Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
of Anatomical Pathology
Medical Faculty
Brawijaya University
TOPICS :
1. Glomerular diseases
2. Diseases affecting tubules and interstitium
* Acute tubular necrosis
* Pyelonephritis
3. Obstructive uropathy
4. Tumor
* Tumor of the kidney :
- Wilm’s tumor, Grawitz tumor
* Tumor of the bladder :
- Urothelial Tumor
5. Prostate
* BPH
* Ca of the Prostate
Glomerular Diseases
• Some of the major problems encountered in nephrology
• Chronic glomerulonephritis (GN) is one of the most common
causes of chronic kidney disease (CKD)
2. Tubulointerstitial Nephritis
1. Acute Pyelonephritis
2. Chronic Pyelonephritis
ATN :
* The most common cause of ARF (± 50%)
* Reversible
(1) (2)
VASO CONSTRICTION OBSTRUCTION (3)
BY CAST S TUBULAR
BACK-LEAK
INTRA TUBULAR
Tubular Fluid
PRESSURE Flow
(4)
DIRECT GLOMERU GFR OLIGURIA
LAR - EFFECT
1. Chronic Obstructive PN
- Obstruction predisposes to infection
- Recurrent infections superimposed on diffuse
or localized obstructive lesion scarring
picture of CPN
- Obstruction parenchymal atrophy
- Bilateral / unilateral
2. Refluks Nephropathy
- Infection from VU reflux the kidney
- Bilateral / unilateral.
Clinical course :
- Insidious in onset / acute recurrent with back
pain, fever, pyuria and bacteriuria
- Loss of tubular function polyuria & nocturia
- CPN is a result of superimposed bacterial
infection in obstructive urine or vesicoureteral
reflux (CPN rarely caused by
bacterial infection alone)
* Clinical course :
- Pain (-)
- Hematuria
- Dysuria
MACROS :
- Solitary mass, well circumscribe
- 10 % bilateral or multicentric
- Soft, homogen, greyish, sometimes with
hemorrhage foci, necrosis and cyst
formation
MICROS :
* There are 3 types of cells :
blastema, epithelial and stromal
- Epithelial differentiation : tubuli &
glomeruli abortive
- Stromal cells : fibrocytic / myxoid, often
with skeletal muscle differentiation
- Rarely : squamous cells, mucinous
epithelium, smooth muscle,
lipid, cartilage, osteoid,
nerve tissue
* 5% : foci of anaplastic cells
2. RENAL CELL CA
(Grawitz tumor / Hypernephroma / Renal Adeno Ca)
- Represent ± 1-3 % of all visceral cancer
- Account for 85-90 % of renal cancer in adult
- Arise from tubular epithelium
* Etiology / Pathogenesis :
- Tobacco incidence in smokers 2x non
smokers
- Viral and chemical carcinogen
- Genetic translocation of Cr 3 & 8 cancer
- Renal adenoma carcinoma
MACROS :
- Commonly affects the poles, particularly
the upper one
- Spherical masses 3 – 15 cm
- Bright yellow-gray-white,
foci of hemorrhage, cystic
- Sometimes : satelite nodule (+)
MICROS :
* 3 types :
# Clear Cell Ca (70-80%)
# Papillary Ca (10-15%)
# Chromophobe Ca (5%)
Clear Cell Ca :
- Tumor cells : rounded / polygonal
- Abundant clear / granular cytoplasm
- Tubular / solid / trabecular
- Most tumor : well differentiated
- Some tumors show marked nuclear atypia,
bizzare nuclei and giant cells
Clinical course :
* Classic diagnostic features :
- Costovertebral pain, palpable mass & hematuria (10%)
* Others :
- Fever, malaise, weight loss
- Paraneoplastic syndrome (abN hormone
production)
- polycytemia, hypercalcemia, hypertension,
feminization/masculinization, Cushing syndrome,
eosinophilia, leukemoid reactions, amyloidosis.
- Tendency to metastasize widely before giving rise
to any local symptoms or signs.
* The most common locations of metastasis :
- lung (50%), bone (23%), lmn, adrenal,
liver, brain
80
80
81
82
MACROS :
- solitary / multiple
- papillary / nodular / flat / mixed papillary-nodular
- red elevated
MICROS :
* Grade I : - close resemble N transitional cells
- mitosis ±, number of layer >, slight loss of
polarity
* Grade II : - mitosis >, layers >>, greater loss of polarity
* Grade III :- mitosis>>, layers >>>, polarity (-)
- anaplastic, giant cells (+)
GRADE I II III
DIFFERENTIATION well moderately poorly
NUMBER of
LAYER
>7 >10 >>10
CELLULAR
VARIATION + ++ +++
(size, shape,
chromatin)
PROSTATE
• Retroperitoneal organ
• Encircling the neck of the bladder & urethra
• Pear-shaped
• Weight (normal adult male) : ± 20 gr
• The prostate disorder usually found in older men
(> 50 yrs old).
• 2 component :
- tubuloalveolar gland
- fibromuscular stroma
Anatomy of the Prostate
Anatomical lobes:
• Anterior, posterior and 2 lateral lobes.
Anatomical zone ( Mc Neal ):
• Peripheral zone
• Central zone
• Periurethral zone and transitional zone.
• Anterior fibromuscular stroma.
Normal prostate, nodular hyperplasia and
adenocarcinoma.
In prostatic hyperplasia, which involves predominantly
the periurethral part of the gland, the nodules compress and distort
the urethra. The expansion of the central prostatic glands leads to
compression of the peripheral parts and fibrosis, resulting in the
formation of a so-called surgical capsule. Prostatic carcinoma
usually arises from the peripheral glands, and compression of the
urethra is a late clinical event.
Prostatic disorders
Only 3 pathological processes affect the prostate gland:
= Non – neoplastic:
• 1. inflammation.
• 2. benign nodular enlargement.
= Neoplastic
• 3. tumors/neoplasm.
Benign enlargements are the most common and occur so often
in advanced age.
Prostatic Hyperplasia
• Weight : 60- 100 grams.
• Incidence : 20 % of men 40 – 45 years.
70 % by the age 60.
90% by the age of 70.
• No correlation between histologik changes with clinical
symptom.
• Morphology : proliferation of acini and fibromuscular
tissue.
• Hyperplasia : stromal & epithelial
discrete nodule in the periurethral region
compress & narrow the urethral canal
obstruction (partial / complete)
Pathogenesis Testosteron
Stromal Cell Epithelial Cell
Sromal Cell
T
T
5-reductase tipe 2
DHT
Androgen
receptors
Nukleus
Growth
factor
Growth
factor
Growth factor
receptors
Macros :
• Usual case : 60 – 100 gm 200 gm
• >> : inner aspect ( TZ & PUZ )
• c/s : nodules fairly readily identified,
pseudo capsules (+)
• Yellow-pink, soft / pale gray, tough
Micros :
• Glandular proliferation / dilatation, lined by 2 layers,
columnar (inner) & cuboidal / flattened (outer) epithel
papillary buds and infoldings (Σ>N)
• Fibromuscular proliferation
Clinical Course
1. Compression of the urethra
difficulty in urination
2. Retention of urine in the bladder
distention, hypertophy, infection
cystitis & pyelonephritis
3. Frequency, nocturia, difficulty in starting &
stopping the stream of urine, overflow dribbling &
dysuria
4. Acute urinary retention catheterization
5. Residual urine → infection → pyelonephritis
6. Hydronephrosis, uremia
Treatment
• Trans Urethral Resection (TUR)
• Open Prostatectomy
TUR
BPH
BPH
Prostatic hyperplasia
Prostatic hyperplasia
Dilated acini
CARCINOMA of the PROSTATE
Insidence :
• Disease of men 50 y.o; 50 y.o : 1%
• > 300.000 new cases / yr, 41.000 lethal
• << in Asians, age-adjusted insidence :
- Japanese : 3-4 / 100.000
- Hong Kong : 1 / 100.000
- USA (whites) : 50-60 /100.000
Etiology : ?
Risk Factors :
• age, race, family history, genetics, hormonal
(androgens/testosterone), environmental (fat
intake)
Morphology:
• ± 70% cases : arises in the PZ, classically in posterior lobe
• c/s : gritty & firm
Micros :
• Adenocarcinoma
Histologic Grading
Gleason System :
5 grades, depend on :
- glandular pattern
- degree of differentiation
( good correlation between d of d and prognosis )
Staging
• TNM:
+ Tx Primary tumor can’t be assessed
+ T0 no evidence of primary tumor.
+ T1a histological incidental finding in < 5% of tissue
resected.
+ 1b > 5% tsuue resected.
+ 1c. Tumor identified by needle biopsy.
+ T2 Tumor confined within prostate.
+ T3. Tumor extend beyond the prostate.
+ T4 Tumor invades adjacent structures other than
seminal vesicles.
Clinical Course