Urinary Bladder

Question 1

Lining of cystitis glandularis

Answer 1

Intestinal type epithelium or glandular metaplasia

Question 2

Type of cystitis with formation of lymhpoid follicles with germinal
Centers

Answer 2

Follicular cystitis

Question 3

Cystitis associated with indwelling catheters

Answer 3

Papillary or polypoid cystitis
- edematous with broad FV cores

Question 4

> 6 weeks cystitis with no identifiable cause and development of Hunner ulcers in late stages

Answer 4

Interstitial cystitis

Question 5

Type of cystitis associated with precipitation of salts with calcified debris embedded in the mucosa

Answer 5

Encrusted cystitis

Question 6

Pneumatosis of the bladder due to trauma, fistula, instrumentation or urinary stasis. Histologically with air bubbles surrounded by FBGCs

Answer 6

Emphysematous cystitis

Question 7

Yellowish submucosal plaques mimicking bladder cancer

Answer 7

Amyloidosis

Question 8

A man with recurrent UTI had a buopsy which showed sheets of foamy macrophages, chronic inflammation, and black intracytoplasmic inclusions
Dx? Stain? Mc organism?

Answer 8

Malakoplakia
Von kossa stain
Michaelis-gutmann bodies
E. Coli

Question 9

A patient had repeated AUS dx on urine cytology and thus had frequent instrumentation. A biopsy done shows papillary and tubular lesions lined by hobnail epithelial cells that seem to infiltrate the lamina propria and superficial detrusor muscle. There was no mitosis, necrosis, solid growth or invasion
IHC (+) PAX8, CK7 and AMACR
dx?

Answer 9

Nephrogenic metaplasia/adenoma
- metaplastic change from chronic irritation or exfoliated renal tubular cells get implanted on these sites
- mimics malignancy

Question 10

A UB papillary tumor with exophytic, thin FV cores lined by normal urothelium (normal thickness)
IHC: (+) CK20 on umbrella cells
Dx? Mutation? Prognosis?

Answer 10

Urothelial papilloma
HRAS, KRAS
BENIGN

Question 11

A 65 year old smoker came in due to hematuria. A polypoid growth is seen in the bladder which was excised. Microsections show a papillary pattern with FV cores lined by urothelial cells with variably increased thickness with cells with mild cytologic atypia and a single nonbasal mitotic figure.
Dx? Molecular? Prognosis?

Answer 11

Noninvasive papillary urothelial carcinoma, low grade
FGFR3 alterations and TERT promoter mutations
Frequent recurrence (50%)
Rare progression to invasive urothelial carcinoma

Question 12

A UB papillary tumor with marked cytologic atypia present in 5% of the tumor.
Ihc: (+) CK20 (full thickness
Dx? Mutations? Prognosis?

Answer 12

non-invasive papillary urothelial carcinoma, high-grade
TERT promoter
FGFR3 alterations
P53 mutations
P16 loss
Progression to invasive urothelial carcinoma

Question 13

A 68 year old man came in due to atypical cells seen un urine cytology. Cystoscopy was done and surgeon saw erythematous mucosal patches which were then biopsied. Microsections show a flat mucosal lining with markedly atypical urothelial cells with disordered architecture.
IHC: (+) ck20 (full thickness), p53 aberrant, increased ki67
Dx? Mutation? Prognosis?

Answer 13

Urothelial carcinoma in situ
TERT, p53, DNA damage repair genes, PI3K and MAPK pathways
Frequent recurrence and progression to Invasive urothelial carcinoma

Question 14

A man working with benzidine dyes came in due to dysuria and hematuria. Cystoscopy showed bladder thickening which was biopsied. Microsections show sheets and single cels invading the lamina propria
IHC: (+) GATA3, p63, HMWCK, CK7 and CK20, uroplakin
(-) Pax8
Dx? Mutations? Risk factors?

Answer 14

Invasive urothelial carcinoma, conventional type
TERT promoter, tp53
Smoking, radiation, benzidine dyes, opiates, high SES

Question 15

What are the urothelial CA with divergent differentiation?

Answer 15

Comventional invasive urothelial carcinoma +

Squamous diff
Glandular diff
Trophoblastic diff

Question 16

Subtype of urothelial CA that is agressive and has frequent LVI and HER2 overexpression?

Answer 16

Micropapillary UC

Question 17

Subtype of UC composed of nests of BLAND urothelial cells resembling Von Brunn nests but infiltrating. Cytologic atypia appears on deeper nests
Dx? Prognosis?
What if nests are larger and with rounded to circumscribed border

Answer 17

NESTED UC
Aggressive
LARGE NESTED

Question 18

Subtype of UC with singly infiltrating plasmacytoid cells with or without cytoplasmic lumina or vacuoles
IHC: (+) CD138, p63, GATA3, cytoplasmic P120
(-) e-cadherin
Mutation?

Answer 18

Plasmacytoid UC
CDH1 gene mutation leading to loss of E-cadherin

Question 19

Other subtypes of UC

Answer 19

tubular and microcystic
Sarcomatoid (+) p63, gata3, hmwck
Lipid rich - with lipoblast like cells
Clear cell/glycogen-rich
Lymhpoepithelioma-like
Giant cell UC
Poorly differentiated

Question 20

Pure SCCA of urinary bladder
Criteria?
Risk factors?

Answer 20

Should not contain concentional UC
indwelling catheter >10 years, bladder stones, smoking, schistosoma haematobium infection

Question 21

Adenocarcinoma, NOS of UB
patterns?
Ihc?

Answer 21

Enteric/colonic type, mucinous, signet ring or mixed
(+) CK20, CDX2, nuclear beta catenin
-/+ CK7 and GATA3

Question 22

A 69 year old male complains of dysuria. A mass was seen on the dome of the bladder. Resection was done including umbilicus. Microsections show enteric adenocarcinoma morphology with central necrosis. Patient has no known other masses on PET CT.
IHC: (+) CK20, CDX2
(-) GATA3
Dx?

Answer 22

Urachal carcinoma
Arises from urachal remnant

Question 23

A 56 year old female complains of difficulty urinating. Cystoscopy showed a urethral mass. Biopsy showed mixed pattern of solid, papillary, tubulocystic areas lined by hobnail cells with clear to eosinophilic cytoplasm.
Ihc: (+) PAX8
(-) GATA3
Dx? Origin?

Answer 23

Clear cell adenocarcinoma
Mullerian

Question 24

Microsections of a UB mass shows sheets of small cells with high N:C ratio, crush artifact, necrosis and apoptosis
IHC: (+) synaptophysin, chromo and TTF-1
Dx? Mutation?

Answer 24

Small cell neuroendocrine carcinoma of bladder
Inactivation of RB1 gene

Question 25

A hypertensive 59 year old woman came in due to micturition triggered headaches. A UB mass was seen and buopsied. Microsections show nested cells with granular cytoplasm separated by FV network and sustentacular cells. (+) synaptophysin, chromo, s100 and GATA3 (-) CK DX? mutation?

Answer 25

Paraganglioma SDH mutation

Question 26

MC cause of hydronephrosis in indants and children

Answer 26

Ureteropelvic junction (UPJ) obstruction If early, bilateral in 20%, more in males, and associated with other anomalies In adults, it is more in women

Question 27

A 46 year old woman came in due to difficulty urinating. Work up showed obstruction on bilateral ureters. What could possibly be the cause? Pathogenesis?

Answer 27

Sclerosing retroperitoneal fibrosis (SRF) - fibrotic proliferative inflammatory process that encases retroperitoneal structures and cause hydronephrosis Primary or idiopathic (Ormond disease) IgG4-related disease

Question 28

MC and serious congenital anomaly of the UB

Answer 28

Vesicoureteral reflux

Question 29

Developmental failure in the anterior wall of the abdomen and the UB. Prognosis?

Answer 29

Exstrophy of the bladder Exposed bladder mucosa—> colonic glandular metaplasia Prone to infection Increased risk of adenocarcinoma of the bladder remnant

Question 30

Result of only a central region of patent urachus. Prognosis?

Answer 30

Urachal cyst - lined by urothelial or metaplastic glandular epithelium Increased risk for neoplastic transformation (adenocarcinoma)

Question 31

Type of cystitis in those who receive systemic chemotherapy or pelvic irradiation

Answer 31

Iatrogenic cystitis

Question 32

Cytotoxic agent that can cause hemorrhagic cystitis

Answer 32

Cyclophosphamide

Question 33

Type of cystitis when submucosa is infiltrated by eosinophils

Answer 33

Eosinophilic cystitis

Question 34

An unpleasant sensation in the UB assoc with UB symptoms of more than 6 weeks in the absence of infection and other identifiable causes. Should it be biopsied? Why?

Answer 34

Interstitial cystitis (chronic pelvic pain syndrome) Yes, to rule out carcinoma in situ (CIS) which mimics interstitial cystitis A late ulcerative phase has chronic mucosal ulcers (Hunner ulcers) —> transmural fibrosis may lead to a contracted bladder

Question 35

A chronic inflammatory reaction that stems from acquired defects in phagocyte function in the setting of chronic bacterial infection mostly by E. Coli or proteus, mostly in the immunosuppressed. Grossly, it is a soft yellow, slightly raised mucosal plaque. Microscopically the macrophages have abundant granular cytoplasm due to phagolysosomes stuffed with bacterial debris. Calcium deposition in the enlarged lysosomes result in laminated mineralized concretions. What are these called? Dx?

Answer 35

Malakoplakia Michaelis-gutmann bodies

Question 36

T or F: extensive and multifocal intestinal metaplasia in cystitis glandularis is a precursor to adenocarcinoma

Answer 36

True Also true for extensive multifocal keratinizing squamous metaplasia —> dysplasia—> scca (Must be distinguished from glycogenated squamous epithelium in the trigone region of the bladder in women)

Question 37

Associated with a worse prognosis in urothelial carcinomas

Answer 37

Invasion of the muscularis propria (detrusor muscle) - 30% 5 year mortality rate - indication for radical cystectomy or radiation therapy with neoadjuvant or adjuvant chemotherapy

Question 38

Assoc mutations in non muscle invasive papillary cancers Progression to muscle invasive cancer?

Answer 38

Gain of function mutations Amplification of FGFR3 Activating mutations in RAS and PI3K Frequently recur but progress to cancer in only 20% of cases

Question 39

Mutations in CIS Progression to muscle invasive cancer?

Answer 39

Rb and TP53 mutations Majority of muscle invasive cancers develop from CIS

Question 40

Difference in prognosis of exophytic papilloma and inverted papilloma?

Answer 40

Exophytic papillomas has a rare chance of progression. Inverted papillomas are completely benign.

Question 41

MC benign mesenchymal tumor in the bladder

Answer 41

Leiomyoma

Question 42

Mc bladder sarcoma

Answer 42

Leiomyosarcoma

Question 43

A small red painful mass in the external urerheal meatus in older females which consists of inflamed granulation tissue covered by intact but friable mucosa which may ulcerate and bleed with the slightest trauma

Answer 43

Urethral caruncle

Question 44

Mc malignant UB tumor in children

Answer 44

Botryoid rhabdomyosarcoma