GU Flashcards
(90 cards)
1
Q
Name the cell of origin for adenomatoid tumors
A
mesothelial cell
2
Q
IF a prostate needle core bx with a conventional adenocarcinoma containing the following patterns: 4-65% 3-30% and 5-5% what is the final gleason score?
A
9
3
Q
Name an IHC stain that highlights the basal cell layer in the prostate
A
p63
4
Q
What is the most common malignancy of the spermatic cord in adult males
A
liposarcoma
5
Q
Invasive urothelial carcinoma of bladder: what pT stage does invasion of muscularis propria correspond with?
A
T2
6
Q
Name a premalignant lesion in the prostate
A
High-grade prostatic intraepithelial neoplasia
7
Q
Name 4 features of balanitis xerotica obliterans
A
- orthokeratotic hyperkeratosis - atrophy of epidermis - homogenous collagen in upper dermis - lymphoplasmacytic lichenoid inflammatory infiltrate
8
Q
Name 3 positive stains in classic seminoma
A
- PLAP - Oct 4 - C-kit
9
Q
What is the common genetic alteration seen in adult germ cell tumors of the testis?
A
- isochromosome 12p
10
Q
Name 4 conditions associated with renal cell carcinoma
A
- Birt-Hogg-Dube - Tuberous sclerosis - Von Hippel Lindau - End-stage renal disese
11
Q
If RCC grows directly into the adrenal gland (ipsilateral) what is the pT stage?
A
- pT4
12
Q
What is the characteristic morphologic finding in malakoplakia?
A
- Michaelis-Guttman bodies
13
Q
Name 4 variants of urothelial carcinoma with poor prognosis
A
- Sarcomatoid urothelial carcinoma - Micropapillary urothelial carcinoma - Nested urothelial carcinoma - Mixed urothelial and small cell carcinoma
14
Q
What stage is a prostatic carcinoma if it invades the base of the seminal vesicle?
A
- pT3b
15
Q
Describe 3 gleason grade 4 histologic patterns
A
- Glomerulations - Chains of fused glands - Poorly formed small glands
16
Q
Name 3 mimics of invasive prostatic adenocarcinoma
A
- glandular atrophy - atypical adenomatous hyperplasia - cowper glands - granulomatous prostatitis - seminal vesicle in bx
17
Q
Name 3 entities associated with intratubular germ cell neoplasia
A
- Cryptochordism - Embryonal carcinoma - Mixed germ cell tumor
18
Q
Testicular bx/smears for fertility: LIst 2 patterns showing spermatozoa and 3 lacking spermatozoa
A
HAVE spermatozoa: hypospermatogenesis, obstruction of sperm excretory ducts NO spermatozoa: germ cell maturation arrest, sertoli cell only, testicular cell atrophy
19
Q
Name 3 patterns seen in urothelial carcinoma in situ
A
- Clinging/denuding - Small cell - Pagetoid - Undermining
20
Q
Discuss the pathogenesis of nephrogenic adenoma
A
- Increased incidence after organ transplantation and immunosuppression - In renal transplant recipients, derived from exfoliated and implanted renal tubular cells in the urinary tract ● In other patients, appears to be metaplastic and not a neoplasm ● Associated with inflammation, calculi, chronic catheterization, exstrophy, interstitial cystitis, intravesical thiotepa, malakoplakia, surgery
21
Q
List the histologic features of nephrogenic adenoma
A
- Tubular, cystic, polypoid, papillary and polypoid patterns - Cuboidal to low-columnar epithelium with scant cytoplasm and occasional hobnail cells common - Basement membrane hyalinzed around tubules - inflammatory infiltrate and stromal edema - minimal atypia, no necrosis
22
Q
Name the anatomic sites where nephrogenic adenoma might be found
A
- Urinary bladder - Ureter - Urethra - Renal pelvis
23
Q
List stains that can help differentiate nephrogenic adenoma from prostatic adenocarcinoma
A
- Nephrogenic adenoma: cytokeratins, racemase, Pax8, EMA, PAX2 - Prostatic adenocarcinoma: racemase, PSA
24
Q
What is the WHO classification of urothelal lesions?
A
Flat: hyperplasia, atypia of unknown significance, urothelial dysplasia, urothelial carcinoma in-situ Papillary: papillary hyperplasia, papilloma, papillary urothelial neoplasm of low-malignant potential, papillary urothelial carcinoma low grade r, papillary urothelial carcinoma high grade, invasive urothelial carcinoma
25
What is the risk of recurrence and death in urothelial lesions?
CIS: 7-15% disease related mortality w/o progression, 50% progress PUNLUMP: low recurrence LG papillary: recurrence in 50-70%, progression and death rare \<5% HG papillary: progression to invasion in 15-40% Invasive urothelial: pT1 5 yr survival 70%, drops off in higher-grades
26
What is the T staging for urothelial carcinomas of the urinary bladder?
Tx, T0 Ta: non-invasive papillary Tis: carcinoma in-situ T1: invades lamina propria T2: invades muscularis (a, inner half b, outer half) T3: invades perivesical (a, microscopic, b, macroscopic) T4a: invades prostate or uterus/vagina Tb: invades pelvic or abdominal wall
27
List the variants of urothelial carcinoma that behave more aggressively
- Nested - Micropapillary - Sarcomatoid variant - Mixed with small cell
28
What IHC stains can differentiate urothelial carcinoma from prostatic adenocarcinoma?
Urothelial: CK7, CK20, HMW keratin (34BE12), p63 Prostate: PSA, PAP
29
What are risk factors for urothelial carcinoma?
- Cigarette smoking - Industrial exposure to arylamines - Long-term analgesic use - Extended cyclophosphamide
30
List 2 other types of carcinoma of bladder and list their risk factors
- Squamous cell ca: Schistosoma haematobium, bladder diverticuli, non-functioning bladder, transplant - Adenoca: non-functioning bladder, extrophy
31
What is the differential diagnosis of cribriform glandular lesions of the prostate?
- HGPIN - Invasive prostatic adenocarcinoma, Gleason 4 - Clear cell cribriform hyperplasia - Central zone prostatic glands - Ductal adenocarcinoma of prostat
32
What features can help differentiate cribriform lesions in the prostate?
- HGPIN: peripheral lobes, enlarged nuclei + nucleoli, flat/micropapillary/tufted, basal cell layer present - Invasive adenoCA: same as HGPIN, but no basal cell layer - CLear cell cribriform hyperplasia; transition zone, no nuclear atypia, polarized areas prominent basal cells - Central zone prostatic zones: central zone, no nuclear atypia, basal cell layer present - Ductal CA: transition zone, true papillary architecture, +/- necrosis, patchy/absent basal cell layer
33
What is the significance of HGPIN?
- precursor lesion to adenocarcinoma - if multifocal (\>2cores or sites involved), on NCbx, higher risk of carcinoma on f/u biopsy
34
List the mimics of adenocarcicnoma in the prostate
- Normal structures: small benign prostate glands, seminal vesicle glands, cowper glands, mesonephric remnants, paraganglia - Metaplastic lesions: mucinous metaplasia - Hyperplastic lesions: adenosis, sclerosing adenosis, nodular hyperplasia, basal cell hyperplasia, veromontanum hyperplasia - Atrophic lesions: glandular atrophy, post-atrophic hyperplasia, partial atrophy - Other lesions: nephrogenic adenoma, radiation atypia, reactive atypia, granulomatous prostatitis, xanthoma
35
Explain the workup of small atypical glandular lesions on prostate needle core biopsy
- IHC for HMWCK, p63, p504s racemase - Serial sections
36
What would you recommend if you can't go further than ASAP
- Repeat NCBx in \<6mo since 50% have prostatic adenocarcinoma on F/U
37
Describe the 5 gleason patterns
1: circumscribed nodule, medium sized acini which are closely packed but separate, uniform and oval 2. fully circumscribed, minimal infiltration at edge, looser arrangement of glands 3. infiltration in and among non-neoplastic acini, discrete glands, smaller than 1/2 with size variation 4. fused microacinar glands, poorly defined lumina, large cribriform glands with irregular border, hypernephromatoid (glomeruloid) 5. No glandular differentiation, sheets/cords/single cells, may show comedonecrosis in solid/cribriform masses
38
In prostate needle core bx, what is the definition of tertiary pattern and how is higher grade reported on bx? How is it reported in radical prostatectomy?
- 3rd most common gleason pattern, usually 5% than listed as tertiary
39
List types of adenocarcinoma in the prostate that aren't graded by gleason score
- Small cell - Squamous cell - Other neuroendocrine - Adenosquamous - basaloid/adenoid cystic - urothelial ca involving prostate - undifferentiated
40
How are mucinous and ductal prostate adenocarcinomas graded?
- Ductal is 4 or 5 (if necrosis) - Mucinous (colloid) is 4
41
Name a common localized therapy to the urinary bladder and the morphologic changes seen after its use
- Bladder installation of Bacillus Calmette- Guerin (BCG) - Morphologic change: chronic inflammatory infiltrate in lamina propria with small granulomas composed of epithelioid histiocytes/multinucleate giant cells
42
State the common clinical setting of postoperative spindle cell nodules in the bladder and their histologic features
- Within 3 months of previous surgical procedure, at same site - interlacing fascicles of mitotically active spindle cells with uniform nuclei and little pleomorphism - Delicate vasculature, scattered inflammatory cells, small foci of edema/hemorrahge and possible myxoid change
43
List 3 lesions in the ddx of post-operative spindle cell nodule and their IHC features
- inflammatory myofibroblastic tumor (ALK-1) - Sarcomatoid carcinoma (34BE12, CK5/6, p63...) - Leiyomyosarcoma (desmin, h-caldesmon) - melanoma... - Schwannoma...
44
List post-instrumentation changes in the bladder
- Post-operative spindle cell nodule - Post-surgical necrobiotic granulomas - Nephrogenic adenoma - eosinophilic cystitis
45
Wht is the classification of germ cell tumors in the testis
- Seminomatous: seminoma, spermatocytic seminoma
- Non-seminomatous: embryonal carcinoma, yolk sac tumor, choriocarcinoma, teratomy
- Mixed germ cell tumors
46
List 3 hormones/serum markers that can be used as biomarkers for germ cell tumors of testes
- LDH, AFP, B-HCG
47
List 4 positive IHC stains in intratubular germ-cell neoplasia
- PLAP
- OCT4
- CKit
- D240
48
Describe how you would handle an orchiectomy for tumor
- Check patient identifiers on container and requisition
- ink spermatic cord margin
- measure specimen
- Take spermatic cord margin and representative spermatic cord sections prior to sectioning tumor
- describe size, colour, consistency of mass and relationship to tunica vaginalis, epididymis, rete testis, spermatic cord
- take sections of above
- submit 1 section/largest diameter of tumor
\*\*\* If white/fleshy/age over 50, consider submitting tissue for flow cytometry in case of lymphoma
49
What is the IHC profile of the testicular germ cell tumors?
Spermatocytic seminoma: +/- PLAP
Seminoma: PLAP, OCT3/4, possible focal b-HCG
Embryonal carcinoma: cytokeratin, PLAP, OCT3/4, CD30,
Yolk sac: cytokeratin, AFP
choriocarcinoma: cytokeratin, PLAP, B-HCG
teratoma: cytokeratin
50
List features to report in the synoptic for testicular germ cell tumors
- Procedure, specimen, laterality
- Tumor types, quantities of each
- Tumor size
- invasion into structures (rete, tunicae, epididymis, spermatic cord)
- LVI
- resection margins
- background parenchyma including ITGCN
51
What are the indications for testicular biopsy for infertility?
- Patients with azoospermia/severe oligospermia
- to differentiate between obstructive azoospermia and primary seminiferous tubule failure
- assess fertility potential in those with a non-obstructive problem
52
What are the major histologic patterns seen in testicular biopsies performed in the investigation of male infertility?
- Normal spermatogenesis
- Sertoli cell only
- Germ cell maturation arrest
- Hypospermatogenesis
- Tubular hyalinization
53
List the causes of infertility associated with normal testicular histolog
- Excurrent duct obstruction
- Abnormalities of sperm tails/heads
- Spermatozoa transport problems
- cliary dyskinesia
54
Where is urachal caricnoma typically located? What are the histologic subtypes of urachal carcinoma?
- Muscular wall of bladder dome
types: mucinous, enteric, signet ring, NOS, mixed type
55
What conditions are associated with penile squamous cell carcinoma?
- HPV
- Penile intraepithelial neoplasia
- Balanitis xerotica obliterans
56
What are features of bowenoid papulosis, and how does it differ from Bowen disease and erythroplasia de Queyrat?
Bowenoid papulosis: Younger patients (20-40), papules on shaft of penis, undergo spontaenous regression. All share similar morphology of epithelial dysplasia
57
What are risk factors for penile squamous cell carcinoma?
- Phimosis
- Chronic inflammatory conditions (BXO)
- smoking
- UV
- HPV
58
What types of squamous cell carcinoma of penis have better and which have worse prognosis?
Better: verrucous, warty, papillary, pseudohyperplastic
Worse: basaloid, sarcomatoid
59
What are the histologic features to report when signing out a case of penile SCC?
- histologic type
- histologic grade
- extent of invasion : subepithelial, corpora cavernosa and spongiosum, urethra, prostate, adjacent structures
- Maximum depth of invasion
- LVI
- PNI
- resection margins
- associated in-situ lesions
60
What are the histologic features of seminoma (classic)?
- Sheets/lobules of loosely cohesive cells divided by fibrous septa containing lymphocytes/plasma cells
- Round or polygonal cells with sharp cell membranes, clear to eosinophilic cytoplasm
- Large and vesicular nuclei with prominent nucleoli
- Possible areas of necrosis, syntitiotrophoblasts or granulomas
61
What is the pattern of spread of classic seminoma, and prognosis? What variant has serum B-HCG ?
Spread: retroperitoneal LN
Prognosis: excellent, also responds to radiotherapy
variant with b-HCG: seminoma with syncytiotrophoblasts, not a mixed germ cell tumor, similar prognosis
62
What are the histologic features of spermatocytic seminoma and IHC pattern? What is the prognosis?
- Cells arranged in sheets in edematous stroma
- 3 cell types: small-6-8 um, smudged chromatin, scant cytoplasm
intermediate, scant cytoplasm with round nuclei, giant uninucleate/multinucleate with filamentous chromatin
IHC: PLAP is variable, CKIT +, all other panel markers neg.
prognosis: excellent, resection only
63
What specific criteria are used to define a tumor as urachal?
- Tumor at dome of bladder
- Sharp demarcation between tumor and normal surface epithelium
- Exclusion of primary adenocarcinoma elsewhere (esp. colonic)
64
What is the importance of distinguishing urachal/non-urachal carcinomas of bladder? Is IHC useful?
- Resection of urachal adenocarcinoma must include removal of entire urachal remnant
- No IHC reliably differentiates urachal/bladder
65
What histologic features are using in staging prostatic adenocarcinoma?
- Microscopic extension of tumor (within gland=T2, outside=T3)
- Extraprostatic extension
- invasion of seminal vesicles
- Invasion bladder neck
- LN metastases
66
Define extraprostatic extension
- Tumor invading periprostatic fat, or extension beyond plane of fat, either as distinct protrusion or within perineural space
67
Describe grossing of a radical prostatectomy
- Check that container/requisition identifiers match
- Weigh, ink (2 or 3 colours), measure dimensions
- Fix in formalin 10:1
- Amputate apex/base and cone
- SEction remaining prostate in 3mm sections, submit in toto if \<35g or \>75% of tissue esp. posterior/peripheral zone or suspicious areas
- include section of seminal vesicles where they meet base
68
Vanishing cancer: no CA on initial review of prostatectomy slides. What do you do?
- Review slides again, show to a colleague
- Submit all tissue if not already done
- Review the core bx slides to confirm diagnosis and location (sextant)
- Explore pt history-any treatment?
- Perform PINCKT, deeper sections in slides with HGPIN or ASAP
- Flip blocks (especially in area of + bx); if HGPIN or ASAP, do deepers/IHC
- Confirm bx/prostatectomy from same pt by molecular testing
- Communicate with clinician regarding work-up of case/explanations
- Communicate with lab director
69
What are possible causes for vanishing cancer on radical prostatectomy?
- Carcinoma in tissue not submitted
- Carcinoma in block but not in slides
- Carcinoma lost during trimming of block
- Carcinoma obscured by treatmetn (hormone)
- Carcinoma obscured by inflammation/infarct
- Carcinoma was extremely focal and removed by bx
- Radical prostatectomy was incomplete, and CA remains in pt
- Bx tissue was misidentified
- Bx tissue was misdiagnosed
70
List major causes of ureteral obstruction
Intrinsic: calculi (\<5mm, at UPJ, where ureters cross iliacs, entrance to bladder), strictures, tumors, blood clots, neurogenic
extrinsic: pregnancy, periureteral inflammation, endometriosis, tumors
71
List 4 congenital malformations in ureters
- Double/bifid ureter
- Ureteropelvic junction obstruction (UPJ)
- abnormal organization of the smooth muscle bunles at the UPJ
- diverticula
72
Obstructive lesions in ureter: what are consequences and clues to site of obstruction?
- Consequences include hydroureter, hydronephrosis, pyelonephritis
- if unilateral: probably proximal, if bilateral: likely distal (eg. prostatic hyperplasia)
73
What is sclerosing retroperitoneal fibrosis?
- Primary/idiopathic--Ormond disease
- Uncommon cause of ureteral narrowing/obstruction characterized by fibrous proliferative inflammatory process encasing the retroperitoneal structures and causing hydronephrosis
- Some causes include drugs (B-blockers, ergot), inflamamtory conditions elsewhere (crohns, diverticulitis), malignant disease
- Related to mediastinal fibrosis, sclerosing cholangitis, riedel thyroiditis
- proposed autoimmune etiology
- Micro features include fibrosis with prominent lymphocytes with germinal centres, plasma cells and eosinophils
74
What are congenital abnormalities of the urinary bladder?
- Diverticula
- exstrophy (defect in bladder wall, or large opened sac)
- vesicoureteral reflux, congenital vesicouterine fistula
- patent urachus
- urachal cysts
75
List 8 agents causing cystitis
- coliforms: E. coli, Proteus, Klebsiella, Enterobacter
- Mycobacterium tubercuosis
- Candida albicans
- Schistosoma haematobium
- adenovirus
- chlamydia
- mycoplasma
- radiation
76
Malakoplakia: Descibe the features and significance
- Vesical inflammatory reaction characterized by soft, yellow mucosa plaques (3-4cm)
- Micro infiltration with large, foamy macrophages with occasional multinucleate giant cells and interspersed lymphocytes
- Macrophages have bacterial membranous debris, minerazlized concretions of calcium in lysosomes=michaelis guttman bodies
- other sites: colon, lungs, bones, kidney, prostate, epidiymis
- usually related to chronic bacterial infection by E.coli or Proteus
- Defect in phagocytic/degrative function of macrophages
- more frequent in immunosuppressed
77
What are some possible genetic alterations in urothelial carcinoma?
- p16, p53. Loss of tumor suppressor genes
- Deletions of 9, 17p, 13q, 11p...
78
What is the management for low-grade papillary urothelial lesions, CIS/HG papillary and what are indications for cystectomy?
- papillary LG: transurethral resection, periodic cystoscopy F/U + urine cytology
- papillary HG/CIS: intravesical BCG
- Indications for radical cystectomy: invasive urothelial CA (in LP or deeper), CIS/HG papillary refractory to BCG, CIS into prostatic urethra/ducts
- advanced CA treated with chemotherapy
79
List 5 causes of bladder obstruction
- BPH
- cystocele
- urethral strictures
- inflammatory urothelial strictures
- inflammatory fibrosis
- bladder tumors
- mechanical obstruction (calculi)
- injury to innervation of bladder
80
What is peyronie disease
- fibrous bands involving corpus cavernosum of penis
- ? variant of fibromatosis
- results in penile curvature and pain during intercourse
81
Organisms in urethritis
- Gonorrhea
- Chlamydia
- E. coli
Mycoplasma (ureaplasma urealyticum)
82
Penile lesions: compare Bowen disease and bowenoid papulosis
Bowen's disease: HPV related, type 16. Age \>35 yrs. Solitary, thickened grey-white plaque. Dysplastic (full thickness), numerous mitoses. 10% go onto invasive.
Bowenoid papulosis: younger, multiple red-brown lesions, HPV 16, never develops into carcinoma and spontaenously regresses
83
What are features of crypt0rchdism?
- 1% of 1 yr olds, usually unilateral
- complete/incomplete failure of intraabdomimal testes to descend into scrotum
- 2 phases: mullerian inhibiting substance to go from lower abdomne, then androgen dependant to go into scrotal sac
- histologic changes start at age 2; arrest in development of germ cells associated with hyalinization and thickening of basement membrane of spermatic tubule, increased sdtroma, prominent Leydig cells
- grossly small and firm
84
What chromosomal abnormality is found in germ cell tumors, regarless of type?
- isochromosome 12
85
What are risk factors for seminoma?
- testicular disgenesis, klinefelter syndrome, family hx (Xq27)
86
Teratomas in testicles: give some features
- Postpubertal male: all teratomas are regarded as malignant, whether ature or not
- large 5-10cm
- heterogenous collection of differentiated structures or immautre, embryonal tissues
- rarely have non-germ cell tumors : eg SCC, and these do not respond to chemo if they spread outside testis
87
What are features of Leydig cell tumors?
- ages 20-60, testicular swelling
- circumscribed nodules, distinctive golden brown and homogenous
- Neoplastic leydig cells are large, round or polygonal with granular eosinophilic cytoplasm with lipid granules/lipofucshin and possible reinke crystals. 10% are invasive and produce mets
- IHC: inhibin, calretinin, melan-A, androgens
88
What are features of SErtoli cell tumors?
- Hormonally silent
- Present as mass
- Firm, small nodules grey-white
- Micro: form cordlike structures/tubules
- usually benign
89
What enzyme converts dihydrotestosterone to testosterone in the prostate?
- 5- a reductase
- in stromal cells (epithelial cells dont' have it)
90
