Practice question answers lower urinary tract pathology

Practice question answers

Lower urinary tract pathology

© Jun Wang, MD, PhD

1. C. Hematuria may be caused by various disorders. Outpouching of ureter without atypical cells are most consistent with diverticula. Urothelial carcinoma of ureter usually presents with mass (filling defects, obstruction, etc) during image studies. In addition, all urothelial neoplasms likely have atypical cells identified in urine, same as bladder cancers.

2. E. The patients presents with symptoms of bilateral urinary obstruction. Image studies reveal a pelvic mass. Microscopic finding of fibrous tissue without atypia is most compatible with a benign fibrotic process, i.e. sclerosing retroperitoneal fibrosis, a condition of IgG4 associated diseases. The plasma cells usually contains IgG4. Diffuse large B cell lymphoma is characterized by sheets of markedly atypical cells expressing CD20, not scattered lymphocytes and plasma cells. Fibrosarcoma is characterized by hypercellular spindle cell growth with herringbone pattern, and cytological atypia. Hodgkin lymphoma has Reed Sternberg cells in a background of inflammatory cells. Plasmacytoma is characterized by sheets of atypical plasma cells.

3. C. Sclerosing retroperitoneal fibrosis, a condition of IgG4 associated diseases. The plasma cells usually contains IgG4. Hypercalcemia can be seen in primary or tertiary hyperparathyroidism and tumor associated bone destruction. Elevated serum CD30 can be seen in a few lymphomas, including Hodgkin lymphoma. Elevated kappa light chain and monoclonal IgG can be seen in plasma neoplasms, including plasmacytoma, multiple myeloma, monoclonal gammopathy of undetermined significance and lymphoplasmacytic lymphoma.

4. D. Small benign intramucosal cystic lesion is most likely ureteritis cystica, a condition associated with recurrent UT infection. It is seen as filling defects protruding into lumen during urography exam. Diabetic nephropathy is associated with increased glomerular extracellular matrix, resulted from hyperglycemia, and presents with proteinuria. It does not have ureter manifestations. All urothelial neoplasms likely have atypical cells identified in urine, same as bladder cancers. Ureter diverticula is characterized by outpouching of ureter without atypical cells.

5. A. Polypoid ureter mass with fibrovascular core and benign urothelial lining is most compatible with fibroepithelial polyp. Low grade papillary urothelial carcinoma have papillary growth with urothelial cytological atypia. Ureter diverticula is characterized by outpouching of ureter without atypical cells. Ureteritis cystica is small benign intramucosal cystic lesion seen as filling defects protruding into lumen during urography exam. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia.

6. B. Glandular structure in bladder lamina propria is suspicious for adenocarcinoma. However, adenocarcinoma of bladder, as adenocarcinoma in any other sites, has irregular gland and cytological atypia. When both are absent, it is likely cystitis glandularis. Low grade papillary urothelial carcinoma and urothelial papilloma have papillary growth, with or without urothelial cytological atypia. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia.

7. C. Presentation of bladder inflammation, with normal laboratory, cystoscopy and image studies is most likely interstitial cystitis. Acute cystitis has evidence of bacterial infection, such as pyuria, positive microbiology studies, etc. Cystitis glandularis usually has raised lesions, due to clustered glandular structures in lamina propria. Papillary urothelial carcinoma and urothelial papilloma have papillary growth, with or without urothelial cytological atypia.

8. C. Aggregates of macrophages with the presence of Michaelis-Gutmann bodies (iron containing, cytoplasmic laminated mineralized concretions) is diagnostic for malakoplakia. Papillary urothelial carcinoma and urothelial papilloma have papillary growth, with or without urothelial cytological atypia. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia.

9. E. Bladder papillary growth with a fibrovascular core and a few layers of normal appearing urothelial covering is urothelial papilloma. Papillary urothelial carcinoma has urothelial cytological atypia. Malakoplakia has aggregates of macrophages with the presence of Michaelis-Gutmann bodies. Polypoid cystitis is polypoid growth associated with chronic bladder inflammation or injury, such as catheterization. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia.

10. B. Urothelial papilloma and papillary urothelial carcinoma may have FGFR3 mutation, especially low grade cases. EGFR, p53 and Rb are more commonly associated with high grade urothelial cancers, including urothelial carcinoma in situ. Racemase overexpression is seen in prostate adenocarcinoma.

11. B. Papillary growth with increased epithelial layers and mildly to moderately atypical urothelium is most likely low grade papillary urothelial carcinoma. High grade papillary urothelial carcinoma has markedly cytological atypia. Squamous cell carcinoma has squamous differentiation, such as intercellular bridges and squamous pearls. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia. Urothelial papilloma have no urothelial cytological atypia.

12. A. See discussion of question 11.

13. D. See discussion of question 11.

14. E. One of the most important character for urothelial carcinoma is multifocality, along the urinary tract, from renal pelvis to bladder/urethra.

15. B. Presence of cords of atypical epithelial cells in lamina propria/muscular layer is always a sign of invasion. This is a case with mildly atypical urothelial cells invading into bladder wall, consistent with low grade invasive urothelial carcinoma. High grade papillary urothelial carcinoma has markedly cytological atypia, and is usually refer to non-invasive form. Normal Brunn nests have regular border and no cytological atypia. Squamous cell carcinoma has squamous differentiation, such as intercellular bridges and squamous pearls. Urothelial carcinoma in situ is a flat lesion with marked cytological atypia. Urothelial papilloma have no urothelial cytological atypia.

16. D. Squamous cell carcinoma of skin rarely metastasize, especially nowadays. Also see discussion of question 15.

17. D. Schistosoma haematobium infection is a leading cause of bladder squamous cell carcinoma in patients from Sudan and Egypt. UV light is the leading cause of skin cancers.

18. A. Irregular glands lined by atypical cells are most compatible with adenocarcinoma, regardless of the site. This case is a bladder adenocarcinoma. Cystitis glandularis has glands with smooth contours, instead of irregular glands with features of invasion. Papillary urothelial carcinoma, urothelial carcinoma in situ and urothelial papilloma do not have glandular differentiation.

19. B. Replacement of urothelium by normal appearing intestinal type is consistent with intestinal metaplasia, a risk factor for bladder adenocarcinoma. Adenocarcinoma of bladder, as adenocarcinoma in any other sites, has irregular gland and cytological atypia. Interstitial cystitis usually does not have epithelial changes. Malakoplakia has aggregates of macrophages with the presence of Michaelis-Gutmann bodies.

20. A. Polypoid growth of urethra with features of inflammation and granulation tissue is most consistent with caruncle. Condyloma has papillary growth and koilocytic changes. Herpes has multinucleated cells with margining of chromatin and nuclear molding. Papillary urothelial carcinoma and urothelial papilloma have papillary growth, with or without urothelial cytological atypia.

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