Renal Pathology 9: Male GU (Dobson) Flashcards
How are bladder cancers staged?
Staged on the basis of invasion of the detrusor muscle
The three points of slight narrowing of the ureter?
- uteropelvic junction
- where the ureter enters the bladder
- where the ureter crosses the iliac vessels
Ureteropelvic junction (UPJ)
most common cause of hydronephrosis in infants and children
Retroperitoneal fibrosis
(AKA Ormond disease) fibrotic proliferative inflammatory process encasing the retroperitoneal structures (SAD PUCKERS) and causing hydronephrosis; tx is steroids, but will need stents and surgery
Cystitis infectious agents
E. coli (most common)
Chlamydia, Mycoplasma, Proteus, Klebsiella
Predisposition to cystitis
Bladder stones (calculi)
Urinary obstruction
DM
Instrumentation
Immune deficiency
Irradiation of the bladder
Triad of symptoms in cystitis?
- increased frequency (need to go every 20 mins)
- lower abd pain (localized to suprapubic region)
- dysuria
Malakoplakia
chronic bacterial cystitis (E. coli or Proteus)
Michaelis-Gutmann bodies
Michaelis-Gutmann bodies
macrophages with intra-lysosomal laminated calcified concentrations seen in malakoplakia (chronic bacterial cystitis)
Polypoid cystitis
inflammatory lesion from irritation of bladder mucosa; most commonly due to indwelling catheters; marked submucosal edema that can lead to bulbous polypoid projections; confused with papillary urothelial carcinoma
Squamous cell carcinoma of the bladder
PAINLESS hematuria; response to chronic inflammation; urothelium replaced by non keratinizing squamous epithelium (more resilient cells); Schistosoma haematobium infections, smoking and chronic UTIs
Urothelium tumors (2 main type)
- Noninvasive papillary tumors (most common)
- Flat noninvasive urothelial carcinoma
Noninvasive papillary tumors
most common precursor lesion to urothelial tumors; orginates from papillary urothelial hyperplasia
Urothelial carcinoma risk factors
predominantly males; age 50-80 yrs; cigarette smoking (the most important) and cyclophosphamide (drug used cancer tx) is another risk
50-80% of all bladder cancers are associated with what?
Cigarette smoking
Papillary Urothelial Neoplasms of Low Malignant Potential (PUNLMP)
slightly larger than papillomas; THICKER urothelium; rarely progress to higher grade
High Grade Papillary Urothelial Cancer
dis-cohesive cells with anaplastic features; loss of polarity; high risk of invasion into the muscular layer, higher risk of progression and significant metastatic potential
Invasive urothelial cancer
Invasive of muscularis mucosae (detrusor muscle) is prognostically important; staging at the initial diagnosis is the most important factor in determining the outlook for the patient
Adenocarcinoma of the bladder
PAINLESS hematuria; rare; some arise from urachal remnants or in the setting of intestinal metaplasia; histologically identical to adenocarcinomas of the GI tract
Bladder Cancer Clinically
PAINLESS hematuria; tend to recur after excision at a higher grade in different sites; treatment responds to chemo but if not then surgery is curative
Prostate enlargement
most common cause of obstruction of the bladder outlet in males due to nodular hyperplasia
Cystocele of the bladder
most common cause of obstruction of the bladder in females
Urethral Caruncle
PAINFUL, small, red inflammatory lesion of the external urethral meatus in older females, bleed easily due to ulceration; excision is curative
Hypospadias
more common than epispadias; congenital anomaly of the penis; urethral opening on the VENTRAL aspect of the penis; incomplete fusion of urogenital folds; can lead to urinary obstruction (severe cases - post renal AKI and hydronephrosis)
Epispadias
congenital anomaly of the penis; urethral opening on the DORSAL aspect of the penis; due to abnormal positioning of the genital tubercle during development; present with exstrophy of the bladder
Balanoposthitis
infection of the glans and prepuce by non specific organisms (not STD); due to poor local hygiene in uncircumcised males
Common infection in uncircumcised males
Balanoposthitis; infection of the glans and prepuce by non specific organisms (not STD); due to poor local hygiene
Condyloma Acuminata
Penile tumor; benign sexually transmitted wart, HPV 6>11, recurs after excision, but rarely transforms to malignancy, may display Kolicytosis- cytoplasmic vacuolization of the squamous cells; characteristic of HPV
Kolicytosis
cytoplasmic vacuolization of the squamous cells; characteristic of HPV seen in Condyloma Acuminata; Penile tumor; benign sexually transmitted wart
Peyronie Disease
benign proliferation of fibroblasts of tunica albuginea; results in fibrous bands involving the penile corpus cavernosum; causes penile curvature and pain during intercourse
Disease that causes penile curvature and pain during intercourse
Peyronie Disease; benign proliferation of fibroblasts of tunica albuginea; results in fibrous bands involving the penile corpus cavernosum
Bowenoid Papulosis
multiple, pigmented papular lesions on external genitalia (penis); histologically indistinguishable from Bowens disease; so use age and number of lesions; younger patients and multiple (compared to older and solitary lesion); also rarely progresses to carcinoma
Cryptorchidism
the most common congenital anomaly of the testes; failure of testes to descent; can lead to tubular atrophy and sterility; 75% unilateral; found in 1% of 1 yr old boys; decreased germ cell development; fibrosis with sparing prominent Leydig cells; completely asymptomatic
most common congenital anomaly of the testes
Cryptorchidism; found in 1% of 1 yr old boys; failure of testes to descent
Inflammation of the epididymis and testis
more common in epididymis, epididymis is first then testis (gonorrhea/TB) if testis first then epididymis (syphilis - but epididymis is commonly spared altogether)
Granulomatous (autoimmune) Orchitis
moderately tender testicular mass of sudden onset; sometimes associated with fever; granulomas are restricted to spermatic tubules
Gonorrhea
from neglected gonococcal infection; RETROGRADE expansion of infection from posterior urethra to prostate, seminal vesicles and epididymis
Gonorrhea left untreated
testis suppurative orchitis
Severe complication of gonorrhea
epididymal abscesses = destruction and scarring
Mumps
systemic viral infection; commonly affects children; testicular involvement is rare; 20-30% of post-pubertal men who are infected present with orchitis 1 week after inflammation of parotid glands
Post-pubertal men who have inflammation of parotid glands and one week later present with orchitis, should make you think what?
Mumps; systemic viral infection; testicular involvement is rare
Syphilis
testes are involved FIRST and the epididymis is commonly spared; nodular gummas; histological hallmark: obliterative endarteritis associated with perivascular cuffs of lymphocytes and plasma cells.
obliterative endarteritis associated with perivascular cuffs of lymphocytes and plasma cells.
Syphilis
STI in men were testes are involved first and then the epididymis is commonly spared
Syphilis
Nodular gummas
Syphilis
Testicular torsion
twisting of the spermatic cord cuts off testicular venous drainage; arterial supply remains patent; occludes venous outflow; true urologic emergency (testis can become enlarged and hemorrhagic); surgery < 6 hours
Adenomatoid tumor
most benign paratesticular neoplasm; small nodules of mesothelial cells near the upper epididymal pole
Rhabdomyosarcoma
most common paratesticular tumor in children
Most common paratesticular tumor in children?
Rhabdomyosarcoma
Liposarcoma
Most common paratesticular tumor in adults
Most common paratesticular tumor in adults?
Liposarcoma
Classification of testicular germ cell tumors
- Seminomatous tumors: cells that look like primordial germ cells
- Nonseminomatous tumors: undifferentiated cells that look like embryonic stem cells
Seminomatous tumors
testicular germ cell tumor were the cells that look like primordial germ cells; remain localized to testis for long time; radiosensitive; good prognosis
Nonseminomatous tumors
testicular germ cell tumors were undifferentiated cells that look like embryonic stem cells; more aggressive; radioresistant; metastasize early
Intratubular germ cell neoplasia (ITGCN)
occurs in utero, dormant until puberty; commonly has a duplication of the short arm of 12 which is always found in all invasive germ cell tumors
Seminoma
most common type of germ cell tumor, 20-30 yrs; almost never in infants; express isochromosome 12p and OC3/4 and NANOG
Most common type of germ cell tumor?
Seminoma; 20-30 yrs; almost never in infants; express isochromosome 12p and OC3/4 and NANOG
Spermatocytic Seminoma
rare and slow growing testicular germ cell tumor; patient > 65 yrs old; excellent prognosis; no associated with ITGCN
Embryonal carcinoma
more aggressive than seminomas; poorly demarcated, small, gray-white mass, positive for OCT3/4, PLAP, CD30, cytokeratin and negative for cKIT
Yolk sac tumor
Endodermal sinus tumor; most common testicular tumor in children <3 years and comes with a very good prognosisl Schiller-Duval bodies (primitive glomeruli)
Choriocarcinoma
highly malignant neoplasm, small palpable nodule without testicular enlargement; derived from chorionic villi in placenta; contains syncytiotrophoblasts - hCG reaches very high levels in the serum; can lead to signs of hyperthyroidism
If hCG reaches very high levels in the serum what should be on you differential?
Choriocarcinoma; highly malignant neoplasm, small palpable nodule without testicular enlargement; contains syncytiotrophoblasts - hCG reaches very high levels in the serum
Teratoma
differentiation in all three germ layers; all embedded in a fibrous or myxoid stroma; post-pubertal = all teratoma s are regarded as malignant
What is the most aggressive nonseminomatous germ cell tumor (NSGCT)?
Pure Choriocarcinoma; rapid hematogenous spread; lungs and liver are involved early; no testicular enlargement
Pure Choriocarcinoma
most aggressive nonseminomatous germ cell tumor (NSGCT); rapid hematogenous spread; lungs and liver are involved early; no testicular enlargement
Stage II of testicular tumor staging
persistent elevation of hCG or AFP concentrations following orchiectomy, even if lymph nodes appear normal
Persistent elevation of hCG or AFP concentrations following orchiectomy, even if lymph nodes appear normal indicates what?
Stage II of testicular tumor staging
AFP biomarker
biomarker markedly elevated in yolk sac tumor (nonseminous tumor)
biomarker markedly elevated in yolk sac tumor
AFP biomarker
hCG biomarker
biomarker markedly elevated in choriocarcinoma; 15% of seminomas have elevated hCG
Leydig cell tumors
2% of all testicular tumors; most are benign; tumor produces androgens, estrogens and corticoidsteroids; present with testicular swelling
Eosinophilic Reinke crystalloids
Leydig cell tumors
Testicular lymphoma
most common form of testicular tumors in >60 yrs; disseminate widely; high incidence of CNS involvement
Lymphoma with high incidence of CNS involvement?
Testicular lymphoma; most common form of testicular tumors in >60 yrs; disseminate widely
Hydrocele
accumulation of serous fluid within the tunica vaginalis; leads to enlargement of scrotal sac that contains clear fluid; will transilluminate (a beam of light can pass through)
Hematocele
accumulation of blood secondary to trauma, torsion or generalized bleeding diathesis; will not transilluminate
Chylocele
accumulation of lymphatic fluid secondary to lymphatic obstruction
Spermatocele
local cystic accumulation of semen in dilated efferent ducts or ducts of the rete testis
Variococele
dilated veins in the spermatic cord; may be asymptomatic; will not transilluminate
Peripheral zone of the prostate
where most carcinomas arise; classically in a posterior location
Transitional zone of the prostate
where most hyperplasia occurs (much more common than tumors)
Nonbacterial Chronic Prostatitis
most common prostatitis; cultures are uniformly negative; no history of recurrent UTI
Chronic Bacterial Prostatitis
frequent bouts of UTI, hx of recurrent UTI; leukocytosis in the expressed prostatic secretions
Granulomatous Prostatitis
the most common cause in the US is from instillation of BCG into the bladder for treatment of superficial bladder cancer
Benign Prostatic Hyperplasia (BPH)
Nodular hyperplasia; most common prostatic disorder; stromal proliferation; can be thought of as a sign as aging; large nodules in the peri-urethral region of the prostate
BPH pathogensis
increased number of epithelial cells and stromal components in the peri-urethral area of the prostate; believe the hyperplasia is because of impaired cell death; DHT-induced growth factors act by increasing proliferation of stromal cells and decrease death of epithelial cells
Diagnosis of BPH
need DRE (palpate a firm rubbery mass); cannot be made on needle biopsy; too small to appreciate nodularity and do not biopsy transition zone where BPH occurs
Clinical presentation of BPH
Nocturia, urgency, hesitancy, difficulty starting and stopping the stream of urine; inability to completely void bladder
BPH are at increased risk for what?
bacterial infections of the bladder and kidney; inability to completely void bladder, reservoir of residual urine, common source of infection; is NOT a precursor for malignancy.
Adenocarcinoma of the prostate
most common cancer in men; uncommon in Asians, more common in Blacks; Rearrangement of ETS family transcription factor gene (ERG or ETV1); most important risk factor is increasing age (60-70 yrs); PSA screenings; develops in the posterior lobe of peripheral zone AWAY from urethra so no urinary symptoms (symptoms think BPH)
Kennedy disease
long trinucleotide expansions of CAGs in x-linked andreogen receptor gene; disease is characterized by muscle cramping and fatigue; shortest expansion = more sensitive= Blacks; intermediate = Whites; Longer = Asians
Prostatic intraepithelial neoplasia (PIN)
obstruction of the urinary tract presenting like BPH; finding of osteoblastic metastases by skeletal surveys or the much more sensitive radionuclide bone scanning is virtually diagnostic of prostate cancer in men, bony metastases are typically osteoblastic and this feature in men strongly points to prostatic origin; is a precursor for malignancy
Benign prostate glands
contain Basal cells
Malignant prostate glands
absent basal cells
Histology shows perineural invasion
specific for prostate cancer
Gleason score of 2-6
grading of prostate cancers; 2-6 have excellent prognosis; 2 = minimum Gleason score and most well differentiated
If tested are not palpable in the scrotum of a child under 1 yr?
Cryptorchidism; did not fully descend from the abdomen; external inguinal ring is the most common location; visible mass in the groin, most spontaneously descend by 6 month
Bilateral cryptochidism is commonly associated with what?
a genetic disorder; commonly Klinefelter syndrome (47 XXY) this syndrome commonly causes hypogonadism
Treatment for cryptochidism
Orchiopexy- surgery
What reflect is absent in testicular torsion?
Cremasteric reflex; normally - pinch skin of upper thigh and see elevation of i/l testis
How does testicular torsion present?
Acute scrotal pain; this is a true testicular emergency!
Diagnosis of hydrocele
with an ultrasound; will transilluminate (a beam of light will pass through; differs in varicocele and trauma)
Bowen disease
penile carcinoma presents with crusting and oozing erythematosis plaques on shaft of penis
Phimosis
fibrosed foreskin that cannot be retracted from the glans
Patent urachus
failure of allantois to completely involute/obliterate; abnormal connection between bladder and umbilicus; leakage of urine from the umbilicus in newborns
