UROPATHOLOGY

Urological cases for Manchester FRCPath Part 2 Surgical Course

From Dr JH Shanks, The Christie NHS Foundation Trust

Case 1

Case No 1

Case 1

Clinical History Male 71 years. Radical orchidectomy for 50 mm diameter testicular tumour.

Case 1

What is your diagnosis?

Case 1

Diagnosis Spermatocytic Tumour

kit (shown here) is often positive in spermatocytic tumour (like classical seminoma) but unlike classical seminoma, PAS (for glycogen), OCT3/4 and PLAP are negative

Case 2

Case No 2

Case 2

Clinical History Male 27 years. 10mm diameter lesion left testis.

Case 2

Case 2

Case 2

What is your diagnosis?

Case 2

Diagnosis Sclerosing Sertoli cell tumour

Case 3

Case No 3

Case 3

Clinical History Male 87. Bladder biopsies.

Case 3

Case 3

Case 3

What is your diagnosis?

Case 3

Diagnosis Keratinising squamous metaplasia with dysplasia and tiny focus in one of the sections cut for teaching, suspicious of the very earliest stage of invasive SCC (difficult to be certain).

Case 4

Case No 4

Case 4

Clinical History Male 55 years. 4cm diameter renal tumour.

Case 4

Case 4

What is your diagnosis?

Case 4

Diagnosis Chromophobe renal carcinoma (mistaken for clear cell carcinoma)

Case 4

c-kit (shown here) is typically positive both in chromophobe renal carcinoma and In renal oncocytoma. CK7 typically shows diffuse submembrane positivity in chromophobe carcinoma but is positive only in scanty scattered cells in oncocytoma

Case 5

Case No 5

Case 5

Clinical History Male 69 years. 5cm diameter renal tumour.

Case 5

Case 5

What is your diagnosis?

Case 5

Diagnosis Oncocytoma (referred initially as a grade 2 RCC)

Case 5

Typical CK7 pattern for oncocytoma (normal tubules also seen top left)

Case 6

Case No 6

Case 6

Clinical History Male 72 years. Orchidectomy for testicular tumour.

Case 6

Case 6

What is your diagnosis?

Case 6

Diagnosis Leydig cell tumour.

Case 6

Inhibin is virtually always positive in Leydig cell tumour of testis. Calretinin, melan A and steroidogenic factor 1 are also typically positive

Case 7

Case No 7

Case 7

Clinical History Male 74 years. Partial penectomy for penile tumour.

Case 7

Case 7

What is your diagnosis?

Case 7

Diagnosis Basaloid Squamous Carcinoma (has bilateral groin lymph node mets)

Case 8

Case No 8

Case 8

Clinical History Male 28 years. Radical nephrectomy for right renal tumour (90 x 60 x 60mm).

Case 8

Case 8

What is your diagnosis?

Case 8

Diagnosis Diagnosis = translocation carcinoma. Has focal calcn; MNF116, AE1/3, CK7 and EMA –ve; TFE3 +ve.

Case 8

TFE-3 immunohistochemistry is shown. MNF116, AE1/3, EMA were negative.

These markers are more often negative in translocation carcinoma than in clear cell carcinoma. CK7 was also negative (unlike papillary carcinoma which is usually positive)

Case 9

Case No 9

Case 9

Clinical History Male 72 years.. 2.5cm diameter renal tumour.

Case 9

Case 9

Case 9

What is your diagnosis?

Case 9

Diagnosis Renal oncocytoma. Sent for opinion with ext. report suggested diagnosis given as renal cell carcinoma, grade 2. It involves perinepric fat and shows some focal calcification. It also shows prominent scattered small tubules in sclerotic stromal areas which unlike the rest of the tumour are vimentin and CK7 +ve (only scatted CK7 in individual cells elsewhere).

Case 10

Case No 10

Case 10

Clinical History Male 60 years. Testicular tumour found at follow up (history of squamous carcinoma of penis in 2007 with groin lymph node metastases).

Case 10

Case 10

Case 10

What is your diagnosis?

Case 10

Diagnosis Classical Seminoma

Case 11

Case No 11

Case 11

Clinical History Female 41 years. Renal mass (100 mm maximum dimension with area of haemorrhage).

Case 11

Case 11

What is your diagnosis?

Case 11

Diagnosis Angiomyolipoma

Case 11

HMB45 positivity is typically focal. Melan A was more widely positive. S100 was negative (except for staining in the fat)

Case 12

Case No 12

Case 12

Clinical History Male 30 years. Foreskin. Sent as ? viral wart ? verruccous carcinoma.

Case 12

Case 12

Case 12

What is your diagnosis?

Case 12

Diagnosis Invasive well differentiated squamous cell carcinoma

Case 13

Case No 13

Case 13

Clinical History Male 51 years, nodule seen in prostate on scan.

Core biopsies taken.

Case 13

Case 13

Case 13

What is your diagnosis?

Case 13

Diagnosis Adenosis (atypical adenomatous hyperplasia in prostate core biopsies

Case 13

A basal cell layer is intact and complete in this case (but in other examples of this lesion it can be only focally present or incomplete in some glands)

Case 14

Case No 14

Case 14

Clinical History Male 52 years. Three week history of right testicular tumour. Slide from orchidectomy.

Case 14

Case 14

What is your diagnosis?

Case 14

Diagnosis Yolk sac tumour with v focal teratoma. Serum AFP was raised. Tumour expresses patchy AFP. OCT (done on 3 blocks on two occasions) was consistently negative.

Case 14

AFP (seen here) is positive, though patchy (this marker is often only focally positive in YST). OCT 3/4 was completely negative in this case (would be always positive in embryonal carcinoma [and/or classical seminoma] but is negative in yolk sac tumour

Case 15

Case No 15

Case 15

Clinical History Male 63 years. Lump excisied from spermatic cord.

Case 15

Case 15

What is your diagnosis?

Case 15

Diagnosis Poorly differentiated adenocarcinoma, almost certainly metastatic from stomach [Hx of gastric cancer]. Sent as ?could this be mesothelioma on basis of calretinin staining] however, focal CK7 and CK20 with strong BerEP4 and LeuM1.

CK5/6 almost negative, WT1-ve, glands contain D/PAS +ve mucin.

Case 15

CDX2 (shown here), CK7 and CK20 were focally positive. OCT 3/4 and PLAP were negative. The features are of a somatic adenocarcinoma with enteric differentiation, most likely from a primary in the GI tract.

Case 16

Case No 16

Case 16

Clinical History Male 39 years. Urethral stricture.

Case 16

Case 16

Case 16

What is your diagnosis?

Case 16

Diagnosis Nephrogenic adenoma. PAX-2 was +ve, AMACR v focally +ve, CK7+ve

Case 17

Case No 17

Case 17

Clinical History Male 28 years. 3.5cm diameter cystic lesion left kidney.

Case 17

Case 17

What is your diagnosis?

Case 17

Diagnosis Differential; diagnosis between multilocular cystic RCC and conventional RCC. Features exclude cystic nephroma.TFE3 was -ve, CAIX >90%

Case 18

Case No 18

Case 18

Clinical History Male 30 years. Left orchidectomy for maldescent.

Described macroscopically as an atrophic testis.

No mass lesion seen macroscopically.

Case 18

Case 18

What is your diagnosis?

Case 18

Diagnosis Intertubular classical seminoma with atrophy, IGCNU and intratubular seminoma

Case 18

The presence of invasive classical seminoma can easily be overlooked in cases that show classical seminoma with an intertubular growth pattern. The invasive component, although very subtle in the H%E, is highlighted by OCT3/4 immunohistochemistry

Case 19

Case No 19

Case 19

Clinical History Male 62 years. Nephrectomy for left lower pole renal tumour measuring 40mm in maximum dimension (this case has rather poor tissue preservation – it was a pathology review from elsewhere).

Case 19

Case 19

Case 19

What is your diagnosis?

Case 19

Diagnosis Favour collecting duct carcinoma (differential diagnoses=urothelial carcinoma or metastasis)

Case 20

Case No 20

Case 20

Clinical History Male 62 years. Right orchidectomy for tumour.

The tumour replaced almost the whole of the testis.

Case 20

Case 20

Case 20

What is your diagnosis?

Case 20

Diagnosis Classical seminoma [put in to show ’compact’ areas sometimes encountered in retroperitoneal core biopsies]. C-kit was diffusely +ve. PLAP was +ve; cytokeratins and lymphoid markers –ve

Case 21

Case No 21

Case 21

Clinical History Male 37 years. Orchidectomy for testicular tumour.

Case 21

Case 21

Case 21

What is your diagnosis?

Case 21

Diagnosis Sex cord stromal tumour, unclassified

Case 21

Cord-like and sheeted areas. It is a sex cord stromal tumour which should be regarded in the category sex cord stromal tumour, unclassified

Case 22

Case No 22

Case 22

Clinical History Male 85 years. Orchidectomy for tumour.

Case 22

Case 22

Case 22

What is your diagnosis?

Case 22

Diagnosis lymphoma (DLBCL)

Case 23

Case No 23

Case 23

Clinical History Male 71 years. 55mm diameter renal tumour left upper pole.

Case 23

Case 23

Case 23

What is your diagnosis?

Case 23

Diagnosis Oncocytoma with striking degenerate nuclear atypia. C-kit +ve; CK7 focal scattered cells

Case 24

Case No 24

Case 24

Clinical History Male 68 years. Prostate core biopsy.

Case 24

Case 24

Case 24

What is your diagnosis?

Case 24

Diagnosis Invasive adenocarcinoma with focal mucinous differentiation. Gleason at least 4+3=7. 70% core length involved

Case 25

Case No 25

Case 25

Clinical History Male 84 years. Bladder abnormal at cystoscopy.

Clinically CIS but not typical appearance.

Case 25

Case 25

Case 25

What is your diagnosis?

Case 25

Diagnosis Diffuse large B cell lymphoma, arising in MALT with angiotropism. Also present is keratinising squamous metaplasia (a risk factor for the development of squamous cell carcinoma).

Case 26

Case No 26

Case 26

Clinical History Male 66 years. Radical cystectomy following neoadjuvant chemotherapy

Case 26

Case 26

Case 26

Case 26

What is your diagnosis?

Case 26

Diagnosis Micropapillary variant of urothelial carcinoma.

This is a highly aggressive variant.

Case 26

Uroplakin III is strongly positive. This is a highly specific marker for urothelial differentiation. It is not very sensitive for conventional high grade urothelial carcinoma but Is frequently positive in the micropapillary variant

Case 27

Case No 27

Case 27

Clinical History Male 20 years. Indurated areas in foreskin?

Multiple sebaceous cysts.

Case 27

Case 27

What is your diagnosis?

Case 27

Diagnosis Foreskin: Granuloma Annulare

Case 28

Case No 28

Case 28

Clinical History Male 71 years. Previous radiotherapy/ hormones for Ca prostate 2003.

Case 28

Case 28

What is your diagnosis?

Case 28

Diagnosis Invasive acinar adenocarcinoma of prostate and intraductal adenocarcinoma

Case 28

It was quite difficult in the H&E to distinguish invasive adenocarcinoma (no basal cell layer) from intraductal adenocarcinoma (basal cell layer present). CK 5/6 is shown.

Intraductal adenocarcinoma, which has more atypia/solid areas/necrosis than HGPIN, is strongly associated with high grade invasive adenocarcinoma. Gleason was 4+3=7

Case 29

Case No 29

Case 29

Clinical History Male 22 years. Bliateral testicular lesions (lumps in testes, unchanged for 10 years). History of atrial myxoma removed 2 years ago. Lesion removed from face previously reported as cutaneous mucinosis. Sptiz naevus removed from face 10 years ago.

Case 29

Case 29

Case 29

What is your diagnosis?

Case 29

Diagnosis Large Cell Calcifying Sertoli Cell Tumour

Case 30

Case No 30

Case 30

Clinical History Female 41 years. Nepherectomy for tumour.

Described as ‘A large well circumscribed variegated mass with extensive central necrosis measuring 145 x 125 x 100 mm situated in 1 pole of the kidney. There is breach in the renal capsule measuring 15 mm in size with soft tissue extruding from it. The renal vein is infiltrated by tumour. The adrenal gland is not identified. The ureter is not involved.’

Case 30

Case 30

Case 30

Case 30

What is your diagnosis?

Case 30

Diagnosis Adrenocortical carcinoma that was mistaken for a renal cell carcinoma in a nephrectomy specimen