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GENITOURINARY PATHOLOGY (A VOLUME IN THE ISBN-13: 978-0-443-06677-1
FOUNDATIONS IN DIAGNOSTIC PATHOLOGY SERIES, ISBN-10: 0-443-06677-9
Series Edited by John R. Goldblum)
Copyright ©2007 by Churchill Livingstone, an imprint of Elsevier Inc.
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Notice
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or
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The Publisher
Library of Congress Cataloging-in-Publication Data
Genitourinary pathology / Ming Zhou, Cristina Magi-Galluzzi, [editors];
series editor, John R. Goldblum.
p. cm. — (Foundations in diagnostic pathology)
ISBN 0-443-06677-9
ISBN-13: 978-0-443-06677-1
1. Genitourinary organs—Diseases. I. Zhou, Ming, MD, PhD II. Magi-
Galluzzi, Cristina. III. Series.
RC871.G455 2007
616.6—dc22
2006040173
Acquisitions Editor: Belinda Kuhn
Developmental Editor: Heather Krehling
Project Manager:David Saltzberg
Design Direction: Louis Forgione
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
To my wife, Lan
To my daughters, Grace and Rebecca
To my parents, Yinhai Zhou and Xiudi Guo
Ming Zhou
To the memory of my mother, Federica Bizzarri
To my father, Orfeo Magi Galluzzi
Cristina Magi-Galluzzi
Other books in this series:
Neuropathology
Gastrointestinal and Liver Pathology
Fine Needle Aspiration Cytology
Endocrine Pathology
Breast Pathology
Hematopathology
Dermatopathology
Gynecologic Pathology
Bone and Soft Tissue Pathology
Pulmonary Pathology
Molecular Pathology
Head and Neck Pathology
Contributors
Mahul B. Amin, MD Eyas M. Hattab
Chairman Assistant Professor
Department of Pathology and Laboratory Medicine Department of Pathology
Cedars-Sinai Medical Center Indiana University School of Medicine
Los Angeles, California Indianapolis, Indiana
Diseases of the Penis, Urethra, and Scrotum Neoplasms of the Kidney
Lois J. Arend, MD, PhD Howard S. Levin, MD
Associate Professor Staff Pathologist Emeritus
Director, Renal Pathology and Electron Microscopy Services Department of Anatomic Pathology
Pathology and Laboratory Medicine Cleveland Clinic
University of Cincinnati Medical Center Cleveland, Ohio
Cincinnati, Ohio Non-neoplastic Diseases of the Testis
Introduction to Renal Biopsy Neoplasms of the Testis
Laura Barisoni, MD Cristina Magi-Galluzzi, MD, PhD
Assistant Professor Director, Genitourinary Pathology
Department of Pathology Departments of Anatomic Pathology,
Renal Pathology Laboratory Cancer Biology, and Urology
New York University Medical Center Cleveland Clinic
New York, New York Cleveland, Ohio
Introduction to Renal Biopsy Non-neoplastic Diseases of the Prostate
Neoplasms of the Prostate and Seminal Vesicles
Stephen M. Bonsib, MD
Non-neoplastic Diseases of the Urinary Bladder
Director
Neoplasms of the Urinary Bladder
Surgical Pathology Professor
Department of Pathology Shane Meehan, MD
Indiana University School of Medicine Assistant Professor
Indianapolis, Indiana Pathology Department
Non-neoplastic Diseases of the Kidney University of Chicago
Chicago, Illinois
Liang Cheng, MD
Introduction to Renal Biopsy
Associate Professor
Department of Pathology Rajal B. Shah, MD
Indiana University School of Medicine Assistant Professor
Indianapolis, Indiana University of Michigan Medical School
Neoplasms of the Kidney Ann Arbor, Michigan
Diseases of the Penis, Urethra, and Scrotum
John N. Eble, MD, MBA, FRCPA
Nordschow Professor and Chairman Ming Zhou, MD, PhD
Department of Pathology and Laboratory Medicine Staff Pathologist
Van Nuys Medical Science Building Departments of Anatomic Pathology,
Indianapolis, Indiana Urology, and Cancer Biology
Neoplasms of the Kidney Cleveland Clinic
Cleveland, Ohio
Jonathan I. Epstein, MD
Non-neoplastic Diseases of the Prostate
The Reinhard Professor of Urologic Pathology
Neoplasms of the Prostate and Seminal Vesicles
Departments of Pathology, Urology, and Oncology
Non-neoplastic Diseases of the Urinary Bladder
Director of Surgical Pathology and Anatomic Pathology
Neoplasms of the Urinary Bladder
The Johns Hopkins Hospital
Baltimore, Maryland
Non-neoplastic Diseases of the Prostate
Neoplasms of the Prostate and Seminal Vesicles
Non-neoplastic Diseases of the Urinary Bladder
Neoplasms of the Urinary Bladder
Foreword
The study and practice of anatomic pathology are both in each chapter is extremely practical, well-organized,
exciting and overwhelming. Surgical pathology, with all and concisely written, focusing on the thorough eval-
of the subspecialties it encompasses, and cytopathology uation of both needle biopsy and resection specimens.
have become increasingly complex and sophisticated, Since virtually all practicing pathologists encounter
and it is not possible for any individual to master the these specimens with some regularity, the information
skills and knowledge required to perform all of these provided by these experts will contribute to resolving
tasks at the highest level. Simply being able to make a problems encountered at the microscope on virtually
correct diagnosis is challenging enough, but the stan- any sign-out day.
dard of care has far surpassed merely providing a diag- This edition is organized into ten chapters covering
nosis. Pathologists are now asked to provide large the full spectrum of genitourinary disorders. Drs. Magi-
amounts of ancillary information, both diagnostic and Galluzzi, Zhou, and Epstein provide separate chapters
prognostic, often on small amounts of tissue, a task on non-neoplastic and neoplastic diseases of the
that can be daunting even to the most experienced prostate and urinary bladder. Dr. Bonsib provides a
pathologist. straight-forward and practical review of non-neoplastic
Although large general surgical pathology textbooks diseases of the kidney, followed by a cutting-edge
are useful resources, they, by necessity, could not pos- discussion of renal neoplasms by Drs. Hattab, Cheng,
sibly cover many of the aspects the pathologist needs to and Eble. A unique chapter by Drs. Barisoni, Meehan,
know and include in their reports. As such, the concept and Arend discusses an approach to the renal biopsy.
behind Foundations in Diagnostic Pathology was born. Diseases of the penis, urethra, and scrotum are
This series is designed to cover the major areas of sur- reviewed by Drs. Shah and Amin, followed by chapters
gical and cytopathology, and each edition is focused on on non-neoplastic and neoplastic diseases of the testis
one major topic. The goal of every book in this series is by my colleague and longtime mentor, Dr. Howard
to provide the essential information that any pathol- Levin.
ogist, whether general or subspecialized, in training or I wish to extend my sincerest gratitude to Drs. Magi-
in practice, would find useful in the evaluation of Galluzzi and Zhou for pouring their heart and soul into
virtually any type of specimen encountered. this edition of the Foundations in Diagnostic Pathology
My colleagues at The Cleveland Clinic, Drs. Cristina series. I also would like to extend my appreciation to the
Magi-Galluzzi and Ming Zhou, both superb genitouri- authors who took time from their busy schedules to
nary pathologists, have edited what I believe to be an contribute their knowledge and expertise. I sincerely
outstanding, state-of-the-art book on the essentials of hope you enjoy this volume of Foundations in Diagnostic
genitourinary pathology. The list of contributors is Pathology.
impressive and includes renowned pathologists from
across the United States, all of whom have built a national JOHNR. GOLDBLUM, M.D.
and international reputation in this field. The content
Preface
We have more than a dozen textbooks on genitourinary other genitourinary pathology textbooks. End-stage
pathology in our possession. This book, Genitourinary kidneys removed for a variety of medical conditions are
Pathology, A Volume in the Foundations in Diagnostic not infrequently encountered in pathology laboratories.
Pathology Series, of which we are privileged to be the An understanding of the basic clinical and pathological
editors, however, has several distinct features that set it features will greatly facilitate our handling and inter-
apart from other books. pretation of these specimens.
First, this book has “Disease fact” and “Pathologic This book is primarily intended to be a comprehen-
feature” tables for each major disease entity of the geni- sive genitourinary pathology textbook, providing up-to-
tourinary tract, so that the essential clinical and patho- date information on the surgical pathology of the wide
logical features of each entity can be easily digested and array of neoplastic and non-neoplastic diseases of the
comprehended, and as such can serve as a quick genitourinary tract, and emphasizing the practical
reference during daily sign-out. diagnostic aspects. These are addressed with more than
Second, succinct clinical features of each disease 1000 high-quality, full color illustrations, as well as
that are most relevant to the pathological diagnosis and numerous boxes and tables to enhance and facilitate the
prognosis are discussed in well-defined categories that presentation of information. Thus, it is a book with
include epidemiology, clinical symptomatology, prog- substantial content that one expects from a major geni-
nosis, and management. Such knowledge is important tourinary pathology textbook, but with a novel format
to practicing pathologists as it will not only help us that allows easy use and learning.
formulate diagnoses and understand the impact of our We are very fortunate to have many world renowned
diagnoses on patient care, but also drive us to modify genitourinary pathologists contribute to this book. To
our practice to meet the demand of the ever-changing all, we are immensely grateful.
medical practice in general.
Third, this book includes a chapter on medical kid- MINGZHOU, MD, PhD
ney diseases, an important topic, yet rarely covered by CRISTINAMAGI-GALLUZZI, MD, PhD
Our thanks go to Dr. John Goldblum, our colleague and the editor of this
book series, and to Dr. Jonathan Epstein, both for their support and
mentorship. We would also like to thank Heather Krehling, Belinda Kuhn,
and the staff at Elsevier, who have lent us all the support and resources
necessary to finish this project. Finally, we would like to acknowledge the
superb secretarial support of Debbie Mitchell and Kelly Uterhark.
Ming Zhou, MD, PhD
Cristina Magi-Galluzzi, MD, PhD
1
Non-neoplastic Diseases of the Prostate
Cristina Magi-Galluzzi Ming Zhou
● ●
Jonathan I. Epstein
preprostatic regions that comprise the periurethral
THE PROSTATE GLAND ducts and the larger transition zone (TZ) (Figs. 1-1and
Fig. 1-2).
The anterior fibromuscular stroma occupies approxi-
mately one third of the prostate, contains very few
ANATOMY AND HISTOLOGY
glands, and consists of smooth muscle and dense fibrous
tissue. The CZ forms a cone-shaped area surrounding
In an adult man without prominent prostatic hyper- the ejaculatory ducts, with the apex at the verumon-
plasia, the average weight of the prostate gland is tanum, and the base at the bladder neck. The PZ is the
approximately 30 to 40 g. The shape of the gland is that prominent area distal to the CZ; it corresponds to a
of an inverted cone, with the base located approximately horseshoe-shaped structure extending posteriorly, pos-
at the bladder neck and the apex distally at the terolaterally, laterally and anteriorly around the inner
urogenital diaphragm (Fig. 1-1A). The prostatic urethra aspect of the prostate.
runs through the center of the gland, with a 35-degree The outer aspect of the prostate gland is divided into
anterior bend at the verumontanum. Posteriorly, CZ and PZ based on histologic differences affecting
Denonvillier’s fascia, a thin layer of connective tissue, these two areas. From a diagnostic standpoint, the CZ
separates the prostate and seminal vesicles from the histology may mimic high-grade prostatic intraepithelial
rectum. neoplasia (PIN). The PZ is frequently affected by carci-
Anatomically, the prostate is divided into inner and noma; the CZ is an uncommon site for origin of carci-
outer regions. The inner region is affected predomi- noma, although it may be secondarily invaded by large
nantly by benign prostatic hyperplasia (BPH), and the PZ tumors.
outer region shows predilection for carcinoma, although The prostate consists of epithelial and stromal cells.
some prostatic cancer occurs centrally and BPH nodules The epithelial cells are arranged in tubuloalveolar
may be seen peripherally. The prostate gland is divided glands consisting of ducts that branch out from the
into four zones: (1) anterior fibromuscular stroma; (2) urethra and terminate into acini (Fig. 1-3A). The acini
central zone (CZ); (3) peripheral zone (PZ); and (4) are characterized by papillary infoldings (Fig. 1-3B).
A B
FIGURE 1-1
A, Diagram of male genitourinary
system anatomy. B,Prostate zones.
1
2 GENITOURINARY PATHOLOGY
Epithelial cells in the prostate are secretory cells, basal
cells (Fig. 1-3B), transitional (urothelial) cells, and
neuroendocrine cells. The proximal portion of the pro-
static ducts is lined by urothelium, similar to the
urethra. The distal portion of the prostatic ducts, as
well as some prostatic acini, may show cuboidal and
columnar epithelium mixed with urothelium (Fig.
1-3C). The urothelium or transitional epithelium is
composed of spindle-shaped epithelial cells with
occasional nuclear grooves, which are often oriented
with their long axis perpendicular to the basement
membrane. The columnar secretory epithelial cells are
tall, with pale to clear cytoplasm (Fig. 1-3D). These cells
are terminally differentiated and stain positively with
prostate-specific antigen (PSA) and prostate-specific acid
phosphatase (PSAP). Secretory cells lack immuno-
FIGURE 1-2
reactivity with antibodies to high-molecular-weight
Cross-section of the prostate of an adult man at the level of the utricle.
cytokeratin (HMWCK) and p63. Basal cells lie beneath
The nodular periurethral area represents the transition zone. The white-
the secretory cells. The nuclei are cigar shaped or
gray fibrous tissue surrounding the utricle divides the TZ from the
peripheral zone.
A B
C
D
FIGURE 1-3
A, The epithelial cells are arranged in tubuloalveolar glands consisting of ducts branching out from the urethra and terminating into acini.
B, The acini are characterized by papillary infoldings lined by secretory and basal cells. C, Some prostatic acini show cuboidal and columnar
epithelium mixed with urothelium. D,The columnar secretory epithelial cells are tall with pale to clear cytoplasm. The basal cells lie beneath
the secretory cells; the nuclei are cigar shaped and oriented parallel to the basement membrane.
