Renal Path 3b Flashcards
Most common cause of hydronephrosis in infants and children
Ureteropelvic Junction (UPJ) obstruction
3 points of ureter narrowing at increased risk of renal calculi impaction
Ureteropelvic junction
Where they cross iliac vessels
As they enter the bladder
Congenital anomalies of ureters
Double and bifid ureters
UPJ obstruction
Diverticulae
Sclerosing retroperitoneal fibrosis is considered an obstructive lesion of the ureters and is considered ____-related (immunologic correlation)
IgG4
Pouchlike evaginations of the bladder wall that may arise as congenital anomalies but more commonly are acquired due to persistant urethral obstruction; d/t increased intravesical pressure, usually multiple with narrow necks
Diverticulae
Differentiate congenital from acquired diverticulae
Congenital form may be d/t focal failure of development of the normal musculature or to some urinary tract obstruction during fetal development
Acquired form most often seen with prostatic enlargement producing obstruction to urine outflow and thickening of bladder wall
Clinical significance of diverticulae
These are sites of urinary stasis, therefore propensity for infection and formation of bladder calculi
May also predispose to vesicoureteral reflux if they impinge on a ureter
Rarely, carcinomas may arise therein, in which case they tend to be more advanced in stage, d/t underlying thinned wall
Developmental failure in anterior wall of abdomen and the bladder; the latter either projects directly through a large defect to the body surface or lies as an unopened sac [M=F, W»B]
Exstrophy of bladder
Clinical significance of bladder exstrophy
Exposed mucosa may undergo colonic glandular metaplasia and is subject to infection that can spread to the upper GU tract
Pts have an increased risk of adenocarcinoma arising in the bladder remnant
However surgery is usually curative
About 1/3 of children with recurrent UTI are found to have what condition?
VUR — ureters enter bladder at unusual angle or length of ureter through bladder is too short —> valve malfunction —> reflux
Reflux becomes a clinical problem when urinary stasis leads to infection that subsequently involves ureter and kidney
A patent urachus may result in complications of infection or what type carcinoma?
Adenocarcinoma
Most common etiologic agents for acute cystitis
Coliforms cause 75-90%: E.coli, proteus, klebsiella, enterobacter
10-15% caused by staph saprophyticus
Much less common: mycobacteria, fungi, viruses, and protozoa, which may cause cystitis, particularly in immunocompromised
Predisposing factors for acute cystitis
Bladder calculi Urinary obstruction Diabetes mellitus Instrumentation Immune deficiency Radiation of bladder
Morphology of acute cystitis
Most cases exhibit non-specific inflammation
May see hyperemia of mucosa, sometimes with associated exudate
What type of cystitis is commonly associated with pts receiving cytotoxic anti-tumor drugs, e.g., cyclophosphamide, as well as those with adenovirus infection
Hemorrhagic cystitis (not associated with bacterial infection!)
Differentiate chronic from acute cystitis
Persistence of acute infection leads to chronic cystitis — differs from acute in nature of inflammatory cell infiltrate and clinical sequelae (thickened bladder wall, bladder stones)
Chronic, persistent, painful form of cystitis most frequently in 30-40 y/o women resulting in intermittent severe suprapubic pain, urinary frequency, urgency, hematuria, and dysuria WITHOUT evidence of bacterial infection (culture negative)
Interstitial cystitis (Hunner ulcer)
Gross and microscopic findings associated with interstitial cystitis
Glomerulations (petechiae)
Hunner’s ulcers
Inflammation and fibrosis of bladder wall, fissures
Varied inflammatory pattern — see MAST cells and lymphocytes
Peculiar pattern of bladder inflammatory reaction characterized by 3-4 cm in diameter soft, yellow, slightly raised mucosal plaques which may involve entire bladder; d/t defective phagosome function and related to chronic infection (usually E.coli)
Malacoplakia
Epidemiology of malacoplakia
F»M; middle aged; occurs with increased frequency in immunocompromised
Most common in bladder but can present in other organs (colon)
Gross and microscopic findings associated with malacoplakia
Marked circumferential bladder wall thickening
Inflammatory exudate and broad, flat plaques
Microscopically, infiltrates of foamy macropahges, multinuclear giant cells, and interspersed lymphocytes, in areas forming granulomas
Laminated mineralized concretions, Michaelis Gutmann bodies, are typically present in macrophages resulting from abnormal, enlarged lysosomes
Inflammatory condition resulting from irritation of the bladder mucosa; indwelling catheters are most common underlying cause; results from extensive submucosal edema and has been misdiagnosed as papillary carcinoma
Polypoid cystitis
What are cystitis cystica (CC) and cystitis glandularis (CG)?
CC and CG are common chronic reactive/inflammatory conditions which occur in the setting of chronic irritation
Metaplasia of the urothelium is incited by irritants such as infection, calculi, outlet obstruction, or even tumor
The urothelium proliferates into buds (nests of von Brunn) which grown down into the CT beneath the epithelium into the LP
The buds then differentiate into cystic deposits of CC or into intestinal columnar mucin-secreting glands (goblet cells) resulting in CG
The histologic features of BOTH are usually present
Epidemiology of CC and CG
Can occur at any age; reported prevalence of 2.4% of children associated with UTIs
Slight male predominance
_____cystitis is characterized by aggregation of lymphocytes in lymphoid follicles in the mucosa and underlying wall; typically associated with chronic infection
Follicular
_____cystitis is manifested by infiltration of submucosal eosinophils, typically also represents nonspecific subacute inflammation, bubt rarely may be manifestation of systemic allergic reaction, autoimmune disorder, parasitic infection, or sequel to radiation or chemo
Eosinophilic
Non-epithelial tumors (benign and malignant) are quite uncommon in the bladder. However, the most common of these is ______
Leiomyoma
Benign vs. malignant non-epithelial urinary bladder neoplasia
Benign: Lipoma Fibroma Neurofibroma Inflammatory pseudotumor
Malignant:
Rhabdomyosarcoma (kids)
Leiomyosarcoma (adults)
Lymphoma
Malignant mesenchymal tumor typically affecting children age 4 [m=f] with one manifestation: sarcoma botryoides
Embryomal rhabdomyosarcoma
Gross vs. histo appearance of embryonal rhabdomyosarcoma
Tumor mass typically fills the lumen of the bladder
Histo: polypoid mass protrudes beneath flattened epithelium; cambium layer = clusters of tumor cells present immediately beneath the epithelium; result in ‘nevoid’ appearance
Leiomyosarcoma epidemiology
Avg age = 60 (rare)
M > F
Sometimes follows radiation or chemotherapy
Primary malignant lymphoma of the bladder typically affects adults, avg 65 y/o, females more likely, especially with hx of chronic cystitis. What type of lymphoma is most common?
What is the prognosis?
Non-Hodgkin lymphoma (diffuse large B-cell and MALT) — CD20+, Bcl-2+
Note much more common as part of systemic disease
Prognosis is good because highly radiosensitive
Most common types of tumors of urinary bladder
Urothelial (transitional cell) tumors
Includes exophytic papilloma, inverted papilloma, CIS, papillary urothelial neoplasms of low malignant potential, low grade and high grade papillary urothelial cancers
Other than urothelial tumors, what are other types of tumors that affect the urinary bladder?
Squamous Cell Carcinoma (many are TCC variants) — 5% of bladder cancers; include mixed carcinoma, adenocarcinoma, and small-cell carcinoma
Sarcomas (and other mesenchymal tumors) — <5% of bladder cancers
What is PUNLMP and what is its major pathologic finding?
Papillary Urothelial Neoplasia of Low Malignant Potential (constitutes 15-20% of papillary tumors)
Major pathologic finding is thickened epithelium covering papillary projections and minimal cellular atypia
There are 4 morphologic patterns of bladder (urothelial) tumors; which of the following is most common?
A. Invasive papillary carcinoma
B. Papilloma-papillary carcinoma
C. Flat noninvasive carcinoma (CIS)
D. Flat invasive carcinoma
B. Papilloma-papillary carcinoma
Grading of urothelial neoplasia
Grade 0/I = normal; mild thickening
Grade II = atypical hyperplasia
Grade III = CIS, many progress to invade (usually preceded by flat non-invasive lesions)
Epidemiology of urothelial carcinoma
Males more common
White males at highest risk
Industrial > non-urban > rural
73 years = median age at dx, but 25% < 65 y/o
Painless hematuria is the dominant, and usually ONLY clinical finding
Uncommonly, ureteral orifice may be blocked by tumor causing acute pyelonephritis or unilateral hydronephrosis
Frequently multiple tumors at time of dx
Risk factors for urothelial carcinoma
Cigarette smoking (3-7x risk!!)
Industrial exposure to arylamines
Schistosoma hematobium (also leads to SCC!)
Long term analgesic use
Long term exposure to cyclophosphamide (nitrogen mustard)
Radiation
Genetic factors associated with urothelial carcinoma — which one is particularly bad prognostic sign?
- Chr 9, monosomy or deletions (30-60%), seen in many superficial and non-invasive, as well as some invasive
- Chr 17p deletions, invasive and CIS (p53)
p53 is particularly bad prognostic signq
Major prognostic factors that must be established in bladder cancer
Stage is critical prognostic factor
Depth of muscle invasion is the MAJOR prognostic issue to be established
Congenital anomalies of the penis
Atypical locations for distal urethra = hypospadias, epispadias
Phimosis = glans becomes ischemic d/t prepuce being too tight
Histology of venereal wart likely shows ______ aka clearing of cytoplasm and pyknotic nuclei
Koilocytosis
What type of carcinoma of the penis is associated with poor genital hygiene and high-risk HPV infection; also associated with circumcision as a protective factor?
SCC
Complete or partial failure of intraabdominal testes to descend into scrotal sac
Cryptorchidism
[likely to be accompanied by other anomalies of GU tract like hypospadias]
Causes of inflammation of testis and epididymis
Granulomatous (autoimmune) orchitis
Specific inflammaions: Gonorrhea, Mumps, TB, Syphilis
Most common solid tumor in men
Testicular germ cell tumors (either seminomas or non-seminomas)
Approximately 15% of seminomas contain _____, in this subset of patients, serum ____ levels are elevated, though not to the extent seen in pts with choriocarcinoma
Syncytiotrophoblasts; HCG
Testing for alpha-fetoprotein is looking for what type of nonseminomatous germ cell tumor?
Yolk sac tumors
What type of cancer’s prognosis is measured by Gleason score?
Prostate carcinoma [gleason of 10 = the worst]
Prostate cancer may spread via ______ invasion, which allows it to metastasize to bone, usually the ______
Perineural; spine
Biomarkers for prostate cancer
PSA (nonspecific)
PCA3 in urine
TMPRSS2-ERG fusion DNA in urine
