Pathology Flashcards
what is meant by agenesis?
complete absence of an organ
what do duplex system congenital abnormalities of the renal system give an increased risk of?
infection
do simple cysts of the kidney usually cause any problems?
no they are very common, usually no functional disturbance
what is the more rare form of polycystic disease and how is it inherited?
infantile type, autosomal recessive polycystic kidney disease
what does the infantile polycystic kidney disease cause? what is the prognosis?
uniform bilateral renal enlargement- elongated cysts- dilation of medullary collecting ducts. causes terminal renal failure, baby usually dies in neonatal period but less severe cases can survive a few months
what does infantile polycystic disease have an association with?
congenital hepatic fibrosis
what is the more common form of congenital cystic disease and how is it inherited?
adult polycystic disease- autosomal dominant polycystic kidney diease
what is the gene defect in ADPKD 1?
defect on chromosome 16
what is the gene defect in ADPKD 2?
defect on chromosome 4
what percentage of ADPKD is type 1?
90%
when does ADPKD usually present?
usually middle adult life
how does ADPKD usually present?
abdo mass, haematuria, hypertension, chronic renal failure
how many times is the enlargement of a kidney in ADPKD compared to normal?
10 times larger
what can be seen on the kidney in ADPKD?
multiple cysts of varying sizes, distortion of reniform shape of kidney.
where can cysts arise in the nephron ADPKD?
at any part of the nephron
what do 1/3rd of patients with ADPKD also have?
cysts in liver, pancreas and lung - usually no functional effect
what is ADPKD associated with?
berry anuerysms in circle of willis - subarachnoid haemorrhage
what are the cysts in ADPKD filled with?
most filled with clear fluid but some can be filled with blood
what are the 2 types of brain haemorrage someone with ADPKD is at risk of getting and why?
ADPKD associated with subarachnoid haemorrhage. Also at more risk if intracellular haemorrhage due to hypertension caused by ADPKD
what are the 4 most common benign renal tumours?
- fibroma
- adenoma
- angiomyolipoma
- JGCT
what is the origin and appearance of a renal fibroma?
medullary origin, white nodules
what is the appearance a renal adenoma and what size would you expect it to be?
yellowish nodules, often less than 2cm
where in the kidney would you find an adenoma?
cortex
what makes up the contents of an angiomyolipoma on the kidney?
mixture of fat, muscle and blood vessels
is an angiomyolipoma solitary or diffuse?
can be solitary but often multiple and bilateral
what condition is renal angiomyolipomas associated with?
Tuberous Sclerosis
how does a JGCT of the kidney cause secondary hypertension?
stimulates production of rennin
what is the commenest intra-abdominal tumour in children and what is it?
a nephroblastoma (Wilm’s tumour). Arises from residual primitive renal tissue
where in the renal system do you most commonly find uroethelial carcinomas?
renal pelvis and calyces
what is the commonest primary renal tumour in adults?
renal cell carcinoma
what is presenting age group and M:F ratio in renal cell carcinoma?
55-60 years. M:F - 2:1
how does a renal cell carcinoma usually present?
abdo mass, haematuria, flank pain, general features of malignant disease
what are the paraneoplastic manifestations of a renal cell carcinoma?
polycythaemia, hypercalcaemia
what causes polycythaemia in renal cell carcinoma?
erythropoietic stimulating substance
what is the macroscopic appearance of a renal cell carcinoma?
large, apparently well circumscribed mass centred on cortex. yellow colour with solid, cystic, necrotic and haemorrhagic areas
where does a renal cell carcinoma commonly extend in to?
into the renal vein
once a renal cell carcinoma is extended into the renal vein, where can it spread to?
into vena cava and up to right atrium
does a renal cell carcinoma usually spread by blood or lymph?
initially by blood- lymphatic spread later
what is the commonest type of renal cell carcinoma?
clear cell type
what are clear cell type tumour cells rich in?
glycogen and lipid
what is the name of the grading system in renal cell carcinoma?
Fuhrman staging
where does a transional cell carcinoma arrise from?
from transitional epithelium from pelvicalyceal system to urethra
transitional cell carcinomas make up what percentage of bladder tumours?
90%
risk factors for developing a transitional cell carcinoma?
-aniline dyes
-rubber industry
-benzidine
-cyclophophamide
-analgesics
- schistosomiasis
smoking
commenest symptom in transitional cell carcinoma?
haematuria
where do transitional cell carcinomas caused by analgesics most commonly occur?
renal pelvis
where do 75% of transitional cell carcinomas occur?
in region of trigone
what happens to the papillae in a transitional cell carcinoma?
has a thicker lining than normal urothelium
what does a stage of pTa mean?
superficial and non-invasive
what does a stage of pT1 mean?
stromal invasion
what does a stage of pT2 mean?
invasion of muscle
what lymph nodes would a transitional cell carcinoma spread to?
obturator nodes in the pelvis
why do patients with a treated transitional cell carcinoma have to be closely followed up?
recurrence is frequent and tumours often progress to higher grade/stage
what is the commonest malignant bladder tumour in children?
embryonal Rhabdomyosarcoma
what predisposes to a squamous carcinoma in the renal tract?
calculi, schistosomiasis
what predisposes to a adenocarcinoma of the renal tract?
- extroversion of the bladder
- urachal remnants
- long standing cystitis cystica
where do you find erythroplasia of Queyrat and what is its appearance?
mostly on glans of penis, has red velvety raised area
what is seen in bowens disease and erythroplasia of Queyrat?
full thickness dysplasia of epidermis
who does squamous carcinoma of the penis almost exclusively occur in?
in uncircumcised men
what things can predispose to a squamous cell carcinoma of the penis?
poor hygiene, HPV infection
what does a SCC of penis look like?
ulcerated indurated tumour or exophytic mass
what percentage of men over 70 have benign nodular hyperplasia of prostate? what % ahve significant symptoms?
atleast 75%. only 5% have significant symptoms
what is benign nodular hyperplasia of prostate?
irregular proliferation of both glandular and stromal prostatic tissue
what is BNH due to?
hormonal imbalance - androgens diminish and oestrogen stays level
what area of the prostate is involved in BNH?
central (peri-urethral)
in which 2 ways can BNH cause disturbance of bladder sphincter?
- physical obstruction
2. physiological inference - peri-urethral glands at internal urethral meatus
what is meant by prostatism?
- difficulty in starting micturition
- poor stream
- overlfow incontinence
what can BNH lead to in the bladder?
bladder hypertrophy and diverticulum formation
if BNH causes bladder obstruction what can this lead to?
hydroureter, hydronephrosis, infection
what drugs are used to treat BNH?
alpha blockers, 5 alpha reductase inhibitors
is BNH pre-malignant?
no
what is the second leading cause of cancer deaths in males?
carcinoma of prostate
peak age incidence for carcinoma of the prostate?
60-80 years
what gives an increased risk of carcinoma of prostate?
if 1st degree relative is affected at young age
where does a carcinoma of the prostate mainly arise?
in peripheral ducts and glands
why can it take symptoms of prostanism a long time to arise in carcinoma of the prostate?
since it is found in peripheral ducts and glands and peri-urethral zone is not involved until later stage
what is meant by “latent” carcinoma?
microscopic cancer foci found incidentally in surgical specimens or at atopsy. but they have no clinical affect. die with them not of them
where can a carcinoma of the prostate spread to locally?
urethral obstruction, capsular penetration, seminal vesicles, bladder, rectum
what lymphatics could a carcinoma of the prostate spread to?
-sacral, iliac, para-aortic nodes
what is the characteristic appearance of a bone met from a carcinoma of the prostate?
osteosclerotic mets
what hormonal therapies are used in treatment of carcinoma of the prostate?
- anti- androgen
- oestrogens, crproterone
when is radiotherapy used in the treatment of carcinoma of the prostate?
in bone mets
when is radical prostatectomy not as effective?
when there is mets
what gives a 10 times increase in risk for a testicular tumours?
testicular maldescent - failure of testes to descend
what is the normal presenting symptoms in a testicular tumour?
painless testicular enlargement
what makes up 90% of testicular tumours?
germ cells tumours
what are the types of germ cell tumours?
seminoma, teratoma and mixed
what makes up 10% of testicular tumours?
lymphoma/leukaemia. stromal tumours
what are the two stromal tumours of the testical?
sertoli and leydig cell
in what age group do primary testicular lymphomas mostly happen in?
elderly
what type of testicular cancer commonly affects young males?
leukaemia relapse to testicles
what testicular tumour often presents with gynaecomastia?
a leydig cell tumour - type of stromal tumour
what is the commonent germ cell tumour?
seminoma
age peak for seminoma of testes?
30-50 years
what is the macroscopic appearance of a seminoma of the testes?
solid, homogenous, pale macroscopic appearance - potato tumour
what is the histological appearance of a seminoma?
large, clear tumour cells with variable stromal lymphocytic infiltrate
what are 2 variants of seminoma?
spermatocytic and anaplastic types
how is a seminoma treated?
radiotherapy
peak incidence of testicular teratoma?
20-30 years
what do teratomas arise from?
all three 3 cells lines - endoderm, mesoderm and ectoderm
macrocopic appearance of a teratoma?
solid areas, cysts, haemorrhage and necrosis
microscopic appearance of a testicular teratoma?
wide variery of tissue types eg primitive brain tissue, pancreastic tissue, smooth muscle, cartilage etc
4 types of teratoma in the classification?
- differentiated teratoma
- malignant teratoma intermediate
- malignant teratoma undifferentiated
- malignant teratoma trophoblastic
what type of tumour releases bHCG?
trophoblastic tumours
what component of a tumour releases AFP?
yolk sac components
what testicular tumours releases placental alkaline phosphatase (PLAP)?
seminoma
what are the 2 types of nephritis?
- glomerulonephritis
- pyelonephritis
what is often the cause of glomerulonephritis?
- immunological mechanism often implicated- but no single cause
what is affected in glomerulonephritis in the early and then later stage?
glomerular tufts involved initially, then secondary tubulointerstial changes can occur
in what type of pattern does glomerulonephritis usually affect the kidney?
usually it is diffuse- every glomerulus is affected. but some forms can cause focal involvement
what is pyelonephritis?
bacterial infection of renal pelvis, calyces, tubules and interstitium
what are the 2 forms of pyelonephritis?
acute and chronic
what type of distribution does pyelonephritis follow?
patchy
what is the commonest organism in pyelonephritis? what are the other less common organism?
E.coli most common, also pseudomonas, strep. faecalis
what sex is pyelonephritis most common in?
females
what are the 2 ways in which bacteria can enter the kidney causing pyelonephrititis?
- blood -borne in septicaemia, post surgery
- ascending infection.
what mode of getting pyelonephritis is much more common? and what is often present?
- ascending infection
- cystitis often present
why are females at higher risk of developing pyelonephritis?
shorter, wider urethra
how many organisms/ml in urine need to present to be classed as a UTI?
> 100,000 organisms/ml
how can pregnancy increase risk of developing a UTI?
causes ureteric dilation
risk factors for developing pyelonephritis?
- urinary tract obstruction
- vesico-ureteric reflux
- diabetes
what things can cause a urinary tract obstruction?
- calculus, stricture, neoplasm, congenital anomaly, prostatic and urethral pathology
what is vesico-ureteric reflux?
incompetence of valves where the ureters enter the bladder. urine can move back up the ureter
what is chronic pyelonephritis associated with?
hypertension and/or uraemia
why do people with chronic pyelonephritis pass large amounts of urine?
kidney not functioning properly so cant concentrate urine effectively
what can be seen on renal imaging in chronic pyelonephritis?
course cortical scarring, distortion of calyces
what can be seen histologically in chronic pyelonephritis?
lymphocytes and plasma cells. destruction of glomeruli in later stages
how is tuberculous usually spread to the kidney and what does it cause?
haematogenous spread usually from lung. causing tuberculous pyelonephritis
symptoms of tuberculous pyelonephritis?
vague symptoms- weight loss, fever, loin pain, dysuria
what is meant by sterile pyuria in relation to TB pyelonephritis?
puss in the urine but in the initial stage of culture it appears sterile as TB bacterium can take weeks to grow
what techniques are used now to detect tuberculous pyelonephritis?
PCR
how does TB pyelonephritis affect the kidney?
caseous foci- slow growth with progressive renal destruction
where can TB pyelonephritis spread to?
to ureters, bladder and other viscera
most common bacteria causing cystitis?
- e.coli
- Klebsiella
- proteus
- psuedomonas
what forms in ureteritis and cystitis cystica?
multiple small fluid filled cysts projecting into the lumen - reactive process
what infection of the bladder predisposes to SCC of the bladder?
schistosomiasis
what happens to the bladder muscle (detrusor) in prolonged bladder outlet obstruction?
hypertrophy and diverticulum formation
what is hydronephrosis ?
dilatation of pelvicalyceal system with paranchymal atrophy
what are the main causes of hydronephrosis?
urinary tract obstruction and reflex
possible causes of bilateral hydronephritis?
- urethral obstruction
- neurogenic disturbance
- vesico-ureteric reflux
- bilateral ureteric obstruction
what is a possible cause of bilateral ureteric obstruction?
tumour eg advanced carcinoma of cervix
possible causes for unilateral hydronephrosis?
- calculi
- neoplasm
- pelvi-ureteric obstruction
- strictures
why is there little pelvicalyceal dilation in a sudden and complete obstruction?
urine production quickly ceases
in severe hydronephrosis what can been seen macroscopically on the kidney?
marked cortical thinning, atrophy and fibrosis
what is a kidney that is hydronephrosed at higher risk of?
secondary infection
what is pyonephrosis?
infection (pus) in the kidney secondary to hydronephrosis
what does bladder muscle look like when it has undergone hypertrophy?
criss-cross appearance
in a young adult, what does the prostate weigh?
around 20g
what is the apex of prostate (posterior portion) continuous with?
striated sphincter
what is the base (superior portion) of prostate continuous with?
bladder neck
what lines the prostatic urethra?
transitional epithelium
where is the verumontanum on the urethra?
just distal to uretheal angulation
what joins to form the ejaculatory duct?
seminal vesicles and each vas deferens
where do they ejaculatory ducts drain to?
each side of prostatic urethra
what are the 3 different zones of the prostate?
- transitional zone
- central zone
- peripheral zone
what does the transitional zone of prostate surround?
the prostatic urethra proximal to the verumontanum
in young men, the transitional zone of prostate accounts for what % of prostatic glandular tissue?
only 10%
what shape is the central zone of prostate and what does it surround?
- cone shaped region that surround the ejaculatory ducts
what percentage of glandular tissue of the prostate is made up by the central zone?
25%
what percentage of prostate cancers arise in the transitional zone of prostate?
only about 20%
what percentage of prostate cancers arise in the central zone of prostate?
only 1-5%
what zone of prostate makes up most of the glandular tissue?
the peripheral zone
where is the peripheral zone of the prostate?
posteriolateral prostate
what percentage of prostate adenocarcinoas arise from the peripheral zone?
up to 70%
what zone of the prostate gives rise to BPH?
the transitional zone
peak age incidence for prostate cancer?
70-74 years
what race are more at risk of prostate cancer?
black men are at a greater risk than caucasians. asians rarely develop it unless they move to the West
what doubles the risk of developing prostate cancer?
one first degree relative
how much is the risk increased if you have 2 first degree relatives affected by prostate cancer?
by 4 folds
what can be felt in a digital rectal exam in prostate cancer?
asymetry of prostate, nodule, fixed craggy mass
what produces PSA?
secretory epithelial cells of the prostate gland
in health, what should the PSA levels be in semen and in serum?
high in semen and low in serum
other conditions (not cancer) that elevate PSA?
- BPH
- Prostatitis / UTIs
- retention
- catheterization
- digital rectal exam
what is the sensitivity of PSA in detecting prostate cancer?
90%
what is the specificty of PSA in detecting prostate cancer?
40%
indications for a trans-rectal USS guided prostate biopsy?
- men with an abnormal rectal exam, an elevated PSA
- previous biopsies showing prostatic intraepithelial neoplasia or atypical small acinar proliferation
- previous normal biopsies but rising PSA trends
how many biopsies are taken from the prostate in a trans-rectal USS guided prostate biopsy?
10 - 5 from each lobe
what are the majority (>95%) of prostate cancers?
multifocal adenocarcinomas
what scoring system is used in grading prostate cancer?
Grading- Gleason’s scoring
what is meant by T3 in prostate cancer?
tumour extends through the prostatic capsule
what is meant by T4 in prostate cancer?
tumour fixed or invades adjacent structures other than seminal vesicles: bladder neck, external sphincter, rectum, levator muscles or pelvic wall
complications of radical surgery on the prostate?
- erectile dysfunction
- incontinence
- bladder neck stenosis
what is the curative approach in locally advanced prostatic cancer?
radiotherapy with neo-adjuvant hormonal therapy
what therapy is used in the management of metastatic disease prostatic cancer?
androgen deprivation therapy
what hormones is growth of prostate cancer cells influenced by?
testosterone and dihydrotestosterone
what happens to prostate cells if they are deprived of androgenic stimulation?
they undergo apotosis
what affect does LHRH agonists have on LH, FSH and testosterone?
chronic exposure to LHRH agonists results in down-regulation of LHRH-receptors, with subsquent suppression of pituitary LH and FSH secretion and testosterone production
what is the testosterone surge in the hormonal therapy, LHRH agonists?
they initially stimulate pituitary LHRH receptors, causing a transient rise in LH and RSH and testosterone production.
how do 20% of patients with testosterone surge due to LHRH agonists present?
with catastrophic spinal cord compression
in hormonal therapy using LHRH agonists, how is testosterone surge prevented?
anti-androgens are given 1 week before starting therapy and 2 weeks after the first dose of LHRH injection
side effects of LHRH agonists for prostate cancer?
- loss of libido
- hot flushes and sweats
- weight gain
- gynaecomastia
- anaemia
- cognitive changes
- osteoporosis
how do anti-androgens work in treatment of prostatic cancer?
- compete with testosterone and DHT for binding sites on their receptor in the prostate cell nucleus, thus promoting apoptosis and inhibiting cancer cell growth
what are the 2 types of anti-androgens?
steroidal and non-steroidal
an example of a steroidal anti-androgen?
cyproterone acetate
side effects of steroidal anti-androgens?
loss of libido, ED, cardiovascular toxicity and hepatotoxicity
examples of non-steroidal anti-androgens?
- nilutamide, flutamide, bicalutamide
side effects of non-steroidal anti-androgens?
gynaecomastia, breast pain and hot flushes, hepatotoxicity
classification of transitional cell carcinoma?
papillary and non-papillary
what percent of transitional cell carcinomas are papillary type?
80%
