Urological pathology

Question 1

Describe the pathology of kidney cancer, using clear cell renal cell carcinoma as an example.

Answer 1

carcinoma that has invaded through the basement membrane

it has access to potential routes of metastasis and so has metastatic potential

Question 2

Grading system used in renal cell carcinoma

Answer 2

Fuhrman grading system (grade 1-4)

Question 3

Describe the most common clinical presentations of renal cell carcinoma.

Answer 3

The classic triad of loin pain, a mass and haematuria is uncommon
More commonly one of these features appears in isolation
an incidental finding on a scan performed for another reason
presentation with symptoms or signs of metastatic disease (typically lung or bone metastases) eg. bone pain, shortness of breath
paraneoplastic syndromes

Question 4

Describe the clinical presentation of urinary stones

Answer 4

loin to groin pain

microscopic haematuria

Question 5

List important causes of macroscopic haematuria and describe its investigation

Answer 5

Causes:
Upper Tract:
kidney cancer (renal cell carcinoma)
stone in kidney or ureter
trauma
Lower Tract:
bladder cancer
infection (bacterial cystitis)

Ix:
urine MC&S
FBC
U&E
refer to urology
cystoscopy 
US

Question 6

Describe the pathological classification of urothelial carcinoma of the bladder

Describe the different prognosis of the three groups.

Answer 6

low risk/superficial urothelial carcinoma: Low risk (superficial) tumours do not invade into the muscularis propria (detrusor muscle) or beyond
They are usually low grade
They tend to have a papillary architecture. regular follow up required due to high shance of recurrence

High risk/ invasive urothelial carcinoma: High risk (muscle invasive) tumours invade into the detrusor muscle or beyond
They are almost always high grade
They tend to be solid (rather than papillary) tumours
They have a much worse prognosis than low risk tumours because they may spread to regional nodes and metastasise to distant sites, leading to death
Radical treatment is required for cure, usually cystectomy

and CIS (carcinoma in situ): CIS is a flat lesion in which the urothelium contains cells that display the nuclear features associated with malignancy (eg. pleomorphism, mitoses etc) BUT there is no invasion through the basement membrane. CIS is a flat lesion. It does not form a mass.
At cystoscopy, areas of CIS may be visible as red patches but they may be indistinguishable from the surrounding normal bladder mucosa and thus not readily apparent with the naked eye
Blue light cystoscopy may identify such lesions: hexyl aminolevulinate (HAL) is inserted into the bladder and the urologist examines the bladder under blue light. CIS is a form of PREcancer: left untreated, about 40% of cases of CIS turn into muscle invasive cancer. CIS is a much more ominous diagnosis than a low risk (superficial) urothelial carcinoma

Question 7

Describe important risk factors for the development of bladder cancer

Answer 7

dye factory workers

smoking

Question 8

Describe the pathology of benign prostatic hyperplasia

Answer 8

BPH typically affects the transition zone around the prostatic urethra

The hyperplasia is gradual, leading to gradual compression of the prostatic urethra

Question 9

Describe the pathology of prostatic adenocarcinoma and outline its relationship to PIN

Answer 9

Most common type of prostatic adenocarcinoma

Question 10

What is used to grade prostate cancer?

Answer 10

Gleason score- tumour given 2 scores according the microscopic appearance and added together

Question 11

Describe the presentation of latent and symptomatic prostate cancer

Answer 11

Latent: other than that wont cause many problems

Symptomatic: symptoms of metastatic disease e.g. bony mets or obstruction

Question 12

Explain and discuss the management dilemma of latent prostate cancer and outline possible management options.

Answer 12

most latent prostate cancers will never cause a man significant problems
a small minority of latent prostate cancers will behave aggressively and, left untreated, would result in death
Unfortunately there is no totally reliable way of predicting how latent cancer will behave in an individual patient

Therefore, we face a dilemma:
over-treating clinically insignificant prostate cancers (side effects)
under-treating potentially lethal cancers

Question 13

What is the staging system for RCC

Answer 13

TNM

Question 14

why might there be raised Hb (erythrocytosis) in RCC

Answer 14

inappropriate EPO production by tumour cells

Question 15

complications of urinary tract stones

Answer 15

staghorn calculus 
impacted ureter
obstruction in the pelviureteric junction, pelvir rim or vesicoureteric junction
UTI 
AKI

Question 16

immediate tx of obstructed kidney

Answer 16

nephrostomy

Question 17

what is papillary tumour

Answer 17

has finger like projections

Question 18

what is papillary tumour

Answer 18

has finger like projections

Question 19

complications of BPH

Answer 19

urinary retention
hydronephrosis 
hydroureter 
loss of renal function 
infection

Question 20

what is prostatic intraepithelial neoplasia?

Answer 20

Prostatic Intraepithelial Neoplasia is the precursor (precancer) of prostatic adenocarcinoma
It is asymptomatic
It may progress to adenocarcinoma but progression is not inevitable

Question 21

tx available for prostate cancer

Answer 21

radical prostatectomy

radiotherapy

radical brachytherapy: Brachytherapy involves the placement of permanent radioactive seeds into the prostate gland. These seeds slowly release radiation over a couple of months.

active surveillance

Question 22

rfs for prostate cancer

Answer 22

increasing age
family history (Lynch syndrome and germline BRCA mutations)
Afro-Caribbean

Question 23

which area of the prostate does prostate cancer affect

Answer 23

peripheral zone

Question 24

does prostate cancer cause osteosclerotic lesions or osteolytic lesions?

Answer 24

osteosclerotic