of non-invasive papillary carcinomas. How are they divided into low vs high grade i.e. what is it based on?

A

frond-like growths (low grade on left, high grade on right)

Divided into low grade and high grade (WHO 2004) based on nuclear atypia

45
Q

True or false: Low grade non-invasive papillary urothelial tumours have a low risk of progression to invasive disease.

A

True =<5%

High grade tumours carry a higher risk of progression to invasive disease

46
Q

What mutations are present in non-invasive papillary urothelial carcinomas?

A

Unstable and carry various genetic abberations including:

  • RB
  • TP53
47
Q

What is an infiltrating urothelial carcinoma?

A

Urothelial tumour displaying invasive behaviour

48
Q

What is treatment of infiltrating urothelial carcinomas based on?

A

Treatment based on depth of invasion

  • Lamina propria
  • Muscularis propria
49
Q

Describe the appearance of flat urothelial carcinoma in situ (CIS). What is the prognosis?

A

May be invisible or appear as a reddish area

Flat urothelial lesion with unequivocal high grade features - high risk of progression

50
Q

What is BPH? How common is it?

A

Benign enlargement of prostate as a consequence of increase in cell number

Very common – symptomatic in 25% of men by age 80 and histologically present in 90% of men by age 80

51
Q

What is the aetiology of BPH? What is treatment based on?

A

Increased oestrogen levels in blood, which rises with age, may induce androgen receptors and stimulate hyperplasia

Treatment based on:

  • alpha blockers
  • 5⍺-reductase inhibitors
  • transurethral resection
52
Q

What are the clinical features of BPH?

A

Presents with “Lower Urinary Tract Symptoms”

  • Frequency
  • Nocturia
  • Urgency
  • Hesitancy
  • Poor flow
  • Terminal Dribbling

Rarely: urinary tract infection, acute urinary retention or renal failure

53
Q

What is shown?

A

BPH - nodule of normal glandular and stromal parts of the prostate which is expanding and growing on its own

54
Q

What is the most common malignant tumour in men?

A

Prostatic adenocarcinoma - malignant epithelial prostate tumour

55
Q

How common is prostatic adenocarcinoma?

A

25% of all male cancers

1 in 8 men will develop it in their lifetime

56
Q

What are some risk factors for prostatic adenocarcinoma?

A
  • Red meat consumption
  • 5-10x risk increase if first degree relative is also affected
57
Q

What does prostatic adenocarcinoma arise from? What mutations are implicated?

A

Arises from Prostatic Intraepithelial Neoplasia (PIN)

Mutations in PTEN, AMACR, GST-pi, p27 and more…

58
Q

What are the presenting features of prostatic aenocarcinoma?

A
  • Usually asymptomatic; usually diagnosed on biopsy following raised serum prostate-specific antigen or digital rectal examination
  • May have lower urinary tract symptoms
  • Rarely may present with metastatic disease e.g. pathological fracture
59
Q

What is the most powerful prognostic factor for prostatic adenocarcinoma?

A

Gleason score - influences treatment decisions

60
Q

Describe how the Gleason score is calculated and the significance of a high score.

A

Expressed as x + y = z

  • Add two most common patterns (or most common pattern + worst pattern in biopsy setting)
  • Patterns range from 1-5
  • 1 and 2 rarely if ever diagnosed so scores typically range from 6-10

Higher scores correlate with aggressive behaviour

  • High volume tumours scoring 8-10 in particular
  • Grade grouping used as well
61
Q

Prostatic Adenocarcinoma – Gleason Grades 1, 2 and 3

Distinct glands of the prostate are present and still resemble glands

A

Prostatic Adenocarcinoma – Gleason Grade 4

There is fusion and cribiform glands

62
Q

Prostatic Adenocarcinoma – Gleason Grade 5

Diagnosed by either:

  • pattern 4 with necrosis
  • OR sheets of tumour cells with no formation of glands
A
63
Q

What is the most common type of testicular tumour? Who is most affected?

A

Testicular germ cell tumours account for 90% of testicular tumour - they are tumours of the testis arising from germ cells

Typically arise in men aged 20-45

64
Q

What are the risk factors for testicular germ cell tumours?

A
  • Undescended testis (3-5x increased risk)
  • Low birth weight / small for gestational age
65
Q

What is the aetiology/pathophysiology of testicular germ cell tumours?

A

Malignant tumours arise from Germ Cell Neoplasia in-situ

  • Process likely begins in foetal life
  • Amplification of i12p
66
Q

What are the clinical features of testicular GC tumours? What % present with metastasis symptoms?

A

Present as painless lump

10% present with symptoms related to metastasis

  • Back pain – drainage is para-aortic so if affected will cause back pain
  • Cough
  • Dyspnoea
67
Q

What subtype of GC tumour is shown?

A

Seminoma - most common subtype, mostly clear cells

68
Q

What subtype of GC tumours is shown?

A

Embryonal carcinoma -anaplastic tissue, high grade appearance

69
Q

What subtype of GC tumour is shown?

A

Post-pubertal teratoma - this tumour is trying to produce keratin, there are some glandular parts and cartilage i.e. trying to produce various tissues from the germinal layers. Therefore, metastases may look very different

70
Q

What subtype of GC tumour is shown?

A

Yolk sac tumour - varying appearance but here small cells are seen with a lace-like growth pattern

71
Q

What subtype of GC tumour is shown?

A

Choriocarcinoma

  • Made up of cytotrophoblast cells (clear) and syncytiotrophoblastic cells (multinucleate cells)
  • Both need to be present to diagnose choriocarcinoma
72
Q

Which treatment are testicular GC tumours sensitive to?

A

Highly sensitive to platinum-based chemotherapy regimes

Prognosis excellent - 5 year survival is 98% in most countries

73
Q

Name 3 testicular non-germ cell tumours.

A
  • Lymphoma - older men, 5% of all testicular tumours
  • Leydig cell tumour - 3% of all testicular tumours
  • Sertoli cell tumour - 1% of all testicular tumours
74
Q

State whether each of these testicular tumours is benign/aggressive:

  • lymphoma
  • leydig cell tumour
  • sertoli cell tumour
A
  • Lymphoma - highly aggressive, poor survival rates
  • Leydig cell tumour - benign usually
  • Sertoli cell tumour - 90% benign
75
Q

List 4 different paratesticular conditions.

A
  • Epididymal cyst
  • Epididymitis
  • Varicocele - dilated venous plexus
  • Hydrocele - fluid between layers of tunica vaginalis
  • Adenomatoid tumour - small tubules lined by mesothelial cells
76
Q

What are the most common causes of epididymitis?

A

Usually related to:

  • C. trachomatis or N. gonnorrhoeae in men under 35;
  • E. coli in men over 35
77
Q

List 4 different penile diseases.

A
  • Lichen sclerosus/balanitis xerotica obliterans - inflammatory condition that causes phimosis
  • Zoon’s balanitis - inflammatory condition that causes red areas
  • Condylomas
  • Peyronie’s disease
  • Penile carcinoma
78
Q

What is the cause of condylomas?

A

HPV 6 and 11

79
Q

What is Peyronie’s disease?

A

Scarring , inflammation, thickening of corpus cavernosa

80
Q

What are the risk factors for penile carcinoma?

A
  • Smoking,
  • HPV,
  • chronic Lichen Sclerosus

Rare, affects elderly men

81
Q

List 4 urethral diseases.

A
  • Urethritis - N. gonorrhoeae, C. trachomatis
  • Prostatic Urethral Polyp - papillary lesion in prostatic urethra
  • Urethral Caruncle - common lesion at urethral meatus in women
  • Urethral Carcinoma - rare, more common in women
  • Malignant Melanoma - rare
82
Q

What cell type are most urethral carcinomas?

A

squamous cell carcinomas

83
Q

List 4 scrotal diseases.

A
  • Epidermoid Cyst – invagination of skin, common
  • Scrotal Calcinosis - rare; may be related to old epidermoid cysts
  • Angiokeratomas - benign vascular lesions
  • Fournier’s Gangrene
  • Scrotal squamous cell carcinoma - very rare, historical interest; chimney sweep
84
Q

What is Fournier’s gangrene?

A

Necrotising fasciitis that affects the genital, perineal, or perianal regions of the body

Mortality 15-20%

85
Q

What are the subtypes of testicular GC tumours?

A
  1. Seminoma
  2. Non-seminoma
    • Embryonal carcinoma
    • Post-pubertal teratoma
    • Yolk sac tumour
    • Choriocarcinoma

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