Pathology Flashcards
Explain each of the following terms:
Agenesis
Hypoplasia
Horseshoe Kidney
Agenesis - absence of one or both kidneys
Hypoplasia - small kidneys, normal development
Horseshoe kidney - fusion at either (usually inferior) pole.
What is the appearance of a child who has bilateral renal agenesis and why?
Looks squashed - most of the amniotic fluid is formed from foetal urine.
Agenesis of one kidney can live a normal life - true/false
True - kidneys have a massive reserve so one kidney is sufficient.
In hypoplasia there may be normal or diminished function - true/false
True
What clinical consequence(s) may occur from a horseshoe kidney?
Very few
May cause obstruction of urinary tract if very large bridge - usually an incidental finding.
What is the most common cystic kidney disease?
Simple cyst
What cell type is a simple kidney cyst lined by?
Squamous epithelium
Simple cysts rarely compromise renal function - true/false
True
Simple cysts are usually incidental/symptomatic findings and can be a consequence of ______
Incidental finding
Consequence of long term haemodialysis.
There are two types of polycystic disease - what are they?
Infantile type PKD & Adult type PKD.
Infantile type PKD is fairly common - true/false
Fairly rare
In the perinatal group, polycystic kidney disease is terminal - true/false. if true, why? if false, why not?
True
Neonates are not suitable for transplanting and not suitable for long term haemodialysis.
Infantile PKD follows which inheritance pattern?
Autosomal recessive
What is seen in infantile type PKD?
Uniform, bilateral renal enlargement
Elongated cysts
Dilation of the medullary collecting ducts
What other disease is infantile type PKD associated with?
Congenital hepatic fibrosis.
Adult PKD is the more common that infantile type PKD - true/false
False - this is the least common form of congenital cystic disease
what chromosomes/genes are affected in adult type PKD?
Chromosome 16 - ADPKD1 (90% of cases)
Chromosome 4 - ADPKD2 (10%)
Why is genetic counselling important?
it presents later so it is important if they wish to have a family.
How does adult PKD usually present?
mid-life
Abdominal mass, haematuria, hypertension and CRF
What percentage of patients on haemodialysis and on the transplant registries have adult PKD?
8%
On examination what will you find in adult PKD?
Grossly enlarged kidney
Multiple cysts, vary in size
distortion of renal shape.
What weight is a normal kidney? How does this compare to PKD?
100g normal
Can be up to and above 1 kg in PKD.
Cysts may spread to _____ & ______ in PKD
Liver and lungs
In PKD, liver and lung cysts have no functional effect; true/false
True
What percentage of patients with PKD will have lung and liver cysts?
33% (1/3)
Subarachnoid haemorrhage is associated with PKD - explain.
there is an increased incidence of berry aneurysm in the circle of willis in PKD patients. this predisposes to a subarachnoid haemorrhage.
Give the 4 types of benign tumour in the kidneys.
Fibroma
Adenoma
Angiomyolipoma
IGCT
Describe a renal fibroma
Common, medullary in origin, white nodules
Describe a renal adenoma
Yellowish nodules, less than 2cm and cortical tumour
Describe a renal angiomyolipoma
Mixture of fat, muscle and blood vessels. Can be multiple, bilateral and associated with tuberous sclerosis.
What percentage of tuberous sclerosis patients will develop renal angiomyolipoma?
70%
Describe a renal IGCT
Benign tumour of the juxtaglomerular apparatus and so secretes renin. A cause of secondary hypertension.
What is a nephroblastoma?
Malignant intra-abdominal mass, occurs between 1 and 10 years and is most common tumour in children.
Nephroblastoma occurs from which tissue(s)?
Residual primitive renal tissue
What is the most common tumour of the kidney?
Renal cell carcinoma
Renal cell carcinoma arises from the renal tubular epithelium - true/false
true
Renal cell carcinoma accounts for __% of all adult visceral tumours and is peak age between ____ & _____. it is ___x more/less common in females than males
3% of all adult visceral tumours
55-60years old
2x more common in females
How will renal cell carcinoma usually present?
Palpable abdominal mass
Haematuria
Flank pain
General symptoms of malignancy
list and explain some of the paraneoplastic manifestations of renal cell carcinoma?
Polycythaemia - increased erythropoietin secretion
Hypercalcaemia - secretes PTH to causes bone resorption.
Renal cell carcinoma on examination will be ___
Well defined Large centred on cortex yellow solid/necrotic/cystic/haemorrhagic areas.
renal vein extension is uncommon in a renal cell carcinoma - true/false
false - it is common and may even extend into the IVC and right atrium - associated with poor prognosis.
majority of spread of a renal cell carcinoma is via _____
Haematogenous spread first lymphatic spread later.
Where are the common metastatic sites for renal cell carcinomas?
Lungs
Bones
Transitional cell carcinoma can occur anywhere from _____ to _____
Pelvicocalyceal system to the urethra
Transitional cell carcinoma accounts for ___% of bladder tumours
90%
Transitional cell carcinoma is most common is which age group?
over 50s
What other hazards are there for transitional cell carcinoma except for age?
aniline dyes Rubber industry work Benzidine Cyclophosphamide analgesics schistosomiasis smoking
What is the commonest symptom of transitional cell carcinoma?
haematuria
If you find blood in urine, you should ____
Escalate it asap
85% of transitional cell carcinoma occur in the trigonal area - true/false
false - 75%
Trigonal transitional cell carcinoma can lead to ____
ureteric obstruction (uni/bilateral) and/or urethral obstruction
Carcinoma in situ can occur in the ____ transitional epithelium
flat transitional epithelium
Carcinoma in situ will spread to which local lymph nodes? Which organs may it spread to?
Obturator
Liver and lungs
Recurrence of transitional cell carcinoma is vanishingly rare - true/false
False - it is very common
Tumours of the penis are common - true/false
False
Tumours of the penis are normally what histological type?
Squamous cell carcinoma arising from the epithelium of the skin.
Like most squamous cell carcinoma, tumours of the penis often have an in-situ component; where are these normal located?
Skin
Glans penis
Give the two clinical appearances of a penile tumour
Bowen’s disease - dried, crusty appearance of the skin. Can get it anywhere that there is skin.
Erythroplasia of Queyrat - pre malignancy where the glans develops a raised, red velvety area
What is seen in either Bowen’s disease or erythroplasia of Queyrat on histological examination?
Full thickness dysplasia of the epidermis in carcinoma in situ.
What percentage of carcinoma in situ will under go malignant change?
5%
Squamous cell carcinoma of the penis is uncommon in the Uk - true/false
True
The incidence of a squamous cell carcinoma is higher in some parts of the world; where?
Latin America, Africa, far East.
Squamous cell Carcinoma of the penis are almost exclusively contained to men who ____
Have not been circumcised.
Circumcision in adulthood gives the same protection from squamous cell carcinoma of the penis as in childhood - true/false
False - childhood circumcision gives much more protection than adult circumcision.
What is the aetiology of squamous cell carcinoma?
poor hygiene allows carcinogen build up.
HPV
What area(s) of the penis is/are affected most commonly by Squamous carcinoma?
The glans and prepuce
How does squamous carcinoma in the penis appear?
Ulcerated, indurating, deeply invasive mass
OR
Exophytic (cauliflower appearance)
SCC of the scrotum is the first cancer associated with occupation - true/false
true
With What occupation is/was scrotal SCC associated?
Chimney sweeps
what percentage of men over 70 are affected by benign nodular hyperplasia of the prostate?
75%
How many of those affected by benign nodule prostatic hyperplasia are symptomatic?
5%
What is benign nodular prostatic hyperplasia?
Irregular proliferation of both glandular and stromal prostatic tissue.
What is often the cause of benign nodular prostatic hypertrophy?
Hormone imbalance - with age androgens decrease, oestrogen increases - peri-urethral prostate is oestrogen responsive
Prostatism is a sign of prostatic hypertrophy - what is this?
It is difficulty in initiating micturition, poor flow and overflow incontinence.
Acute urine retention can be a fairly dramatic urological emergency - true/false
true
Name a few complications of benign nodular prostatic hypertrophy
Bladder hypertrophy Bladder diverticulae Hydroureter Hydronephrosis Infection (due to hydronephrosis)
Treatments for BNPH are ____
alpha blockers
5-alpha reductase inhibitors
BNPH is a premalignant disease, it increases true risk of malignancy - true/false
False - it has no effect on your risk of malignancy
Carcinoma of the prostate is common and causes 11% of male cancer deaths - true/false
true - second leading cause in males
Prostatic carcinoma is common/uncommon in what age groups?
Peak incidence - 60-80
Very uncommon -
What greatly increases risk of prostatic carcinoma?
1st degree relative had it at a young age.
Prostatic carcinoma has a large association with BNPH - true/false
False - there is no association
But as both are common, you may have both simultaneously.
Where does prostatic carcinoma arise first?
Periphery of the prostate particularly the posterior lobe
Prostatism is an early presentation of prostatic cancer - true/false
False - later presentation. It doesn’t affect the centre until later so no obstruction until late stage disease.
How does a prostatic carcinoma spread?
Locally to obstruct urethra, penetrate the capsule and infiltrate rectum, bladder and seminal vesicles.
Lymphatic to the sacral, iliac and lumbar (para-aortic) nodes
Blood to bone in lumbosacral area, lungs or liver
Why is metastatic bone disease from the prostate different from other causes?
Osteosclerotic; causes bone formation and so large sclerotic patches that are much more dense than the surrounding bone. Most metastatic tumours destroy bone.
What percentage of patients have locally advanced or metastatic disease at presentation with prostatic carcinoma?
2/3
If suspected prostatic carcinoma, what examination should be first line? What would you expect to find?
PR exam
Expect to find irregular, hard, craggy mass.
What imaging would you do for prostatic carcinoma?
Ultrasound
skeletal X-rays
bone scanning
What biochemistry could be done for prostatic carcinoma? How effective is this as a test?
Prostate specific antigen.
Fairly good; will be raised in a majority of cases but not all.
Definitive diagnosis of a prostatic carcinoma is via transurethral resection - true/false
False - 10-20years ago this was true.
Now we use 8-10 core needle biopsies (4-5 in each lobe) guided by ultrasound.
How is prostatic carcinoma managed?
Anti-androgens, oestrogen and cyproterone.
Radical prostatectomy for confined disease, can be curative
Radiotherapy for painful, extensive boney mets and surgical inoperability
testicular cancer is common/uncommon and has increased by a factor of _____ over the last 20years.
Uncommon
Factor of 20
What percentage of cancer deaths is caused by testicular cancer?
1%
Testicular cancer is the least common, solid organ malignancy in young adult males - true/false
False - most common in young adult males
If you have undescended or maldescended testes, risk of malignancy is ____x that of normally descended testes.
10x that of normally descended testes
Presenting complaint of testicular cancer is usually painful/painless testicular enlargement
Painless
Painful is usually infective
What else may testicular cancer be associated with?
Hydrocele
Gynacomastia (Moobs)
General effects of malignant disease
90% of testicular tumours are what type of tumours?
Germ cell tumours
Germ cell tumours of the testis are subdivided into:
Seminomas
Teratomas
mixed
What makes up 10% of testicular tumours?
Lymphoma, leukaemia, stromal tumours, mets (espec. prostate) and paratesticular (e.g. adenomatoid - epithelial lining of tunica vaginalis)
Seminoma is the most common germs cell tumour - true/false
true
What age group is seminoma most common in?
30-50
Seminoma is common pre-pubertally - true/false
False - virtually unheard of.
Describe the appearance of seminoma macroscopically
Solid
Homogenous
Pale macroscopic
Potato tumour.
Describe the appearance of seminoma microscopically
Large Clear cells
Variable stromal lymphocytic infiltrate (host reaction)
The smaller the host reaction to seminoma the better the prognosis - true/false
False - larger stromal lymphocytic is associated with better prognosis
Where is the regional nodes that a testicular tumour will drain to first?
Lumbar (para-aortic).
can be massive at presentation
Where is blood spread of a testicular tumour to?
Liver and lungs
Radiosensitivity is very high/low in seminoma and is very poor in multiple metastasis
High in seminoma
Very good even with multiple mets
What is the cure rate with radiotherapy in the seminoma?
> 95%
Define a teratoma?
A tumour occurring from all three germ layers
what is the peak incidence of testicular teratoma?
20-30 years old
testicular teratoma is very aggressive in childhood - true/false
False - very benign
How will a teratoma appear macroscopically?
Solid areas Cysts Haemorrhages Necrosis all above are possible
bHCG can be used to detect which type of teratoma?
Trophoblastic - highly secreted by trophoblastic components
AFP can be used to detect which type of tumour?
Yolk sac components of tumours
PLAP can be used to detect which type of tumour?
Seminoma
What is glomerulonephritis?
non-infective inflammation which is immunologically caused by there is no single cause. Usually occurs several weeks post UTI.
What changes may be made in glomerulonephritis?
Late tubulointerstitial changes.
Diffuse, all nephrons affected. Occasionally can be focal
What is pyelonephritis?
Infective inflammation of the renal pelvis, calyces, tubules and interstitium.
What symptoms will acute pyelonephritis give?
Acute infective symptoms:
Pyrexia, swelling + urinary tract symptoms.
Acute pyelonephritis is more common than chronic - true/false
False - usually more chronic than acute.
Common organisms causing pyelonephritis include:
Coliforms e.g. E. Coli,
Pseudomonas
Strep faecalis
Males are more at risk than females of pyelonephritis - true/false. Explain
False; women are more at risk due to the shorter length and wider diameter of the urethra found in females.
Describe the pathogenesis of pyelonephritis.
May occur post-op but more commonly an ascending infection. Cystitis often present. Any anatomical or physiological disruption will predispose you to it.
What risk factors are there for pyelonephritis?
Female Pregnancy Instrumentation/surgery to Urinary Tract Obstruction (calculi/stricture) Congenital abnormality Vesiculo-Ureteric reflux Diabetes
How does pregnancy change risk of pyelonephritis?
Increases
Ureteric dilation due to hormones
OR
Due to the pregnant uterus.
Describe what happens in vesiculo-ureteric reflux and how it alters risk of pyelonephritis
Normal ureters enter bladder obliquely, bladder contracts and distal ureter is closed off.
Some variations enter perpendicular, doesn’t close off and so some urine refluxed into the proximal tract. Infected urine reflux causes ascending infection.
Describe chronic pyelonephritis
Most common
Often no history of UTI
Vague symptoms (generally unwell, weightloss) and insidious onset.
What is the correlation between hypertension and chronic pyelonephritis?
Chronic established pyelonephritis will often give hypertension. Strong association between chronic renal disease and hypertension.
Patients with chronic pyelonephritis often present with very small volumes of urine - true/false
False - unable to concentrate urine, therefore large volumes.
What imaging signs will you see in chronic pyelonephritis?
Very coarse cortical scarring
Interspersed with normal areas and calyceal dilation.
What inflammatory cells are present in chronic pyelonephritis?
Lymphocytic and plasma cell infiltration.
This will cause glomerular destruction if longstanding.
How common is renal/urinary tract TB?
Not very anymore.
How does TB infect the renal system normally?
Haematogenous spread from the lung.
What symptoms will a patient have in renal TB?
Weight loss, fever, loin pain and dysuria.
What will you see in urine and urine culture in renal TB?
Puss in urine but nothing grows for many weeks on culture -> Sterile pyuria.
What is a good diagnostic lab test for TB?
PCR
In gross pathology for renal TB you will see…
Caseous necrosis leading to progressive destruction and spread to distal tract and other viscera through rupture.
Histologically in pathology for renal TB you will see…
Necrotising granulomatous inflammation and Ziehl-Nielsen stain positive bacilli. Very scarred, necrotic material, multinucleate cells in the walls
Cystitis is very/not very common.
Very common
Name the most likely causative organism of cystitis
E. Coli
Klebsiella
Proteus
Psuedomonas
Cystitis is normally acute but can become necrotising if there is outlet obstruction, particularly in males - true/false
True.
What are long term consequences of cystitis?
Reactive bladder changes or ureteric changes (cystitis cystica/uretitis cystica)
What do these so called reactive changes show?
Small fluid filled cysts projecting into bladder lumen. May appear like tumours.
Schistosomiasis is uncommon in Britain - true/false
True
Where is schistosomiasis important?
Africa
What causes schistosomiasis?
S. Haematobium worms.
What can schistosomiasis predispose to?
urothelial malignancy especially SCC if chronic infection.
What causes the problem in schistosomiasis?
Not the worm but its eggs.
Urinary tract obstruction can occur at what sites?
Anywhere from renal pelvis to the external urethral orifice.
Urethral obstruction is just as common in males as females - true/false
False - almost entirely confined to males
What can cause urethral obstruction?
Stricture, valve abnormality, benign prostatic hypertrophy and prostatic carcinoma (most common are latter two)
What does prolonged bladder outlet obstruction cause?
Hypertrophy of detrusor and possibly the formation of diverticulae
What is hydronephrosis?
Dilation of the pelvicalyceal system with parenchymal atrophy
What are the main causes of hydronephrosis?
Urinary Tract Obstruction
Reflux
Bilateral hydronephrosis is due to ______
Urethral obstruction
Neurogenic disturbance
Reflux
Bilateral ureteric obstruction e.g. by pelvic cancers such as cervical cancer.
Unilateral hydronephrosis is usually due to _______
Stones
neoplasm
Pelviureteric obstruction
stricture
Do you get hydronephrosis in sudden, complete obstruction?
no - urine production ceases immediately; little dilations.
Do you get hydronephrosis in very gradual onset obstructions?
Yes
What signs are there of severe hydronephrosis?
Cortical thinning
Atrophy
Fibrosis
Secondary infection follows urine stasis and is called _______
Pyonephrosis.
