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Renal and Urological Pathology > Histo: Urology > Flashcards

Histo: Urology Flashcards

1
Q

What are urinary calculi?

A

Crystal aggregates in the renal collecting ducts that can be deposited anywhere in the tract

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2
Q

What is the epidemiology of urinary calculi?

A
  • 15% lifetime incidence
  • M:F = 3:1
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3
Q

List the three main types of urinary tract calculi in order of prevalence.

A
  • Calcium oxalate (Weddelite) - 75%
  • Magnesium ammonium phosphate (Struvite) - 15%
  • Urate - 5%
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4
Q

What is the basic mechanism behind the formation of calcium oxalate stones?

A

Increased urinary calcium concentration (hypercalciuria)

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5
Q

List some underlying conditions that can lead to the formation of calcium oxalate stones.

A
  • Absorptive hypercalciuria - excessive calcium absorption from the gut
  • Renal hypercalciuria - impaired absorption of calcium in the proximal renal tubule
  • Hypercalcaemia e.g. hyperparathyroidism (RARE)
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6
Q

Describe how magensium ammonium phosphate stones (triple stones) are formed.

A
  • Results from infection by a urease-producing organism (e.g. Proteus)
  • Ammonia produced by the bacteria alkalinises the urine leading to precipitation of magnesium ammonium phosphate stones
  • Often form “staghorn calculi” – very large and painful
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7
Q

Which patients are predisposed to the formation of urate stones?

A

Conditions causing hyperuricaemia

  • Gout
  • Rapid cell turnover (e.g. chemotherapy)

Most patients do not actually have hyperuricaemia or increased uric acid excretion in urine - believed to be due to tendency to produce slightly acidic urine

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8
Q

What are 3 common presentations of urinary calculi?

A
  • Haematuria
  • Colic
  • Recurrent UTI
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9
Q

Where do urinary calculi stones tend to get stuck within the urinary tract?

A
  • Pelvic-ureteric junction
  • Pelvic brim
  • Vesico-ureteric junction

This causes renal colic symptoms

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10
Q

What are the consequences of large stones?

A
  • Obstruction
  • Risk of infection
  • CKD

This is because large stones tend to get stuck in the kidney

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11
Q

What is the management of renal calculi?

A
  • Small stones may pass spontaneously
  • Large stones may be removed by endoscopic or percutaneous methods or using lithotripsy
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12
Q

List three types of benign renal neoplasm.

A
  • Papillary adenoma
  • Renal oncocytoma
  • Angiomyolipoma
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13
Q

Define papillary adenoma.

A

Benign renal epithelial tumour with a papillary or tubular architecture

  • They must be <15 mm in size
  • Well-circumscribed
  • Linked to papillary renal cell carcinoma

Frequent found incidentally in nephretomies and autopsies (especially in those with damaged kidneys e.g. CKD)

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14
Q

Describe the histological appearance of a papillary adenoma

A
  • Bland epithelial cells growing in a papilliary or tubopapilliary pattern
  • Well circumscribed cortical nodules
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15
Q

What are the genetic associations of papillary adenomas?

A
  • Trisomy 7 and 17
  • Loss of Y chromosome (can occur in the cells of men with age)
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16
Q

What is a renal oncocytoma?

A
  • Benign renal epithelial tumour composed of oncocytic cells
  • They are usually well-circumscribed and usually sporadic

NOTE: often an incidental finding

Oncocytes are cells that have accumlated numerous mitochondria

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17
Q

Name a syndrome that is associated with renal oncocytoma.

A

Birt-Hogg-Dubé syndrome

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18
Q

Describe the histological appearance of oncocytes.

A
  • Large cells
  • Pink (eosinophilic) granular cytoplasm (due to numerous mitchondria)
  • Prominent nucleolus
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19
Q

Describe the histological appearance of a renal oncocytoma

A

Macroscopic – mahogany brown
Microscopic – sheets of oncolytic cells, pink cytoplasm, form nests of cells

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20
Q

What is an angiomyolipoma?

A

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

  • Derived from perivascular epitheloid cells
  • Mostly sporadic

NOTE: often an incidental finding but may cause flank pain, haemorrhage and shock (if >4cm)

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21
Q

Describe the histological appearance of an angiomyolipoma

A

Fat spaces, thick bloods vessels and spindle cell components

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22
Q

Which hereditary condition is associated with angiomyolipoma?

A

Tuberous sclerosis

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23
Q

What is renal cell carcinoma?

A

Malignant epithelial kidney tumour

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24
Q

List some risk factors for renal cell carcinoma.

A
  • Smoking
  • Hypertension
  • Obesity
  • CKD requiring long-term dialysis
  • Genetic (e.g. von Hippel Lindau)
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25
Q

How does renal cell carcinoma tend to present?

A
  • Painless haematuria (50% of cases)
  • Remaining cases are detected incidentally on imaging
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26
Q

Name the subtypes of renal cell carcinoma in order of prevalence.

A
  • Clear cell renal cell carcinoma (70%)
  • Papillary renal cell carcinoma (15%)
  • Chromophobe renal cell carcinoma (5%)
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27
Q

What are clear cell renal cell carcinoma.

A

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

  • Macroscopic – golden yellow with haemorrhagic areas
  • Microscopic – nests of epithelium with clear cytoplasm
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28
Q

What is a common cytogenetic finding in clear cell renal carcinoma?

A

Loss of chromosome 3p

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29
Q

Describe papillary renal cell carcinoma

A

Epithelial kidney tumour composed of papillae and/or tubules

  • By definition >15mm in size
  • Cytogenetics show trisomy 7 and 17, and loss of Y chromosome
  • 2 histological subtypes

NOTE: this is the malignant counter part of papillary adenoma.

30
Q

Describe the macroscopic and microscopic appearance of papillary renal cell carcinoma

A
  • Macroscopic – fragile, friable brown tumour
  • Microscopic – papilliary / tubopapilliary growth pattern
31
Q

Describe the histological appearance of the two types of papillary renal cell carcinoma.

A
  • Type 1: composed of a single layer of small and flat cells. You see a lot of islands of cells.
  • Type 2: there is pseudostratification of the cells

NOTE: type 2 tends to have a worse prognosis than type 1

32
Q

Define chromophobe renal cell carcinoma.

A

Epithelial kidney tumour composed of sheets of large cells that display

  • Soap-bubble appearance
  • sharply-defined cell borders
  • reticular cytoplasm
  • thick-walled vascular network

NOTE: grossly appears as a well-circumscribed solid brown tumour

33
Q

What is the 5-year survival for renal cell carcinoma?

A

60% across all types

34
Q

What grading system is used for clear cell and papillary renal cell carcinoma? What staging system is used?

A
  • Grading: ISUP Nuclear Grade (1-4)
  • Staging: TMN 8th Edition
35
Q

What risk progression index is used for clear cell carcinoma?

A

Leibovich Risk Model (takes into account grade, stage, lymph node status etc.)

36
Q

What is Nephroblastoma (Wilm’s tumour)?

A

Malignant triphasic kidney tumour of childhood:

  • Blastema (small round blue cells)
  • Epithelial
  • Stromal

Typically present with an abdominal mass in children aged 2-5 years

NOTE: 95% have an excellent prognosis

Second most common childhood malignancy

37
Q

What is urothelial carcinoma?

A

Also known as transitional cell carcinoma

Group of malignant epithelial neoplasms arising from the urothelial tract (anywhere from renal pelvis, ureter, bladder, urethra)

Most commonly bladder

38
Q

What are the major risk factors for urothelial carcinoma?

A

Smoking

Aromatic amines

39
Q

How do most urothelial carcinomas present?

A

Painless haematuria

40
Q

What are the three main subtypes of urothelial carcinoma?

A
  • Non-invasive papillary urothelial carcinoma
  • Infiltrating urothelial carcinoma
  • Flat urothelial carcinoma in situ
41
Q

Describe the macroscopic appearance of non-invasive papillary urothelial carcinoma.

A
  • Appears as frond-like growths
  • Can be divided into low or high grade dependent on nuclear atypia
  • Low grade tumours have low risk of progression to invasive disease
  • High grade tumours have high risk of invasion - are genetically unstable and carry numerous mutations including RB and TP53
42
Q

Describe the histological appearance of invasive urothelial carcinoma.

A
  • This is urothelial tumour that has started showing invasive behaviour
  • Usually grow as solid masses, fixed to tissue
  • Once urothelial cells to invade, the morphology becomes very diverse (e.g. squamous, adenocarcinoma, sarcoma etc.)
  • Treatment is based on the depth of invasion: lamina propria, muscularis propria
43
Q

What is flat urothelial carcinoma in situ?

A

High grade lesion in situ (high risk of progression to invasive)

Gross appeance: may be invisble or appear as a reddish area

44
Q

Define benign prostatic hyperplasia. Which area of the prostate does it affect?

A
  • Benign enlargement of the prostate gland as a consequence of increased cell number
  • Arrises from the transitional zone (surrounds urethra)
45
Q

Describe the epidemiology of BPH?

A

Very common - symptomatic in 25% of men by age 80

Histologically present in 90% of men by age 80

46
Q

What is a possible mechanism for the onset of BPH?

A
  • Increased oestrogen with ageing induces androgen receptors
  • Stimulates dihydrotestosterone-mediated hyperplasia of prostatic stromal and epithelial cells
  • Results in the formation of large nodules.
  • Nodule formation compresses prostatic urethra leading to outflow tract obstruction
47
Q

Describe the histological appearance of BPH

A

Nodule formation, prostatic epithelial ducts with duct spaces

48
Q

List some treatment options for BPH.

A
  • Alpha blockers (tamsulosin)
  • 5alpha-reductase inhibitors (finasteride)
  • Transurethral resection of the prostate (TURP)
49
Q

How can BPH present?

A
  • LUTS (most common)
  • UTI
  • Acute urinary retention
  • Renal failure
50
Q

What symptoms are included in LUTS?

A
  • Frequency
  • Urgency
  • Nocturia
  • Terminal dribbling
  • Hesitancy
  • Incomplete voiding
  • Poor flow
  • Straining
51
Q

What is the most common malignant tumour in men?

A

Prostate cancer (adenocarcinoma)

52
Q

Descibe the epidemiology of prostate adenocarcinoma?

A
  • 25% of all male cancers
  • Will affect 1 in 8 men
  • 5-10x increased risk if first degree relative is affected
53
Q

What is the precancerous lesion that prostate cancer arises from?

A

Prostatic intraepithelial neoplasia (PIN)

54
Q

List some mutations that are implicated in prostate cancer.

A
  • PTEN
  • AMACR
  • P27
  • GST-pi
55
Q

What are presenting symptoms of prostate adenocarcinoma?

A
  • Usually asymptomatic - diagnosed on biopsy following raised PSA or DRE
  • May have LUTS
  • May present with metastatic disease - back pain, pathological fracture
  • Weightloss and loss of appetitie if extensive disease
56
Q

What scoring system is used for prostate cancer? Explain how it is calculated.

A

Gleason score (1-10)

  • 1-5 based on differentiation (5 is least differentiated and most aggressive)
  • Take a biopsy and classify the most common pattern seen and the worst pattern seen
  • Add these two numbers together to get a result out of 10
  • Expressed as x + y = z
  • Higher scores are associated with poorer prognosis
57
Q

What is the epidemiology of testicular germ cell tumours?

A
  • Account for 90% of testicular tumours
  • Arise in men aged 20-45
58
Q

List some risk factors for testicular germ cell tumours.

A
  • Undescended testicles
  • Low birth weight
59
Q

What is the pre-malignant lesion associated with testicular germ cell tumours?

A

Germ cell neoplasia in situ

NOTE: this process probably begins in foetal life

60
Q

Which genetic factor is associated with testicular germ cell tumours?

A

Amplification of i12p

61
Q

How do testicular germ cell tumours present

A

Painless lump

10% present with symptoms related to metastasis:

  • Back pain
  • Cough
  • Dyspnoea
62
Q

List the five histological subtypes of testicular germ cell tumours.

A
  • Seminoma (most common)
  • Embryonal carcinoma
  • teratoma
  • Yolk sac tumour
  • Choriocarcinoma

Single tumour may be purely one subtype or contain a mixture of multiple subtypes

63
Q

Describe the histological appearance of:

  1. Seminoma
  2. Embryonal carcinoma
  3. Post-pubertal teratoma
  4. Yolk sac tumour
  5. Choriocarcinoma
A
  1. Seminoma
    • Mostly made up of clear cells with a prominent lymphocytic infiltrate
  2. Embryonal carcinoma
    • High-grade appearance with prominent nucleoli
  3. Post-pubertal teratoma
    • The tumour is trying to produce a variety of tissues (e.g. keratin, cartilage, glands)
    • This is malignant - any component of the tumour can become malignant
  4. Yolk sac tumour
    • Smaller cells
    • Lace-like pattern
    • Some pink inclusions
  5. Choriocarcinoma
    • Made up of two cell types: cytotrophoblasts (clear looking cells) and syncytiotrophoblasts (multinucleated cell)
    • NOTE: both components are needed to define choriocarcinoma
64
Q

How are testicular germ cell tumours treated?

A

They are highly sensitive to platinum-based chemotherapy

Excellent prognosis: 5-year survival is 98%

65
Q

Name three types of testicular non-germ cell tumours.

A
  • Lymphoma - more in older men; highly aggressive with poor prognosis
  • Leydig cell tumour - may cause precocious puberty (if pre-pubertal)
  • Sertoli cell tumour - 90% benign
66
Q

What are the causes of epididymitis?

A
  • <35 years = N. gonorrhoea and C. trachomatis
  • 35+ years = E. coli
67
Q

What is a varicocele and hydrocele?

A

Varicocele - dilated veins of the pampiniform plexus

Hydrocele - fluid accumulation between layers of tunica vaginalis

68
Q

What is an adenomatoid tumour?

A

Benign tumour consisting of small tubules lined by mesothelial cells

69
Q

List some types of benign penile diseases.

A
  • Lichen sclerosus - inflammatory condition that causes phimosis
  • Zoon’s balanitis - inflammatory condition that causes red areas
  • Condylomas (gential warts) - HPV6 and 11
  • Peyronie’s disease - scarring, inflammation and thickening of the corpus cavernosa

Penile lichen sclerosus also know as balanitis xerotica obliterans

70
Q

List some risk factors for penile carcinoma.

A
  • HPV
  • Smoking
  • Chronic lichen sclerosus
71
Q

List and describe some benign diseases of the urethra.

A
  • Urethritis - gonorrhoea and chlamydia
  • Prostatic urethral polyp - papillary lesion in the prostatic urethra
  • Urethral caruncle - common lesion at the urethral meatus in women

NOTE: malignant diseases include urethral carcinoma (squamous cell carcinoma) and malignant melanoma

72
Q

List and describe some diseases of the scrotum.

A
  • Epidermoid cyst (common)
  • Scrotal calcinosis
  • Angiokeratomas (benign vascular lesions)
  • Fournier’s gangrene - necrotising fasciitis of the scrotum and perineum
  • Scrotal squamous cell carcinoma

Renal and Urological Pathology (8 decks)

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