L15- Renal and Bladder Tumors

Question 1

list the common benign renal tumors

Answer 1

• renal adenoma
• renal oncocytoma
• angiomyolipoma

Question 2

list the common malignant renal tumors

Answer 2

• renal cell carcinoma (90%, RCCa)
• urothelial carcinoma (TCCa)

-Wilm’s Tumor / Nephroblastoma (in children)

Question 3

Angiomyolipoma is a (benign/malignant) tumor and is considered triphasic because it (2). 50% present with (3) which is usually (4). Some present sporadically and occur with (5).

Answer 3

(most common benign tumor)
1- benign (rarely malignant)
2- involves muscle, fat, vessels
3- tuberous sclerosis (25 yrs)
4- asymptomatic, small in size
5- (45 yrs) flank pain, mass, hematuria, retroperitoneal hemorrhage
(good prognosis, treat by excision)

Question 4

The most common kidney cancer is (1) and it is a (benign/malignant) tumor of the (3). The majority of tumors are described as (single/multiple), (uni/bi)-lateral, (predictable/sporadic).

Answer 4

1- RCCa (renal cell carcinoma- 90%)
2- malignant
3- tubular epithelial cells
4- single, unilateral, and sporadic (majority, some are syndrome related)

Question 5

(1)% of RCCa is hereditary with the following 3 types: (2)

Answer 5

1- 5%
2-
i) Autosomal Dominant RCCa
ii) Von-Hippel-Lindau disease (VHL)
iii) hereditary papillary RCCa (multiple and bilateral found in younger people)

glial cell RCCa are most common

Question 6

RCCa mostly in occurs in (1) age group among (males/females) most.

Answer 6

1- 50s

2- males > females (2:1)

Question 7

RCCa usually presents with (1) as the most common sign with (2) as a very seldom accompanied sign. One of the most distinguishing features is that RCCa causes (3).

Answer 7

1- hematuria
2- flank pain, (palpable mass <10% of Pts)
3- paraneoplastic syndrome

Question 8

describe the related issues of RCCa and paraneoplastic syndrome

Answer 8

• polycythemia (EPO)
• HTN (renin)
• hypercalcemia (PTH)
• Cushing’s syndrome (ACTH)
• leukemoid rxn (leukoxytosis)
• amyloidosis

Question 9

RCCa is diagnosed via….

Answer 9

• renal US
• CT
• IV pyelography
• biopsy

Question 10

RCCa is graded based on (1).

Describe the 4 stages of RCCa: (2)

Answer 10

1- nucleus appearance: Fuhrman 1-4

2-
Stage I) confined to kidney (5yrs, 60-80%)
II) perirenal fat (5yrs, 40-70%)
III) lymph node + IVC (5yrs, 10-40%)
IV) adjacent organs / metastasis (5yrs, 5%)

Question 11

RCCa is treated by….

Answer 11

nephrectomy (radical or partial)

Question 12

(1) is the most common solid tumor in children, usually affecting them before (2) y/o. It is the result of a (3) mutation.

Answer 12

1- Wilm’s Tumor
2- <6 y/o (90%)
3- 2 mutated suppressor genes (WT1/WT2 loss of function mutations; *somatic mutation, not inherited)

Question 13

Wilm’s tumor appears (1) on gross inspection. It is considered to have a triphasic pattern because (2). (3) is the main description of cell status upon microscopic investigation.

Answer 13

1- single, well circumscribed, encapsulated, soft, fleshy, grey-white/tan
2- it involves blastema, stroma, epithelial (tubular structure and glomeruli)
3- anaplasia (nuclear size is 3x bigger, abnormal mitosis)

Question 14

list and briefly describe the 3 congenital abnormalities involved with the bladder (malformations)

Answer 14

• Extrophy: bladder protrudes out of abdomen wall
• Diverticula: extra pouch stemming from bladder wall (through the muscle, inc chance for infection, renal stones)
• Urachus: remnant of allantois which drained fetal bladder via umbilical cord (urine from navel and cyst in canal is common)

Question 15

list the 3 inflammatory (infectious) lesions of the bladder

Answer 15

• acute cystitis
• chronic interstitial cystitis
• malacoplakia

Question 16

Cystitis (acute) is more common in (males/females) because of (2).

Answer 16

1- females

2- short urethra

Question 17

list the common pre-disposing factors that help lead to cystitis (acute)

Answer 17

(females > males, short urethra)

• DM
• instrumentation (catheter, cystoscopy)
• bladder calculi (stones)
• bladder outlet obstruction (BPH)

Question 18

Cystitis (acute) is usually secondary to (1), but it can also occur as a result of (2).

Answer 18

1- Infection:

• bacteria: E.Coli, Proteus, Klebsiella, Enterobacter
• fungus: Candida
• parasite: Schistoma hematobium

2- Iatrogenic: chemotherapy, radiation => hemorrhagic cystitis

Question 19

list the symptoms / clinical presentation of cystitis (acute)

Answer 19

• urinary frequency (up to 20 times daily)
• dysuria (pain or burning micturition)
• microhematuria
• pain over bladder / suprapubic pain
• fever, chills

(Dx via UA)

Question 20

Chronic interstitial cystitis is caused by (1) and is most common in (2) people (age/gender).

Answer 20

1- unknown

2- middle aged women

Question 21

list the signs and symptoms of chronic interstitial cystitis

Answer 21

• suprapubic pain (pain with bladder filling)
• urinary frequency / urgency
• nocturia, hematuria

Question 22

Chronic interstitial cystitis has (1) appearance on cystoscopy and (2) via pathological examination

Answer 22

1- edema, hemorrhage, ulceration

2- chronic inflammation, mast cells

Question 23

list the 3 types of urothelial neoplasms (indicate if usually benign or malignant)

Answer 23

• Epithelial
• Mesenchymal (sarcomas, bengin or malignant, not kidney)
• secondary tumors (metastatic tumors via kidney, not common)

Question 24

list the breakdown of epithelial tumors

Answer 24

Benign: urothelial papilloma

Malignant: urothelial carcinoma (TCCa, 90%), SCC (via infection, 7%), adenocarcinoma (via Urachus, 1-2%)

Question 25

describe the 4 types of gross features of urothelial tumors (aka the 4 classifications)

Answer 25

i) Papilloma (papillary carcinoma)
ii) Invasive papillary carcinoma

iii) flat noninvasive carcinoma (carcinoma in situ, serious dysplasia)
iv) flat invasive carcinoma

Question 26

Urothelial carcinomas, aka (1), are most common in (2) age group and more common in (males/females). It is also associated with the following mutations: (4).

Answer 26

1- TCCa (transitional cell carcinoma)
2- 50-80 y/o
3- males > females, 3:1
4- p53, Rb, p16 genes

Question 27

list the risk factors for bladder cancer

Answer 27

• Smoking: biggest factor, inc 2x
• Drugs: analgesic abuse (phenacetin), cyclophosphamide
• Chemicals (in workplace): naphthylamine, rubber
• Infections: schistosomiasis (parasite)

Question 28

list the clinical features of urothelial carcinoma

Answer 28

• painless hematuria (70-90%)
• dysuria (20%)
• urinary urgency / frequency
• flank pain
• metastatic disease (up to 20%)

Question 29

(1) is the most common bladder tumor. It grows (endo/exo)-phytic and is a (high/low) grade tumor with (superficial/deep) invasion, (no/single/multiple) recurrences, and is describes as (uni/multi)-focal in terms of the urinary tract.

Answer 29

1- Papillary carcinoma (75%)

exophytic, both low/high grade, superficial invasion, multiple recurrences, multifocal (multiple locations on urinary tract)

Question 30

flat noninvasive urothelial carcinoma is also called…

Answer 30

carcinoma in situ (CIS)

Question 31

Most invasive urothelial carcinomas are (flat/papillary) and are (high/low) grade tumors with frequent metastasis to (3), therefore giving it a (good/poor) prognosis.

Answer 31

1- flat (papillary is ~10% of invasives)
2- high grade (poor differentiation)
3- regional nodes, liver, lung, bone
4- poor prognosis

Question 32

describe the treatment for urothelial carcinomas based on stage

Answer 32

i) CIS: TUR (transurethral ressection) if localized, chemotherapy if multifocal
ii) noninvasive papillary: TUR
iii) invasive CA: TUR if superficial, surgical/cystectomy if deep, radiotherapy
iv) metastatic CA: chemotherapy

Question 33

list the prognostic factors affecting Stage and Grade of urothelial carcinomas

Answer 33

Stage: depth of invasion of bladder wall, nodal metastases, distant metastases

Grade (via architecture and cytology): low and high grade

Question 34

The 5 yr survival rate for urothelial carcinomas is (1).

• (2) for 10 yr rate in low grade tumors
• (3) for 10 yr rate in high grade tumors
• (4) for 5 yr rate in deeply invasive tumors

Answer 34

1- 57%
2- 98%
3- 40%
4- 20%

Question 35

SCC urothelial neoplasm is a (primary/secondary) tumor, mostly caused by (2) and has a (good/bad) prognosis

Answer 35

1- primary (5% of total)
2- Schistosoma Hematobium (parasite)
3- bad, the worst prognosis