Practice questions Lower urinary tract pathology

Practice questions

Lower urinary tract pathology

© Jun Wang, MD, PhD

1. A 45-year-old man presents with intermittent painless hematuria and dysuria for a month. His past medical history is unremarkable. Physical examinations reveals no significant abnormality. Laboratory tests are normal except 6 red cells per high power field in urinalysis. No white cells, casts or abnormal epithelial cells are seen. Intravenous pyelogram reveal normal filling of renal pelvis and bladder. The ureters are patent with a few outpouchings at the mid and distal segments. What is the most likely diagnosis?

A. High grade urothelial carcinoma of ureter

B. Low grade urothelial carcinoma of ureter

C. Ureter diverticula

D. Urothelial carcinoma in situ of ureter

2. Use this case for next two questions. A 40-year-old man presents with vague low back pain for 4 months. He has a history of classic Hodgkin lymphoma of cervical lymph nodes 15 years ago, that was treated with chemotherapy, and Riedel thyroiditis. Physical examination reveals vague discomfort at lower abdomen and mild costovertebral angle tenderness. His laboratory tests are within normal ranges. Sonographic examination reveals mild bilateral hydronephrosis and a poorly circumscribed mass extending from pelvis to pancreas, surrounding aorta and inferior vena cava. Biopsy of the mass reveals fibrous tissue with scattered lymphocytic and plasma cell infiltrate. No significant atypia nor necrosis are noted. What is likely the diagnosis?

A. Diffuse large B cell lymphoma

B. Fibrosarcoma

C. Hodgkin lymphoma

D. Plasmacytoma

E. Sclerosing retroperitoneal fibrosis

3. A 40-year-old man presents with vague low back pain for 4 months. He has a history of classic Hodgkin lymphoma of cervical lymph nodes 15 years ago, that was treated with chemotherapy, and Riedel thyroiditis. Physical examination reveals vague discomfort at lower abdomen and mild costovertebral angle tenderness. His laboratory tests are within normal ranges. Sonographic examination reveals mild bilateral hydronephrosis and a poorly circumscribed mass extending from pelvis to pancreas, surrounding aorta and inferior vena cava. Biopsy of the mass reveals fibrous tissue with scattered lymphocytic and plasma cell infiltrate. No significant atypia nor necrosis are noted. What is likely to be elevated in his serum?

A. Calcium

B. CD30

C. IgG4

D. Kappa light chain

E. Monoclonal IgG (M protein)

4. A 44-year-old woman presents with dysuria for a week. She has a history of type 2 diabetes and recurrent urinary tract infection for 10 years. Her past medical history is otherwise unremarkable. Physical examination reveals no significant abnormalities. Her laboratory tests, including renal function tests and urinalysis, are within normal ranges. Microscopic examination of urine reveals no atypical epithelial cells. Image studies reveals a few small filling defects in her left ureter. Her right ureter, bilateral kidney and bladder are normal. Ureteroscopic biopsy reveals small intramucosal cystic lesions lined by benign appearing urothelium. What is the diagnosis?

A. Diabetic nephropathy

B. Low grade urothelial carcinoma of ureter

C. Ureter diverticula

D. Ureteritis cystica

E. Urothelial carcinoma in situ of ureter

5. A 41-year-old man presents with intermittent hematuria for 2 months. His past medical history is unremarkable. Physical examination reveals mild left costovertebral angle tenderness. His laboratory tests are within normal ranges. Urinalysis reveals 10 red cells per high power field. No atypical epithelial cells are seen. Image studies reveal mild left hydronephrosis and a 4.3 cm intra-luminal mass of left proximal ureter. The mass is removed. Microscopically it has a fibrous core covered by urothelial cells. The surface is smooth. No cytological atypia is noted. What is the diagnosis?

A. Fibroepithelial polyp of ureter

B. Low grade urothelial carcinoma of ureter

C. Ureter diverticula

D. Ureteritis cystica

E. Urothelial carcinoma in situ of ureter

6. A 32-year-old woman presents with dysuria, urinary frequency and urgency for 6 months. She denies history of fever or hematuria. She has a history of diabetes and recurrent urinary tract infection. Physical examination and laboratory tests reveal no significant abnormalities. Image studies reveal a 2.5 cm mass at the trigone area. Biopsy of the mass reveals glandular structures within lamina propria. These glandular structures have smooth contour. No cytological atypia is noted. The bladder surface urothelium is normal. Scattered lymphocytes and plasma cells are seen in the stroma. What is the diagnosis?

A. Adenocarcinoma

B. Cystitis glandularis

C. Low grade papillary urothelial carcinoma

D. Urothelial carcinoma in situ

E. Urothelial papilloma

7. A 31-year-old woman presents with lower abdominal pain, dysuria, urinary frequency and urgency for 1 month. She does not have history of fever, weight change or infection. Her past medical history is unremarkable. Physical examination and laboratory tests are all within normal range. Image studies and cystoscopy examination reveal no significant abnormalities. What is the most likely diagnosis?

A. Acute cystitis

B. Cystitis glandularis

C. Interstitial cystitis

D. Papillary carcinoma

E. Papilloma

8. A 52-year-old man presents with fatigue, weakness, and urinary frequency for a week. He does not have fever or weight loss. He is HIV positive due to intravenous drug use. Physical examination reveals no significant abnormalities. Urinalysis reveals proteinuria, many neutrophils and significant amount of E. coli. Cystoscopy reveals multiple thickened areas with flat smooth surface of bladder lateral wall and trigone. No ulcer or hemorrhage is seen. Biopsy reveal aggregates of macrophages, some contain basophilic inclusions with mineralized concretions. These inclusions are positive for iron stain. No cytological atypia is notes. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Low grade papillary urothelial carcinoma

C. Malakoplakia

D. Urothelial carcinoma in situ

E. Urothelial papilloma

9. Use this case for next two questions. A 50-year-old man presents with intermittent hematuria for 2 months. He does not have urinary frequency, urgency, fever or weight loss. His past medical history is unremarkable. Physical examination are normal. Urinalysis reveals 15 red blood cells per high power field. A few mildly atypical epithelial cells are seen. Image studies reveal no significant abnormalities of his kidneys and ureters. Cystoscopy reveals a 1.5 cm exophytic growth at the left lateral wall of his bladder. Biopsy reveal finger like projects with fibrovascular cores, covered by 3 to 4 layers of urothelial cells. No cytological atypia nor inflammation are noted. What is the diagnosis?

A. Low grade papillary urothelial carcinoma

B. Malakoplakia

C. Polypoid cystitis

D. Urothelial carcinoma in situ

E. Urothelial papilloma

10. A 50-year-old man presents with intermittent hematuria for 2 months. He does not have urinary frequency, urgency, fever or weight loss. His past medical history is unremarkable. Physical examination are normal. Urinalysis reveals 15 red blood cells per high power field. A few mildly atypical epithelial cells are seen. Image studies reveal no significant abnormalities of his kidneys and ureters. Cystoscopy reveals a 1.5 cm exophytic growth at the left lateral wall of his bladder. Biopsy reveal finger like projects with fibrovascular cores, covered by 3 to 4 layers of urothelial cells. No cytological atypia nor inflammation are noted. Abnormality of what gene is likely to be associated with these findings?

A. EGFR

B. FGFR3

C. p53

D. Racemase

E. Rb

11. A 79-year-old man presents with intermittent hematuria for 6 months. He has a history of type II diabetes for 30 years, and multiple skin squamous cell carcinoma and basal cell carcinoma in the past 20 years. He smokes cigarette 1 pack a day for 50 years, and drink wines 2 glasses a day for 45 years. Physical examination is unremarkable. Urinalysis reveals 25 red blood cells per high power field. A few mildly atypical epithelial cells are seen. Other laboratory test results are within normal range. Image studies reveals a 2.5 cm mass at the base of bladder. Cystoscopy reveals an exophytic mass. Microscopically, this mass has finger like projects containing fibrovascular core covered by approximately 10 layers of mildly to moderately atypical urothelial cells. No invasion is noted. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Low grade papillary urothelial carcinoma

C. Squamous cell carcinoma

D. Urothelial carcinoma in situ

E. Urothelial papilloma

12. A 65-year-old man presents with intermittent hematuria for 3 months. His past medical history is unremarkable. He smokes cigarette 1 pack a day for 40 years, and drink wines 2 glasses a day for 30 years. Physical examination is unremarkable. Urinalysis reveals 25 red blood cells per high power field. A few markedly atypical epithelial cells are seen. Other laboratory test results are within normal range. Image studies reveals a 1.5 cm mass at the base of bladder. Cystoscopy reveals an exophytic mass. Microscopically, this mass has finger like projects containing fibrovascular core covered by approximately 10 layers of markedly atypical urothelial cells. No invasion is noted. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Low grade papillary urothelial carcinoma

C. Squamous cell carcinoma

D. Urothelial carcinoma in situ

E. Urothelial papilloma

13. Use this case for next two questions. A 59-year-old man presents with intermittent hematuria for 3 months. His past medical history is unremarkable. He smokes cigarette 1 pack a day for 30 years, and drink wines 2 glasses a day for 25 years. Physical examination is unremarkable. Urinalysis reveals 15 red blood cells per high power field. A few markedly atypical epithelial cells are seen. Other laboratory test results are within normal range. Image studies reveal no significant abnormalities in kidneys, bilateral ureters and bladder. Cystoscopy reveals no recognizable abnormal changes. Random biopsies were performed. One biopsy from posterior wall reveals flat urothelial mucosa covered with markedly atypical urothelial cells. No invasion is noted. Biopsies from other sites are unremarkable. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Low grade papillary urothelial carcinoma

C. Squamous cell carcinoma

D. Urothelial carcinoma in situ

E. Urothelial papilloma

14. A 59-year-old man presents with intermittent hematuria for 3 months. His past medical history is unremarkable. He smokes cigarette 1 pack a day for 30 years, and drink wines 2 glasses a day for 25 years. Physical examination is unremarkable. Urinalysis reveals 15 red blood cells per high power field. A few markedly atypical epithelial cells are seen. Other laboratory test results are within normal range. Image studies reveal no significant abnormalities in kidneys, bilateral ureters and bladder. Cystoscopy reveals no recognizable abnormal changes. Random biopsies were performed. One biopsy from posterior wall reveals flat urothelial mucosa covered with markedly atypical urothelial cells. No invasion is noted. Biopsies from other sites are unremarkable. Additional biopsy reveals similar findings as the posterior wall at the base and left anterior lateral walls of his bladder. What is the cause of these findings?

A. Aggressive invasion

B. Implanting

C. Intraepithelial spread

D. Metastasis
E. Multifocality

15. A 49-year-old man presents with gross hematuria and left lower back pain for 1 month. His past medical history is unremarkable. He has a 20 pack-year smoking history. He denies alcohol usage or illicit drug use. Physical examination is unremarkable. Urinalysis reveals 20 red blood cells per high power field. A few atypical cells are seen. Other laboratory tests are normal. Image studies reveal a 7 cm exophytic mass at the left posterior wall of bladder. Mild left hydronephrosis is noted. No other abnormalities are noted. Biopsy of the mass reveals cords of slightly atypical cells in lamina propria and muscular tissue. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Invasive urothelial carcinoma

C. Normal Brunn nests

D. Squamous cell carcinoma

E. Urothelial carcinoma in situ

16. Use this case for next two questions. A 59-year-old man presents with progressive dysuria, frequency and intermittent hematuria for 3 months. He has a history of type II diabetes for 10 years, and multiple skin squamous cell carcinoma in the last 5 years. He is an immigrant from North Africa, and has worked in a local farm since age 25. He smokes cigarette 1 pack a day for 30 years, and drink beers 2 cans a day for 10 years. Physical examination is unremarkable. Urinalysis reveals moderate amount of red cells and a few markedly atypical cells. Cystoscopy examination reveals a 3.5 cm ulcerated mass at the left anterior wall. Biopsy of the mass reveals irregular cords of atypical cells with abundant cytoplasm and marked nuclear pleomorphism. Intercellular bridges and squamous pearls are seen. What is the diagnosis?

A. High grade papillary urothelial carcinoma

B. Invasive urothelial carcinoma

C. Metastatic squamous cell carcinoma from skin

D. Squamous cell carcinoma of bladder

E. Urothelial carcinoma in situ

17. A 59-year-old man presents with progressive dysuria, frequency and intermittent hematuria for 3 months. He has a history of type II diabetes for 10 years, and multiple skin squamous cell carcinoma in the last 5 years. He is an immigrant from North Africa, and has worked in a local farm since age 25. He smokes cigarette 1 pack a day for 30 years, and drink beers 2 cans a day for 10 years. Physical examination is unremarkable. Urinalysis reveals moderate amount of red cells and a few markedly atypical cells. Cystoscopy examination reveals a 3.5 cm ulcerated mass at the left anterior wall. Biopsy of the mass reveals irregular cords of atypical cells with abundant cytoplasm and marked nuclear pleomorphism. Intercellular bridges and squamous pearls are seen. What is most likely associated with his condition?

A. Alcohol usage

B. Genetic background

C. Mutation of androgen receptor

D. Schistosoma haematobium infection
E. Ultraviolet light

18. A 55-year-old man presents with gross hematuria and progressive dysuria for 1 month. He has a history of kidney and bladder stones 10 years ago. He has type 2 diabetes and recurrently urinary tract infection for 5 years. Physical examination is unremarkable. Image studies reveals a 3.5 cm mass at the posterior wall of bladder. Biopsy of the mass reveals irregular glandular structures lined by atypical cells. Some of the glandular structures are seen in muscular layers. What is the diagnosis?

A. Adenocarcinoma

B. Cystitis glandularis

C. Low grade papillary urothelial carcinoma

D. Urothelial carcinoma in situ

E. Urothelial papilloma

19. A 42-year-old woman presents with urinary urgency and intermittent hematuria for 3 weeks. She has history of type II diabetes and recurrent urinary tract infection. She was diagnosed with intramucosal adenocarcinoma of sigmoid colon a month earlier and was treated with mucosal resection. Physical examination and laboratory tests are within normal range except mild hematuria. Image studies are unremarkable. Cystoscopy examination reveal foci of slightly raised area in the roof and trigone. Biopsy of these areas reveals tissue covered by single layer of columnar cells with mucin production. Tubular glandular structure lined by same type of cells are seen. No atypia is noted. Mild lymphocytic and plasmacytic infiltration is seen in the background. What is the diagnosis?

A. Adenocarcinoma of bladder

B. Intestinal metaplasia

C. Interstitial cystitis

D. Malakoplakia

E. Metastatic adenocarcinoma of colon

20. A 57-year-old woman presents with dysuria for 2 weeks. She has a history of type II diabetes and recurrent urinary tract infection. Physical examination reveals a 1.2 cm pink mass protruding outside urethral meatus. No other abnormality is noted. Biopsy of the mass reveals urothelial mucosa with acute and chronic inflammation and small vascular proliferation. No atypia is noted. Special stain is negative for fungal element. What is the diagnosis?

A. Caruncle

B. Condyloma

C. Herpes

D. Papillary urothelial carcinoma

E. Urothelial papilloma

Answers

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