Lower Urinary Tract And Male Genital Tract Question and Answers

Lower Urinary Tract and Male Genital Tract

Question 1. Write a note on the grading of urothelial tumors (seen in the urinary bladder).
Answer:

WHO/International Society of Urological Pathology (ISUP) grading of urothelial tumors

• Urothelial papilloma
• Urothelial neoplasm of low malignant potential
• Papillary urothelial carcinoma, low-grade
• Papillary urothelial carcinoma, high-grade
• Carcinoma in situ
• Invasive urothelial cancer

Read and Learn More Preparatory Manual of Pathology Question and Answers

1. Urothelial papillomas

• Small superficial exophytic structures attached to the bladder mucosa with a stalk
• Papillae have a central core of loose fibrovascular tissue covered by epithelium, which resembles normal urothelium histologically

2. Papillary urothelial neoplasms of low malignant potential (PUN LMP)

• These tumors are larger than papillomas
• Papillae with a thicker urothelial layer in comparison to papilloma

3. Low-grade papillary urothelial carcinomas, non-invasive

• Urothelial cells have an orderly architectural and cytological appearance
• Tumor cells are cohesive and show mild nuclear atypia with a few cells showing hyperchromatic nuclei and infrequent mitotic figures

4. High-grade papillary urothelial cancers, non-invasive

• Tumor cells are dyschezia with large hyperchromatic nuclei
• Atypical mitotic figures are frequent
• These tumors can show invasion into the muscular layer

5. Carcinoma in situ

• Can present as reddening, granularity, and thickening of the bladder mucosa
• Tumor cells lack cohesiveness and can be easily shed in urine
• Microscopy: It shows the presence of cytologically malignant tumor cells within a flat urothelium

6. Invasive urothelial cancer:

• Highly atypical pleomorphic tumor cells with invasion into the deeper muscular layers
• The extent of the invasion into the muscular mucosae is of prognostic significance

Question 2. Write a note on the etiopathogenesis of transitional cell carcinoma of the bladder.
Answer:

Factors implicated in the causation of bladder cancer/ transitional cell carcinoma

• Cigarette smoking
• Industrial exposure to arylamines
• Schistosoma crematorium infection
• Long-term use of analgesics
• Heavy long-term exposure to cyclophosphamide
• Pelvic irradiation for other cancers
• Genetic alterations:
  • Gain of function mutations in FGFR3
  • Loss of function mutations in TP53 and RB tumor suppressor genes
  • Activating mutations in HRAS oncogene
  • Monosomy or deletions of chromosome 9p and 9q

Question 3. Write a short note on condyloma acuminate (warts) affecting the male genital tract.
Answer:

Condyloma acuminatum

• Causative agent (sexually transmitted disease): Human papillomavirus (HPV) types 6 and 11
• The site and gross features: Most commonly affect the coronal sulcus and the inner surface of the prepuce, where they present as single or multiple, sessile or pedunculated, red papillary excrescences

Microscopy

• The lesion is composed of branching, villous, papillary connective tissue stoma, covered by the epithelium with hyperkeratosis and acanthuses (thickening of the underlying epidermis)
• Surface epithelium shows characteristic viral cytopathic change/ pilocytic Styria
• Koilocytic atypia: Manifests as nuclear enlargement, hyperchromasia, and a cytoplasmic perinuclear halo

Question 4. Write a short note on Bowen’s disease.
Answer:

Bowen disease

• Affects males more than 35 years of age
• Site: Involves the skin of the shaft of the penis and the scrotum
• Gross: Solitary, thickened, gray-white, opaque plaque

Microscopy

• Epidermis appears hyperplastic
• Cells in the stratum spinous show full-thickness epithelial dysplasia with large hyperchromatic nuclei and lack orderly maturation with numerous mitosis
• The basement membrane is intact
• Can transform into infiltrating squamous cell carcinoma

Note:

• Bowen disease of the glans is termed erythroplasia of Quart

Question 5. Write a short note on cryptorchidism.
Answer:

Cryptorchidism. Definition:

Complete or partial failure of intra-abdominal testes to descend into the scrotal sac. Undescended testis is at a greater risk of developing testicular cancer than is the descended testes

Two phases of testicular descent

1. Trans-abdominal phase

• Testis comes to lie within the lower abdomen or brim of the pelvis
• Controlled by a hormone called müllerian-inhibiting substance

2. Inguinoscrotal phase

• Testes descend through the inguinal canal into the scrotal sac
• Occurs due to the release of calcitonin gene-related peptide from the genitofemoral nerve
• The most common site of arrest is in the inguinal canal

Morphology

• Unilateral in most cases, bilateral in 25% of patients

Microscopy

• Altered morphological changes in testes appear as early as 2 years of age
• Characterized by maturation arrest of germ cells
• Tubules show only Sertoli cells
• Marked hyalinization and thickening of the basement membrane of the tubules
• Leydig cells appear prominent

Treatment

• Orchiopexy (placement in the scrotal sac) should be done preferably before 2 years of age
• Orchiopexy does not guarantee fertility and development of cancer in the testes
• Cancer may also develop in the contralateral, normally descended testis

Question 6. Classify germ cell tumors. Discuss gross and microscopic pictures of seminoma testis.
Answer:

Germ cell tumors

1. Seminomatous tumors

• Seminoma
• Spermatocytic seminoma

2. Non-seminomatous tumors

• Embryonal carcinoma
• Yolk sac (endodermal sinus) tumor
• Choriocarcinoma

3. Teratoma

4. Sex cord-stromal tumors

• Leydig cell tumor
• Sertoli cell tumor

Seminole

• The most common type of germ cell tumor
• Seen most commonly in the third decade
• The ovarian counterpart of Seminole is dysgerminoma
• Contains ISO-chromosome 12p
• Expresses OCT3/4 and NANOG
• 25% of these tumors have activating KIT mutations

Morphology

Gross

• Produce bulky masses
• Cut surface: Appears homogeneous, gray-white, lobulated
• Hemorrhage or necrosis is not seen

Microscopy

• The tumor is composed of sheets of uniform tumor cells
• Tumor cells are divided into poorly demarcated lobules by delicate fibrous septa
• The fibrous septae contain lymphocytic infiltrate
• Tumor cells are large, round to polyhedral, have distinct cell membranes; clear or watery-appearing cytoplasm, a large, central nucleus with one or two prominent nucleoli

Question 7. Write a short note on spermatocyte seminoma.
Answer:

Spermatocytic seminoma

• Slow growing tumor
• Affects individuals older than age 65 years
• Excellent prognosis
• Gross: Soft, gelatinous appearance

Microscopy

Three cell populations

1. Medium-sized cells (most numerous) containing a round nucleus and eosinophilic cytoplasm with a characteristic spire chromatin (which resembles that of spermatocytes in the meiotic phase)
2. Smaller cells resembling small lymphocytes
3. Scattered giant cells, either uninucleate or multinucleate

Question 8. Write a note on the pathogenesis and morphology of benign prostatic hypertrophy.
Answer:

Benign prostatic hyperplasia (BPH)

Etiopathogenesis

• Hyperplasia occurs due to impaired cell death rather than increased epithelial cell proliferation
• Androgens required for the development of BPH, increase cellular proliferation and inhibit cell death
• Dihydrotestosterone (DHT) is the major androgen in the prostate
• DHT is formed in the prostate from testosterone by the action of an enzyme called type 2 5α-reductase
• This enzyme is located in stromal cells
• Hence, stromal cells are responsible for androgen-dependent prostatic growth
• DHT binds to the nuclear androgen receptors (AR) present in both stromal and epithelial prostate cells
• DHT is more potent than testosterone because it has a higher affinity for AR
• The binding of DHT to AR stimulates the transcription of androgen-dependent genes, which includes several growth factors and their receptors
• DHT-induced growth factors act by increasing the proliferation of stromal cells and decreasing the epithelial cell death

Question 9. Write a short note on prostatic intraepithelial neoplasm.
Answer:

Prostatic intraepithelial neoplasm (PIN)

• Also called prostatic carcinoma in situ
• Involves prostatic ducts and acini
• Divided into three grades: PIN I, II, III
• Categories: PIN I and PIN II—low grade, PIN III—high grade
• Morphological differentiation between low grade and high grade is based on: Cell crowding and stratification; nuclear enlargement, pleomorphism, and chromatin pattern; and appearance of nucleoli
• High-grade PIN has an association with prostatic adenocarcinoma