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I
Congenital dis. Of kidney
Agenesis
The absence of both kidneys is not compatible with life.
Absence of one kidney, the other kidney undergoes compensatory
hypertrophy to maintain normal renal function
Hypoplasia
failure of one kidney to reach adult size. , the other kidney undergoes
compensatory hypertrophy
(The horseshoe kidney is a form of ectopic kidney in which the poles of the two kidneys
fuse in the pelvic cavity prior to ascending.
This leads to a large U-shaped kidney which is unable to ascend to the level of L1
because it is blocked by the inferior mesenteric artery at the aorta. )
• In the early stages of cyst development, the cysts are connected to the tubules from
which they arise and the fluid content is glomerular filtrate.
• When the cyst diameter exceeds 2 mm, most detach from the patent tubule and the
fluid content is derived from secretions of the actual lining epithelium.
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• With time, the cysts enlarge and cause progressive damage to adjacent functioning
nephrons.
• Cysts develop along the entire length of the nephron
Pathogenesis:
• The basic pathologic process may be considered a proliferative /hyperplastic
abnormality of the tubular epithelium.
• In the early stages of cyst development, the cysts are connected to the tubules from
which they arise and the fluid content is glomerular filtrate.
• When the cyst diameter exceeds 2 mm, most detach from the patent tubule and the
fluid content is derived from secretions of the actual lining epithelium.
• With time, the cysts enlarge and cause progressive damage to adjacent functioning
nephrons.
Epidemiology:
• Relatively common, occurring in one in 500 to 1000 individuals.
• Adult PKD is the third most common cause of end-stage renal disease.
• Some cysts however show epithelia with features of proximal tubules, distal tubules
and collecting ducts.
• Tissues between the cysts may show unremarkable or atrophic nephron elements.
Clinical Correlations:
• usually present in the fourth to fifth decade of life with progressive renal
insufficiency and bilaterally enlarged cystic kidneys.
• Hypertension is a common complication
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Extrarenal manifestations include:
hepatic, pancreatic and splenic cysts;
intracranial and aortic aneurysms;
and cardiac valve abnormalities.
The cysts uniformly arise in the collecting ducts, rather than the whole nephron.
As compared to ADPKD, the cysts are diffuse and evenly distributed.
Renal failure is virtually inevitable, usually occurring in childhood, but it can occur in
adulthood.
Etiology:
Genetic, autosomal recessive.
Pathogenesis:
• The pelvis, calyces, papillae as well as the nephrons are believed to develop normally in
the initial stages of renal genesis.
• The cystic development of the collecting ducts are believed to occur subsequently by a
hyperplastic process.
Epidemiology:
• Developmental disorder of the kidneys discovered in developing fetuses (by
ultrasound) or in the newborn period (enlarged kidneys).
• Cut surface of the kidneys shows elongate cylindrical spaces radially arranged from the
medulla into the cortex. This feature blurs the normal distinct cortico-medullary junction.
Clinical Correlations
• Cases are discovered antenatally if prenatal care includes utrasonographic studies.
• Most cases that go to term die shortly after birth from respiratory difficulties due to the
enlarged kidneys that have resulted in developmental pulmonary hypoplasia.
• This disease is not invariably fatal. Those cases that survive infancy may subsequently
develop hepatic portal fibrosis, portal hypertension and splenomegaly.
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ACQUIRED PKD
PATHOGENESIS: Happens with renal failure patients on dialysis.
CLINICAL ,COMPLICATIONS
Renal Cell Carcinoma is the most common complication..
II
Glomerular Diseases
Glomerular Diseases
• Glomerular diseases are one of the MC causes of CRF
Glomerular Diseases
•diffuse – all glomeruli are involved
• focal – only a certain proportion of the glomeruli are involved
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Systemic Diseases with Glomerular Involvement (Secondary)
Systemic lupus erythematosus
Diabetes mellitus
Amyloidosis
Microscopic polyarteritis/polyangiitis
Wegener granulomatosis
Henoch-Schönlein purpura
Bacterial endocarditis
Hereditary Disorders
Alport syndrome
Thin basement membrane disease
Fabry disease
Mesangial antigens
Others
Planted antigens
Exogenous (infectious agents, drugs)
Cytotoxic Antibodies
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HISTOLOGIC ALTERATIONS
Various types of glomerulonephritis are characterized by one or more of four
basic tissue reactions.
Hypercellularity.
Basement Membrane Thickening.
Hyalinization and Sclerosis.
Hypercellularity.
Some inflammatory diseases of the glomerulus are characterized by an increase in
the number of cells in the glomerular tufts.
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Types of glomerulonephritis
The most common types with established pathological and clinical characteristics are:
Acute diffuse post-streptococcal proliferative glomerulonephritis
Rapidly progressive glomerulonephritis (crescentic glomerulonephritis).
Membranous glomerulonephritis.
Membranoproliferative glomerulonephritis
Minimal change glomerulonephritis (lipoid nephrosis
Focal glomerulosclerosis
Focal glomerulonephritis.
Chronic glomerulonephritis.
Nephrotic syndrome
NEPHRITIC SYNDROME
A group of renal diseases with the following common clinical features
Hematuria
Oliguria (GFR↓, Cr↑, BUN↑)
Edema (salt and water retention)
Hypertension
Proteinuria
Hypoalbuminemia
NEPHROTIC SYNDROME
A group of renal diseases with the following common clinical features
Proteinuria (“nephrotic range” >3.5g/24h)
Hypoalbumimenia
Edema
Hyperlipidemia
Lipiduria
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Acute Proliferative Glomerulonephritis
characterized histologically by diffuse proliferation of glomerular cells with an influx
of leukocytes
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IF Granular flourescence of glom. cap. wall & mesangium.for
C & IgG
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•Characterized clinically by rapid & progressive loss of renal function with severe
oliguria
Type II RPGN
• immune complex-mediated disease
• can be a complication of any of the immune complex nephritides
• granular pattern of staining for Ig’s & C3
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IF Granular or linear flour.
May be negative in pauci immune type
Fibrin is seen in the crescents.
Goodpasture’s syndrome
Definition:
A form of rapidly progressive glomerulonephritis (Bilateral pulmonary hemorrhage
+rapidly progressive GN)
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Progressive decrease in kidney function,
Accompanied by a cough with bloody sputum.
More in children especially ♂
NEPHROTIC SYNDROME
A group of renal diseases with the following common clinical features
Proteinuria (“nephrotic range” >3.5g/24h)
Hypoalbumimenia
Edema
Hyperlipidemia
Lipiduria
Membranoproliferative G.N
2- SLE.
3- Diabetic glomerulosclerosis
4- Amyloidosis
5- Infections as syphilis. malaria , viral hepatitis B
6- Malignancy esp. lymphoma.
7- Drugs as NSAI.
complications:
apart from chronic renal failure
•⇑ infections due to loss of Ig’s & complement
•0 ⇑ thrombosis due to loss of anticoagulant factors
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Membranous Glomerulopathy
•MC cause of nephrotic syndrome in adults
• primary membranous GN (85% of cases)
• secondary membranous GN
• drugs (e.g., penicillamine, NSAIDs)
• malignancies (esp. carcinoma of lung & colon, melanoma)
• SLE
• infections (e.g. hepatitis B & C, syphilis)
• Hashimoto thyroiditis
•secondary membranous GN is caused by deposition of immune complexes
•primary membranous GN is caused by autoantibodies directed against an Ag on the
visceral epithelial cells
morphology
• diffuse thickening of glomerular capillary wall
• EM reveals subepithelial deposits
• spikes can be seen (silver stains )
• granular deposits of Ig’s & complement on IF
• GBM becomes progressively thicker and compresses
the capillary lumens
Clinical Course
• usually present with nephrotic syndrome
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Minimal Change Disease
Most common in children
Etiology:
Idiopathic
Drugs – NSAID
Toxins – Mercury, Lead
Infections – HIV, Mononucleosis
Tumors – Hodgkin disease
Patient usually normotensive, nephrotic sediment, normal renal function.
(Lipoid Nephrosis)
• peak incidence 2-6 years of age
• MC cause of nephrotic syndrome in children
• sometimes follows a respiratory infection or vaccination
• ⇑ incidence in patients with Hodgkin disease
• morphology
• glomeruli are normal by light microscopy
• epithelial cells exhibit diffuse loss of foot processes on EM
• proximal tubular cells are often laden with lipid
• no Ig or complement deposits detected by IF
etiology & pathogenesis
• evidence indicates an immune mechanism
•immune dysfunction ⇒ circulating cytokine ⇒ injures
visceral epithelial cells ⇒ proteinuria
• some cases are caused by mutations in genes that
encode slit diaphragm proteins
clinical course
• massive proteinuria, mostly albumin
• renal function remains good, usually no ⇑ BP or hematuria
• most children exhibit a dramatic response to cortico- steroid
• long-term prognosis is excellent
Membranoproliferative Glomerulonephritis
Membranoproliferative glomerulonephritis (MPGN) can
present with the nephrotic syndrome, nephritic syndrome,
or, most often, a mixture of the two.
The two most common variants of MPGN are
Type I MPGN (also called mesangiocapillary GN)
Type II MPGN (also called dense deposit disease).
Characterized by
alterations in the GBM,
proliferation of glomerular cells &
leukocyte infiltration
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MPGN accounts for 10-20% of cases of nephrotic syndrome in children & young
adults
Pathogenesis
type I MPGN
• deposition of immune complexes with activation of both classical & alternative
complement pathways
• Ag’s involved in primary MPGN are unknown
type II MPGN
• ⇓ serum C3, factor B & properidin, but normal serum C1 & C4 ⇒ activation of
alternative complement pathway
• > 70% of patients have C3 nephritic factor (C3NeF)
•0 C3NeF stabilizes alternative pathway C3 convertase
EM &IF
Type I MPGN
subendothelial electron-dense deposits
granular deposits of C3 and often IgG, C1q & C4
Type II MPGN
lamina densa is extremely electron-dense (dense-deposit disease)
C3 is present in the GBM & mesangium (mesangial rings)
IgG, C1q & C4 are usually absent Diseases of Urinary System 02
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Diseases of the Tubules & Interstitium
• May occur secondary to :
1. glomerular disease
2. Vascular disease
3. Cystic disease
4. Metabolic :DM
• Primary interstitial Nephritis
Pyelonephritis
This means suppurative inflammation of the pelvicalyceal ayatem and the renal
parenchyma; it is usually bilateral.
affects the women more than men.
Most commonly, it occurs as a result of urinary tract infection.
Incidence
About 3 to 7 out of 10,000 people.
Predisposing factors
• Obstruction of the urinary tract with stasis of urine
• vesicoureteric reflux:
)Normally, the urine does not ascend along the ureters during micturition due to
the oblique course of the intravesical portion of the ureter, which provide a
sphincter-like effect during contraction of the bladder.) If this effect is disturbed
due to congenital or acquired reasons, the urine will ascend along the ureter and
may even reach the kidneys during bladder emptying.
• Bilharsisis.
• Instrumentation of the urinary tract.
• Diabetes mellitus due to ???
• Female more due to short urethra.
• Pregnancy due to hormonal relaxation of smooth muscle and pressure of the
gravid uterus.
Causative organism :
any pyogenic bacteria as E.coli, B. proteus, B pyocyaneus, Klebsiella and Strop .
foecalia.
Routes of infection:
1. Ascending infection from the lower urinary tract.
2. Lymphatic spread from the intestinal tracL
3. Blood borne infection complicating boils or carbuncles.
Pathology:
Acute pyelonephritis
Chronic pyelonephritis
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Acute pyelonephritis
Grossly:
The plevicalyceal system is acutely inflamed,
the renal parenchyma shows multiple foci of suppuration which appear as yellow streaks
radiating from the renal papillae, to expand into "abscesses" in the cortex.
Microscopically:
The pelvicalyceal system is acutely inflamed.
The renal parenchyma is congested and infiltrated by neutrophils which collect in
the interstitial tissue or within the tubular lumena to form abscesses.
Fate :
It may resolve,
kill by acute renal failure or
progress to chronic pyelonephritis
Chronic pyelonephritis
Chronic pyelonephritis results when the kidneys become increasingly damaged due to
repeated urinary infections. Or unresolved acute attack
Incidence
1 in 4 of the people who are diagnosed as having chronic kidney failure have chronic
pyelonephritis.
Grossly :
The kidneys are unequally shrunken with multiple irregular depressed scars
On cut section, these scars extend from deformed calyces towards the surface .
Thickened,opaque pelvicalyceal mucosa
Microscopically:
Periglomerular fibrosis.
Tubular atrophy .
In foci tubules are dilated and filled with hyaline casts giving an appearance reseinbling
thyroid follicles ( thyroidization).
Infiltration of interstitial tissue by chronic inflmmatory cells and neutrophils.
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chronic tubulointerstitial nephritis.
VASCULAR DISEASES OF
THE KIDNEY
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70% of stenoses are caused by obstructive atheromatous plaques at the origin of the renal
artery
The remainder by fibromuscular dysplasia.
Fibro or fibromuscular thickening of intema,media or adventia (3 types:intimal,medial or
advential)
Ischaemic kidney
Small size due to ischemic atrophy
Arteries in ischemic kidney are protected from high pressure
Contra lateral non ischemic kidney
Arteries will show hyaline arteriolosclerosis
Bilateral cortical necrosis
very rare . ischaemic in origin, it appears probable that vascular spasm followed by
thrombosis.
Causes:
1. Toxaemia of pregnancy.
2. Severe infections: Such as pneumonia, diphtheria and scarlet fever.
Grossly:
cortex of both kidneys, with the exception of a very thin surface layer (supplied
by the capsular arteries), is bright yellow outlined with red.
Microscopically:
coagulative necrosis of the cortex of both kidneys.
Clinically:
There is oliguria or anuria with the development of acute renal failure.
It is an ischaemic necrosis
may be due to an accompanying pyelonephritis due to some predisposing factors such as
1. diabetes mellitus,
2. excess intake of phenacetine or
3. chronic alcoholism.
HYDRONEPHROSIS
It is the dilatation of the pelvis and calyces of the kidney leading to pressure atrophy of
the kidney tissue.
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It is due to gradual, incomplete or intermittent obstruction to the flow of urine.
Microscopically:
There is atrophy of the tubules and the glomeruli with fibrosis.
Causes of hydronephrosis:
In the urinary bladder: If the cause is in the bladder neck it will cause bilateral
hydronephrosis, but elsewhere it will cause unilateral hydronephrosis.
1.Bilharzial stricture: Either in the ureteric orifice or causing bladder neck obstruction.
2.A large stone in the urinary bladder.
3.Tumours: As carcinoma or papilloma of the urinary bladder.
Types
1.Calcium oxalate(phosphate)stones 75%
)hypercalcinuria, hypercalcemia, excess)
2.Magnesium Ammonium phosphate stones10-15%
)alkaline urine due to infection(
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3.Uric acid stones 6%
) gout, leukemias, acidic urine)
4.Cystine stones 1-2%
Pathogenesis :
For calcium stones
↑ urine conc. of the stone constituent (supersaturation)
Hypercalcemia with hypercalcuria
hyperparathyroidism,
bone metastases,
↑ Ca++ absorption
↓ renal reabsorption
Hypercalcuria without hypercalcemia
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- Carcinomas of the lung, breast and prostate.
- Sarcomas, like osteosarcoma.
- Malignant melanoma and choriocarcinoma.
Renal Cell Carcinoma
6th to 7th decade
Male predominance 3:1
Yellow round mass, 3 -15 cm
Often invade renal vein and extend into the inferior vena cava
Chromosome 13
General features
A tumour which arises from the epithelial cells of the renal tubules
One of the many peculiarities of renal cell carcinoma is its occasional regression in the
absence of all treatment, a phenomenon found also with gestational choriocarcinoma,
malignant melanoma, neuroblastoma,
Renal cell carcinoma is the most common "recipient" of the curious phenomenon of
metastasis of a cancer into another cancer. Lung carcinoma is the most common "donor,"
the resulting microscopic appearance leading to interesting problems of interpretation
Renal cysts.
Renal cell carcinomas (nearly all, if they live long enough) bilateral, often multiple.
Clinical features
Renal carcinoma usually presents with
Hematuria (59%)
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Flank pain (41%), or
Abdominal mass (45%).
Weight loss (28%),
Anemia (21%),
Fever (7%), and
Symptoms caused by a metastatic deposit (10%).
Grossly
most renal cell carcinomas are well delineated and centered on the cortex
In about 5% of the cases, multiple tumor nodules are seen scattered throughout the organ
In a typical case, the cut surface shows a solid golden yellow tumor sharply separated
from the surrounding tissues by a fibrous pseudocapsule
Hemorrhage, necrosis, calcification, and cystic change
Microscopically,
the tumor cells may be large with clear cytoplasm, resulting from the accumulation of
glycogen (clear cell type) or
may be smaller in size with granula cytoplasm (granular cell type), or
most often there is a mixture of clear and granular cells (mixed cell type).
The stroma of the tumour is scanty, very vascular with areas of haemorrhage and
necrosis.
Paraneoplastic syndrome:
RCC is known for its hormonal & hormone like effect
e.g. it can produce parathyroid like hormone
hypercalcemia
Wilm ’s tumor
Also known as nephroblastoma (currently the preferred term), embryoma,
carcinosarcoma, adenosarcoma, and adenomyosarcoma.
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Chromosome 1 -loss of cancer suppression gene WT -1
Clinical features
The classic clinical presentation of Wilms'
an abdominal mass felt by the mother
Hypertension
Proteinuria
Hematuria and pain are rare.
Grossly
solitary, well circumscribed, rounded,
soft.
variable size
rapidly growing, destroying the kidney
infiltrating the renal capsule.
Infiltration of renal pelvis & ureter is rare & late
The cut section is solid and pale gray or tan
cystic change, necrosis, and hemorrhage
Microscopically
Most Wilms' tumors show a representation of three major components:
Undifferentiated blastema,
The blastematous areas are extremely cellular and composed of small round-to-oval
primitive cells;
Epithelial tissue.
formation of embryonic tubular (and sometimes glomerular) structures that closely
recapitulate the appearance of normal developing metanephric tubules (and glomeruli)
but the proportions vary widely. Some tumors are biphasic, and still
others are monophasic (monomorphous).
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The most common sites of distant metastases are
lungs, liver, and peritoneum.
bone metastases in only 1% of the cases
2. Epispadius:
The urethra opens on the dorsum of the penis.
3. Hypospadius:
The urethra opens on the ventral surface of the penis.
4. Patent urachus:
A fistulous tract between bladder & umbilicus, discharging urine
5. Valves (mucosal folds) in the posterior urethra:
Which may lead to obstruction.
CYSTITIS
Clinical Manifestations:
frequency, pain, dysuria
Causes:
1Infections: E. coli, Proteus, et al; TB, Candida, Chlamydia, Schistosomiasis,
Adenovirus
2 Radiation & chemotherapy
3 Prolonged catheterization.
Morphologic Types:
Acute: nonspecific, hemorrhagic, suppurative, or ulcerative
Chronic: nonspecific, cystitis follicularis & eosinophilic
cystitis
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Special Forms of Cystitis:
Interstitial Cystitis (Hunner’s ulcer)
painful chronic cystitis MC seen in women
Predisposing factors:
1. Bilharziasis
2. Stasis of urine: due to obstruction nodular hyperplasia of prostate, stricture of the
urethra and tumours of the urinary bladder.
3. Inflammation of nearby organs, such as kidneys, ureters, prostate, vulva, vagina,
cervix and urethra.
4. Trauma to the urinary bladder by stones or catheter.
5. General diseases, such as diabetes.
6. Females are more commonly affected due to short wide urethra
Grossly :
wall is thickened , oedematous, red and congested
and may be areas of haemorrhage,ulceration and necrosis.
Chronic non specific cystitis: may follow acute or may start as such
Grossly : The wall is thickened, congested with increased fibrosis granularity of the
mucosa reduction of the lumen of the urinary bladder.
Follicular cystitis: In which the mucosa of the trigone shows minute greyish nodules due
to the presence of lymphoid follicles even with germ centers, in the sub-epithelial
tissues.
Emphysematous cystitis:
caused by gas-forming bacteria
associated with gas filled vesicles in the bladder wall.
About 50% of the patients are diabetic.
Malakoplakia:
rare condition associated with immune deficiency states.
The mucosa of trigone shows multiple nodular yellow soft thickenings 1-4 cm
Microscopically,
chronic inflammatory cells
foreign body giant cells containing calcified material known as Michaelis - Gutmann
bodies ( an end result of bacterial degradation.)
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Tumours of the urinary bladder
Benign tumours
• Transitional cell papilloma:
commonly near the ureteric orifices and bladder neck.
It usually recurs after removal
considered potentially malignant.
It is considered by some authors as grade I carcinoma
• Inverted papilloma
a benign epithelial tumor, more in adult and elderly males,
mostly located in the trigone, bladder neck, or prostatic urethra.
It is usually solitary
presents with haematuria and obstruction.
• Others:
o Fibroma,
o Leiomyoma,
o Rhabdomyoma,
o Neurofibroma,
o Angioma and
o Myxoma
Malignant Tumors
Are common occurring more in males above the age of 40 years
Precancerous lesions:
a) Urinary bladder bilharziasis: It may be due to :
Mechanical irritation of the ova
Tryptophan metabolites as a carcinogenic agents which are usually present in high
concentration in the urine.
Metaplastic changes including cystic glandularis squamous metaplasia.
b) Transitional cell papilloma.
c) Aniline dyes used by dye workers.
d) Cigarette smoking.
e) Chronic irritation by stones, chronic cystitis.
f) Leucoplakia.
g) Congenital anomalies (ectopia vesica).
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Site:
The region of the trigone, as a consequence, partial or complete blockage of one
or both ureters is frequent.
Types :
Transitional cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Gross Morphology:
The better differentiated urothelial neoplasms commonly project into the lumen
and have a delicate papillary appearance.
In contrast poorly differentiated neoplasms are solid ulcerative lesions that
frequently show evidence of infiltration of the bladder wall.
Microscopic appearance:
Over 90% are transitional cell carcinoma.
Squamous or glandular differentiation commonly occur in transitional cell
carcinoma (especially in invasive types).
Grading :
The International World Health Organisation histologic grading system for
urothelial neoplasms recognize 4
histologic grades:
Grade I transitional cell carcinoma shows
• well formed papillary structures
• lined by epithelium that is cytologically normal but thicker than 7 layers.
• Invasion is uncommon.
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• Most of these lesions are sessile, cauliflower-like, necrotic and ulcerated.
• Microscopically papillary areas are absent,
• cellular atypia and pleomorphism are so marked that the transitional cell nature
may be obscured.
• Mitotic figures are frequent.
Prognosis:
depends on histologic grade & stage
papillomas & grade I tumors – 98% 10 yr. survival rate
grade III tumors – 40% 10 yr. survival rate
Well differentiated keratinizing squamous cell carcinoma tends to form large bulky mass.
Since foci of squamous cell differentiation are common in high grade transitional
carcinoma, the term squamous cell carcinoma should be reserved for those tumours that
are squamous throughout.
Adenocarcinoma:
May arise from:
a) urachal remanents in the dome of the bladder.
2) areas of cystitis glandularis. (after metaplasia by bilharziasis).
Non epithelial neonlasms:
a) Paraganglioma (pheochromocytoma).
b) Mesenchymal neoplasms:
i) Leiomyoma and leiomyosarcoma.
ii) Embryonal rhabdomyosarcoma (sarcoma botroides) in young children.
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