Christopher J.

VandenBussche
Carla L. Ellis Editors

Genitourinary
System Cytology
and Small Biopsy
Specimens
Essentials in Cytopathology
Series Editor
Momin T. Siddiqui

123
Essentials in Cytopathology
Series Editor
Momin T. Siddiqui, Department of Pathology and Laboratory
Medicine, Weill-Cornell Medicine, New York Presbyterian
Hospital, New York, NY, USA
The subspecialty of Cytopathology is 60 years old and has become
established as a solid and reliable discipline in medicine. As
expected, cytopathology literature has expanded in a remarkably
short period of time, from a few textbooks prior to the 1980’s to a
current library of texts and journals devoted exclusively to
cytomorphology that is substantial. Essentials in Cytopathology
does not presume to replace any of the distinguished textbooks in
Cytopathology. Instead, the series will publish generously
illustrated and user-friendly guides for both pathologists and
clinicians.
Christopher J. VandenBussche
Carla L. Ellis
Editors

Genitourinary
System Cytology
and Small Biopsy
Specimens
Editors
Christopher J. VandenBussche Carla L. Ellis
Department of Pathology Department of Pathology
Johns Hopkins University Northwestern University
Baltimore, MD, USA Chicago, IL, USA

ISSN 1574-9053     ISSN 1574-9061 (electronic)

Essentials in Cytopathology
ISBN 978-3-030-87874-0    ISBN 978-3-030-87875-7 (eBook)
https://doi.org/10.1007/978-3-030-87875-7

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To my family, for
unconditionally supporting
and loving me throughout my
career. To my patients, for
allowing a very tough time in
your lives to contribute to my
personal learning, the
teaching of my trainees, and
the overall ability to become a
great pathologist – I am
forever grateful. To our junior
authors and to my co-editor:
We did it!!!
CLE
To Roland.
CJV
Foreword

Pee in a cup, we’ll tell you what’s up!

While this statement seems facetious rather than factual, it

truly applies to urinary cytology. With the advent of The Paris
System for Reporting Urine Cytology (TPS) in 2016, cytologic
examination of urinary tract liquid samples has received recogni-
tion as a valid diagnostic system. Although unable to localize the
origin of any abnormal cells, the recognition of such cells in a
urine sample will start the cascade of the diagnostic workup of the
patient. Once found, a tissue sample of the lesion, obtained either
by forceps biopsy, FNA, or core, informs patient management,
treatment, and follow-up.
This latest volume in the Essentials in Cytology Series includes
the common and unusual lesions of the genitourinary tract, and
describes the relationship between exfoliated cells and tissue
architecture obtained by biopsy. Gleaning so much information
from so small a sample is impressive enough when evaluated by
light microscopy. If coupled with immunohistochemical testing,
indeterminate interpretations can often be resolved, saving time,
money, and anxiety for patients and their clinicians. Essential to
any pathology text are excellent photomicrographs that illustrate
the diagnostic criteria of each pathologic entity. This volume ful-
fills that requirement.
The intended readership is practitioners in histopathology and
cytopathology. Clinicians will find the algorithmic approach use-
ful when planning the workup of their patients with suspected

vii
viii Foreword

urinary tract disease. The authors share their experience and

expertise with clarity and pragmatism. Their efforts will contrib-
ute to better outcomes for patients, the beneficiaries of optimized
medical practice.

Professor Emerita Dorothy L. Rosenthal, MD, FIAC

Pathology/Cytopathology
The Johns Hopkins
University School of Medicine
Baltimore, MD, USA
Preface

Genitourinary system cytopathology specimens and small biopsies

are common specimens, with a growing number of renal fine needle
aspirations and core biopsy procedures being performed each year.
Those who routinely practice cytopathology have been increasingly
reviewing cell blocks and small tissue biopsy specimens, which
allow for ancillary methods such as immunohistochemistry and
molecular testing to improve diagnosis and patient care.
Genitourinary System Cytology and Small Biopsy Specimens
covers the full spectrum of benign and malignant conditions of the
genitourinary tract with emphasis on common entities encoun-
tered in daily practice. The authors focus on the correlation
between urinary tract cytology and surgical pathology, including
the evaluation of germ cell tumor metastasis to distant sites. Aspi-
ration and exfoliative cytology samples obtained from all areas of
and related to the genitourinary tract are highlighted in individual-
ized chapters for these entities.
The volume is heavily illustrated and contains useful algo-
rithms that guide the reader through the differential diagnosis and
cytohistologic correlation of common and uncommon entities
with appropriate clinical correlations. Recent updates in terminol-
ogy, guidelines, and ancillary studies are included. This book will
serve as a valuable quick reference for pathologists, cytopatholo-
gists, cytotechnologists, fellows, and residents in the field.

Baltimore, MD, USA Christopher J. VandenBussche

Chicago, IL, USA Carla L. Ellis

ix
Contents

1 
Urinary Tract Exfoliative Cytology and Biopsy
Specimens: Nonneoplastic Findings ��������������������������������1
Derek B. Allison, Carla L. Ellis,
and Christopher J. VandenBussche
2 
Urinary Tract Exfoliative Cytology and Biopsy
Specimens: Low-Grade Urothelial Neoplasms��������������23
Derek B. Allison, Carla L. Ellis,
and Christopher J. VandenBussche
3 
Urinary Tract Exfoliative Cytology and Biopsy
Specimens: High-Grade Urothelial Carcinoma������������39
Derek B. Allison, Carla L. Ellis,
and Christopher J. VandenBussche
4 
Urinary Tract Exfoliative Cytology and Biopsy
Specimens: Other Urothelial Tract Neoplasms ������������57
Derek B. Allison, Christopher J. VandenBussche,
and Carla L. Ellis
5 
Renal Fine Needle Aspiration and Core Biopsy
Specimens: Renal Cell Carcinomas��������������������������������85
Patrick C. Mullane, Sara Mustafa,
Christopher J. VandenBussche, and Carla L. Ellis

xi
xii Contents

6 Renal
 Fine Needle Aspiration and Core Biopsy
Specimens: Urothelial Carcinoma and Other
Nonrenal Malignancies��������������������������������������������������129
Patrick C. Mullane, Christopher J. VandenBussche,
and Carla L. Ellis
7 Renal
 Fine Needle Aspiration and Core
Biopsy Specimens: Benign Entities
and Nonneoplastic Findings������������������������������������������151
Sara Mustafa, Christopher J. VandenBussche,
and Carla L. Ellis
8 Adrenal Gland����������������������������������������������������������������179
Sara Mustafa, Christopher J. VandenBussche,
and Carla L. Ellis
9 Fine
 Needle Aspiration and Core Biopsy
Specimens: Germ Cell Neoplasms��������������������������������201
Kimberly S. Point du Jour,
Christopher J. VandenBussche, and Carla L. Ellis
10 Miscellaneous
 Lesions of the Genitourinary
System ����������������������������������������������������������������������������231
Kimberly S. Point du Jour,
Christopher J. VandenBussche, and Carla L. Ellis
Index�������������������������������������������������������������������������������������� 243
Contributors

Derek B. Allison University of Kentucky College of Medicine,

Lexington, KY, USA
Kimberly S. Point du Jour Emory University School of Medi-
cine, Atlanta, GA, USA
Carla L. Ellis Department of Pathology, Northwestern Univer-
sity, Chicago, IL, USA
Patrick C. Mullane Emory University School of Medicine,
Atlanta, GA, USA
Sara Mustafa Old Dominion Pathology Associates, Annandale,
VA, USA
Christopher J. VandenBussche The Johns Hopkins University
School of Medicine, Baltimore, MD, USA

xiii
Urinary Tract Exfoliative
Cytology and Biopsy 1
Specimens: Nonneoplastic
Findings

Derek B. Allison, Carla L. Ellis,

and Christopher J. VandenBussche

Specimen Procurement

Cystoscopy is an endoscopic procedure that affords direct visual-

ization of the urinary tract system and allows urologists to sample
any abnormal-appearing tissue. These include flat lesions that
may be erythematous or ulcerative and exophytic lesions that may
be nodular or papillary. Random biopsies may also be taken to map
the extent of disease and to detect lesions that may be difficult to

D. B. Allison (*)
University of Kentucky College of Medicine, Lexington, KY, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 1

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_1
2 D. B. Allison et al.

appreciate on cystoscopy, such as carcinoma in situ (CIS), which

is flat and appears red and velvety, much like areas of inflamma-
tion. Random biopsies and small lesions (<1 cm) are usually sam-
pled with cold-cup biopsy forceps and yield small superficial
fragments of urothelial tissue devoid of cautery artifact, while vis-
ible exophytic tumors (>1 cm) are usually sampled via a proce-
dure called transurethral resection of a bladder tumor (TURBT),
which has the added benefit of being both diagnostic and thera-
peutic. Additionally, TURBT allows for assessment of deeper tis-
sue for accurate staging. Although these samples are much larger,
they consist of multiple fragments of unoriented tissue, which
may have large areas significantly affected by cautery artifact.
When interpreting either type of biopsy, it is imperative to have an
understanding of the normal components lining the urothelial
tract, and more specifically, the bladder. See Chap. 6 for a discus-
sion of upper urinary tract samples.
The cytomorphologic findings in urinary tract cytology (UTC)
will vary depending on how a specimen was procured. Voided
urine specimens contain naturally exfoliated cells (both benign
and neoplastic), as well as entities that form or proliferate within
the urinary tract (such as crystals and bacteria). In washing speci-
mens, forcibly exfoliated cells tend to predominate; larger and
more numerous fragments are often present. In specimens that are
not collected through a catheter, extra-urinary contaminants may
be seen, such as squamous cells from the genital areas.

Normal Histology and Cytology

The urothelial bladder consists of four layers of tissue, including

the urothelial lining, lamina propria, muscularis propria, and
adventitia. Cold-cup biopsies generally include the urothelial lin-
ing, lamina propria, and occasionally a superficial portion of mus-
cularis propria, while TURBT specimens should almost always
contain muscularis propria (Fig. 1.1). The presence of these three
layers in a biopsy allows for the determination of superficial inva-
sion (involving lamina propria, T1) versus muscle invasive cancer
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 3

a b

Fig. 1.1 Specimen type. (a) Cold-cup biopsy allows examination of the
superficial urothelium and the underlying lamina propria. Rarely, muscularis
propria may be present, particularly when sampling the bladder neck [H&E
stain; medium power]. (b) Transurethral resection of bladder tumor sample
showing the different layers of the bladder. Note the superficial urothelium,
the underlying lamina propria with dilated vessels, and deeper muscularis
propria characterized by thick muscle bundles. Fat can be present in multiple
layers and cannot be used to determine the depth of invasion in cancer cases
[H&E stain; low power]

(involving muscularis propria, T2), which is a crucial distinction

for clinical management.
The urothelial lining contains superficial cells, intermediate
cells, and basal cells. The superficial cells are called umbrella
cells, and they directly interface with the urinary contents.
Umbrella cells are large with abundant eosinophilic cytoplasm
and often contain multiple nuclei. Their shape is largely depen-
dent on how contracted or extended the bladder is, as does the
overall thickness of the urothelial lining. The majority of the uro-
thelial lining is composed of intermediate cells, which are ori-
ented perpendicular to the basement membrane. These cells have
moderate amounts of eosinophilic cytoplasm and contain oval
nuclei with nuclear grooves, fine chromatin, and indistinct nucle-
oli. The basal cell layer consists of a single row of cuboidal epi-
thelium which may not be easily appreciable.
The lamina propria lies between the basement membrane of
the urothelial lining and the muscularis propria. Its contents vary
somewhat depending on the location in the bladder; however,
generally, it consists of a highly vascularized network of connec-
4 D. B. Allison et al.

tive tissue, nerve, and muscularis mucosae. Occasionally, fat and

paraganglia may be present. The muscularis mucosae consists of
thin wisps of isolated bundles of smooth muscle that is often dis-
continuous and superficial to medium-sized arteries and nerves
(Fig. 1.2). In some circumstances, such as benign prostatic hyper-
plasia, the muscularis mucosae can become hyperplastic, result-
ing in a thicker bundle or muscle that may be haphazardly arranged
and difficult to assess. It is imperative not to mistake these thin
bands of muscle for muscularis propria when assessing the extent
of invasion in cancer cases.
The muscularis propria consists of large bundles of smooth
muscle with rounded and smooth contours. These fascicles may
be separated by connective tissue containing fat and neurovascu-
lar structures. The thickness of the muscularis propria changes
depending on the location in the bladder and extends extremely
close to the surface urothelium at the bladder neck. TURBT biop-

Fig. 1.2 Layers. High-power view highlighting the thin wisps of intersecting
smooth muscle fibers that make the muscularis mucosae of the lamina propria
[H&E; high power]
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 5

sies are fragmented and unoriented and often yield multiple frag-
ments of cauterized tissue, making the d­istinction between
muscularis mucosae and muscularis propria difficult. In all cancer
cases, it is important to note the presence of muscularis propria in
the sample as a means to provide feedback to the urologist on
whether or not the lesion was adequately sampled to determine
the depth of invasion.
The most common indication for a urinary tract specimen is to
exclude the presence of neoplasia, and the performance of UTC is
best for the detection of HGUC/CIS, as discussed in subsequent
chapters. In such samples, the reporting of other items, such as
crystals, may or may not be desired or required by the submitting
physician. In young patients with nonspecific urinary tract symp-
toms and who are not likely to have urothelial carcinoma, the
reporting of such items may aid the clinical team.
The most commonly exfoliated cells in UTC specimens are
squamous cells (from the urethra or areas of squamous metapla-
sia), urothelial cells (including umbrella cells), and renal tubular
cells.

Squamous Cells

Squamous cells in UTC specimens may be derived from meta-

plastic areas of the urothelium, the urethra, or genital regions (cer-
vix, vagina, penis, vulva, etc.). Given that benign squamous cells
from these areas have similar morphology, it is often not certain
which areas contribute to squamous cell populations in voided
urine specimens. The process of voiding may forcibly exfoliate
squamous cells into the urine stream. Generally, most mature
squamous cells in a specimen are assumed to be extra-urinary
contaminants. The cells are large and platelike with small, pyk-
notic nuclei and resemble those seen in Pap test specimens
(Fig. 1.3a). The presence of significant atypia, such as dysplastic
changes that would be diagnosed as LSIL, ASC-H, or above in a
Pap test specimen, should be mentioned, as discussed further in
Chap. 4.
6 D. B. Allison et al.

a b

c d

Fig. 1.3 Normal components of the urine. (a) Superficial squamous cells
appear identical in urine cytology as in the gynecologic Pap test. Note the
normal urothelial cells in the middle of the field [Pap stain; high power]. (b)
Normal parabasal-type urothelial cells with abundant cytoplasm and small,
round nuclei with smooth contours and open chromatin [Pap stain; high
power]. (c) Benign urothelial tissue fragment due to disruption from a urinary
washing procedure [Pap stain; high power]. (d) Small, variably sized tissue
benign urothelial tissue fragments can mimic small papillary fragments; how-
ever, note the completely bland cytology. Furthermore, note the variably
vacuolated nature of the cytoplasm [Pap stain; high power]

Parabasal-Type Urothelial Cells

Most urothelial cells in a UTC specimen are parabasal-type cells,

named so because of their resemblance to parabasal cells seen in
Pap test specimens. Because true parabasal cells derived from
extra-urinary squamous linings do not tend to exfoliate, it is
assumed that any cell with parabasal cell morphology in a UTC
specimen is most likely a urothelial cell. Parabasal-type cells have
the appearance of fried eggs, with an oval-shaped nucleus and
round-to-oval-shaped cytoplasm. The cells have smooth nuclear
borders and bland chromatin. The cells typically have N/C ratios
of approximately 0.3 (Fig. 1.3b). In benign voided urine speci-
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 7

mens, parabasal-type cells are not usually present in great num-

bers. Their numbers are often increased in washing specimens;
they will also be seen in tissue fragments in such specimens
(Fig. 1.3c, d). The absence of parabasal-type cells in a given spec-
imen should be noted, but their absence does not make a voided
urine specimen of sufficient cellularity inadequate.

Umbrella Cells

The number of umbrella cells in a UTC specimen is highly vari-

able. Specimens from patients with urolithiases or other reactive
processes often demonstrate a greater number of umbrella cells.
Umbrella cells are usually outnumbered by parabasal-type uro-
thelial cells, but in some specimens, umbrella cells may be the
only urothelial cell type seen. Umbrella cells are often larger than
parabasal-type urothelial cells and have abundant, granular cyto-
plasm. Often they are binucleate, though multinucleated and
mononucleated forms can also be seen. In rare instances, umbrella
cells may be extremely large in size and cause concern for multi-
nucleated, pleomorphic HGUC cells. Umbrella cell nuclei are
round and have regular borders. The chromatin is marginated and
several small chromocenters or nucleoli are seen (Fig. 1.4).
Importantly, the quality of cytoplasm and chromatin should be

a b

Fig. 1.4 Umbrella cells. (a) Umbrella cells can have a single, two, or multi-
ple nuclei and have abundant granular cytoplasm [Pap stain; high power]. (b)
An umbrella cell with three nuclei and abundant granular cytoplasm. Note the
marginated chromatin and the small, punctate chromocenters [Pap stain; high
power]
8 D. B. Allison et al.

similar between most if not all umbrella cells in a specimen. This

is helpful in identifying degenerating umbrella cells, in which the
cytoplasm becomes smaller, causing an increase in N/C ratio.
These cells may otherwise be identified as being atypical and/or
suspicious for HGUC.

Renal Tubular Cells (RTCs)

Renal tubular cells are small and form small clusters of 4–15 cells
in voided urine specimens. The cells form loose clusters with hob-
nailed edges. The cells may appear hyperchromatic and have high
N/C ratios; thus, if they are not properly identified as renal tubular
cells, they may cause concern for HGUC when viewed at high
magnification. They are best identified at low magnification, as
they form distinctive clusters and are rarely present in great num-
bers. In rare instances, RTCs may be larger in size and be difficult
to distinguish from atypical urothelial cells. However, they con-
tinue to cluster in a similar fashion, which provides a clue that the
finding is benign rather than atypical.

Reactive Changes

 on Brunn Nests, Cystitis Cystica, and Cystitis

v
Glandularis

von Brunn nests are located in the superficial lamina propria and
consist of invaginated normal urothelial proliferations that pro-
duce rounded and well-circumscribed groups (Fig. 1.5a). These
nests are architecturally arranged in a lobular configuration that is
usually less than 5 mm across. The nests should be evenly spaced
and contain urothelial cells with bland cytologic features, although
the nuclei may be larger than the overlying urothelial surface. von
Brunn nests may be an incidental finding or may produce a small
nodule that is visualized on cystoscopy. In either case, these
­proliferations are of no pathologic significance. However, it is
important to distinguish these benign proliferations from the
remarkably bland nested variant of urothelial carcinoma, which
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 9

a b

Fig. 1.5 (a) von Brunn nests present in the superficial lamina propria dis-
playing a rounded, lobular architecture and intact basement membrane sur-
rounding each nest. Note the bland cytologic features of the urothelium and
the abundance of cytoplasm [H&E; high power]. (b) Cystitis glandularis
showing cystic dilatation in nests of urothelium that are lined by columnar-­
type epithelium. Note the lobular architecture of this group and the lack of
cytologic atypia [H&E; medium power]. (c) Urothelium showing intestinal-­
type metaplasia, characterized by the presence of goblet cells. Note the lack
of dysplastic features, which would be assessed for atypia utilizing the same
criteria as in the intestinal tract [H&E; high power]

should be larger than 5 mm, grow in an irregular pattern, and

extend deep into the lamina propria or muscularis propria (see
Chap. 4). When von Brunn nests become cystically dilated, the
term cystitis cystica is used. When the lining of cysts undergoes
glandular metaplasia, the term cystitis glandularis is used
(Fig. 1.5b). Occasionally, the glandular epithelium may contain
goblet cells, which is referred to as cystitis glandularis with
­intestinal metaplasia (Fig. 1.5c). Most importantly, however, these
proliferations and metaplastic processes lack significant cytologic
atypia and should not be misinterpreted as a malignancy.
10 D. B. Allison et al.

Metaplasia

Non-keratinizing squamous metaplasia is present in the trigone

region of the bladder in most women and should not be overinter-
preted as a pathologic process (Fig. 1.6a). On the other hand,
keratinizing squamous metaplasia is often the result of chronic
mucosal injury from urinary tract stones, prolonged catheteriza-
tion, chronic infection (such as schistosomiasis), and diverticular
disease, to name a few (Fig. 1.6b). It is important to mention kera-
tinizing metaplasia in the pathology report and to assess for atypia
in these lesions because they are likely a precursor to pure squa-
mous cell carcinomas that arise in the bladder. Similarly, glandu-
lar metaplasia, recognized by the presence of cuboidal or columnar
epithelium, may replace the normal surface urothelial lining as a
response to chronic irritation. These glands may contain goblet
cells and resemble intestinal-type epithelium. In many cases,
there will be coexisting cystitis glandularis underlying surface
glandular metaplasia. Recognizing the well-circumscribed nature
of the cystitis glandularis and the lack of cytologic atypia will
prevent the pathologist from interpreting the invaginations as
superficial invasion. Due to the fact that long-standing glandular

a b

Fig. 1.6 Squamous metaplasia. (a) Non-keratinizing squamous metaplasia

showing normal maturation and a lack of cytologic atypia. Squamous meta-
plasia is common in the trigone of the bladder in women, and, as long as there
is no atypia or keratinization, it is an incidental finding [H&E; high power].
(b) Keratinizing squamous metaplasia showing dyskeratotic cells and para-
keratosis. Note that keratinizing squamous metaplasia is a risk factor for
developing squamous cell carcinoma [H&E; medium power]
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 11

metaplasia is sometimes observed in patients who develop pri-

mary adenocarcinoma of the bladder, this process should be men-
tioned in the pathology report.

Nephrogenic Adenoma

Nephrogenic adenomas are often incidentally discovered on cys-

toscopy as polypoid masses that mimic papillary neoplasms or as
flat velvety lesions that mimic CIS. These lesions most likely rep-
resent implantation of renal tubular epithelial cells in a site of
injury, but a metaplastic etiology for a subset of cases has not been
entirely ruled out. When these lesions are papillary, they are most
often lined by cuboidal epithelium and resemble their renal epi-
thelial counterparts (Fig. 1.7a). When present in the lamina pro-
pria, they can appear as tubules or cysts with flat or hobnail nuclei
that may have a significant amount of degenerative atypia
(Fig. 1.7b). In most cases, the cytology is bland; however, it is
important to note that the cells may have prominent nucleoli.
Mixed patterns are common and these lesions can mimic papillary
neoplasms and adenocarcinomas of the bladder or prostate. These
tumors stain with renal markers, including PAX8 and Napsin-A;

a b

Fig. 1.7 Nephrogenic adenoma. (a) Nephrogenic adenoma showing papil-

lary structures lined by simple cuboidal epithelium with eosinophilic cyto-
plasm and focal hobnail features [H&E; medium power]. (b) Nephrogenic
adenoma showing surface papillary projection and tubules in the lamina pro-
pria that are variably sized. The mixed architecture is one of the most helpful
clues to the diagnosis [H&E; medium power]
12 D. B. Allison et al.

however, rare cases may show GATA3 positivity or focal PSA/

PSAP staining, making immunohistochemistry only one tool in
making a definitive diagnosis.

Polypoid Cystitis

Polypoid cystitis is the result of chronic irritation from a variety of

causes, such as indwelling catheters or fistula tracts. These lesions
may be recognized on cystoscopy as small edematous areas with
friable polypoid nodules. On biopsy, polypoid cystitis consists of
predominantly broad or broad and narrow-based simple, non-­
branching papillary fronds with mixed acute and chronic inflam-
mation (Fig. 1.8a). Additionally, some fronds may show a marked
amount of congestion or edema in the lamina propria. The overly-
ing urothelium is typically of normal thickness and normal histol-
ogy; however, mild reactive atypia may be diffuse (Fig. 1.8b–d).
Most cases can be easily recognized on low power by recognizing
the simple, broad-based papillae with associated inflammation
and bland-to-reactive overlying urothelial cytology.

Treatment-Related Cystitis

Intravesicular bacillus Calmette-Guérin (BCG) therapy is used

in the treatment of patients with urothelial carcinoma in situ
(CIS) and high-grade papillary urothelial carcinoma. BCG
comes in direct contact with the lining of the bladder and aims
to eliminate superficial disease. It produces an intense inflam-
matory response that may be seen on repeat biopsy or follow-up
urine cytology. Findings include surface ulceration, reactive
urothelial atypia, and superficial granulomatous inflammation
(Fig. 1.9a).
After TURBT, patients may develop necrotizing granulomas
rimmed by multinucleated palisading giant cells at the site of
resection. These areas can be surrounded by a mix of eosinophils,
lymphocytes, plasma cells, and eventually fibrosis and calcifica-
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 13

a b

c d

Fig. 1.8 Reactive changes. (a) Polypoid change as a result of acute inflam-
mation in the urothelium and lamina propria. Note the significant amount of
edema and the lack of a fibrovascular core in the polypoid projection [H&E;
medium power]. (b) Reactive epithelial changes, including slight nuclear
enlargement, irregular contours, and nucleoli most prominent at the left por-
tion of the field. Note the urothelium maintains polarity [H&E; high power].
(c) Reactive urothelium with acute intraepithelial inflammation. Although
there is some nuclear enlargement, the nuclei are still small compared to lym-
phocytes and have open chromatin with small punctate nucleoli [H&E; high
power]. (d) Reactive urothelium with acute intraepithelial inflammation and
reactive changes. Note that there is a significant amount of edema in the lam-
ina propria and that there is overlying denudation at the left surface of this
field [H&E; high power]

tion (Fig. 1.9b, c). In most cases, an eosinophilic infiltrate is non-

specific and is the result of an acute injury or can be seen associated
with cancer.
In urinary tract cytology specimens, granulomatous inflamma-
tion is a nonspecific finding but is usually associated with BCG
therapy in patients being evaluated for HGUC in UTC specimens.
The amount of granulomatous inflammation seen in a specimen is
usually reduced compared to that in corresponding tissue biopsies
14 D. B. Allison et al.

a b

Fig. 1.9 Treatment-related changes. (a) Non-caseating granulomas com-

prised of epithelioid and multinucleated histiocytes in the lamina propria sec-
ondary to treatment with intravesicular BCG [H&E; medium power]. (b)
Mixed inflammatory response due to injury from prior TURBT [H&E; high
power]. (c) Calcifications, multinucleated giant cells, and mixed inflammation
are present secondary to injury from prior TURBT [H&E; medium power]

and may even be absent in many cases. Single inflammatory cells

such as lymphocytes and histiocytes may be difficult to identify
in the background. Cohesive clusters containing epithelioid his-
tiocytes and lymphocytes may be present and mimic urothelial
tissue fragments containing cytomorphologic atypia. Perhaps
the easiest to identify are multinucleated giant cells, which can
be distinguished from umbrella cells by their very numerous
nuclei (Fig. 1.10a). A background of acellular, granular debris
may be present, reflecting the presence of necrosis (Fig. 1.10b).
Granulomatous inflammation is often associated with a relative
paucity or absence of parabasal-type urothelial cells.
Occasionally, radiation/chemotherapy can induce a pseudocar-
cinomatous hyperplastic process that extends into the lamina pro-
pria but not the muscularis propria. In addition to mild-to-moderate
cytologic atypia, these proliferations often acquire abundant eosin-
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 15

a b

Fig. 1.10 (a) A multinucleated epithelioid histiocyte secondary to treatment

with intravesicular BCG [Pap stain; high power]. (b) Occasionally, necrosis
secondary to BCG treatment may be appreciated in urine cytology samples
[Pap stain; high power]

Fig. 1.11 Pseudocarcinomatous stromal atypia with surrounding mixed

inflammation and lamina propria edema, rather than a typical desmoplastic
response, in a patient treated with systemic neoadjuvant chemotherapy [H&E;
high power]

ophilic cytoplasm that can mimic paradoxical differentiation pres-

ent in tongues of early invasive urothelial carcinoma (Fig. 1.11).
The key diagnostic feature is the associated surrounding granula-
tion tissue-like reaction, which is not a common stromal reaction
16 D. B. Allison et al.

seen in invasive bladder cancer. In addition, fibrin may or may not

be present, and if present, it is suggestive of pseudocarcinomatous
urothelial hyperplasia.

Microorganisms

Bacteria

Bacteria are sometimes seen in urinary tract specimens. Bacteria

stuck to squamous cells are likely extra-urinary contaminants.
Bacteria may continue to grow in unrefrigerated or unpreserved
specimens, and thus the amount of bacteria seen in a specimen is
not necessarily relevant. The presence of contaminating or rare
bacteria does not need to be noted in the diagnosis of a cytologic
specimen. While no specific criterion exists, specimens in which
bacteria substantially obscure cells of interest should be consid-
ered nondiagnostic.

Fungus

Fungal organisms in a urine specimen are often extra-urinary con-

taminants. Candida spp. are most commonly seen, either in
hyphal or yeast form. The reporting of fungal forms depends on
whether they are felt to be contaminants and whether the type of
fungus seen is pathogenic.

BK Polyomavirus

In the United States, most adults are thought to be infected with

BK polyomavirus, which lies dormant. Reactivation of the virus
can occur in immunosuppressed patients and is particularly threat-
ening to renal transplant patients. Screening of these patients is
often done using molecular methods but urinary tract cytopathol-
ogy may also be used. Immunocompetent individuals, for
unknown reasons, sometimes experience reactivation of BK virus,
which may be associated with hematuria. BK virus cells are
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 17

a b

Fig. 1.12 BK polyomavirus cytopathic effect. (a) Note the nuclear enlarge-
ment compared to the adjacent parabasal-type urothelial cell. Although
enlarged, the nucleus is round and regular with a glassy characteristic [Pap
stain; high power]. (b) Note the ground-glass appearance of the nucleus and
the peripheral margination of the chromatin [Pap stain; high power]

labeled “decoy cells” as they share some similarity with HGUC

cells in urinary tract specimens (Fig. 1.12). “Decoy cells” have
high N/C ratios and large nuclei with regular borders and appear
hyperchromatic at low magnification. The chromatin is typically
marginated and will have a “ground-glass” appearance or form
degenerated strings that give a “spider web” type appearance. The
cytoplasm is usually degenerated and/or absent. Decoy cells may
sometimes resemble degenerated HGUC cells and distinguishing
between these may be greatly challenging. TPS recommends
placing decoy cells under the NHGUC category, but if any con-
cern for HGUC exists, an indeterminate category may be more
appropriate. Decoy cells are usually seen in only few numbers,
which can help prevent a misdiagnosis of malignancy. If sufficient
material exists, immunostaining with SV40 can help demonstrate
infected cells; however, there have been reports suggesting that
HGUC cells can sometimes be positive for BK virus and thus
would also stain positively with SV40.

 erpes Simplex Virus (HSV) and Cytomegalovirus

H
(CMV)

HSV and CMV that may be seen in urinary tract specimens are usu-
ally extra-urinary contaminants in voided urine specimens. Their
cytomorphology is like that seen in Pap test specimens (Fig. 1.13).
18 D. B. Allison et al.

a b

Fig. 1.13 HSV cytopathic effect. (a) Note several multinucleated cells with
marginated clear chromatin and a hint of nuclear molding [Pap stain; high
power]. (b) HSV viral cytopathic effect can be seen in the center of this field
[Pap stain; high power]

Protozoa

While uncommon, protozoa found in urinary tract specimens are

often extra-urinary contaminants, for instance, ova from
Enterobius vermicularis, the human pinworm. In patients from
geographic regions endemic for Schistosoma haematobium
(Middle East and Africa), ova from these organisms may be seen
in a background of inflammation and granular debris (Fig. 1.14).
Such patients are at increased risk of developing primary bladder
squamous cell carcinoma, especially in Egypt and surrounding
areas.

Exfoliated Acellular Components

Crystals

Crystals and crystalloids are commonly seen in urinary tract spec-

imens and reflect various pathophysiologic states of a patient
(Fig. 1.15a). In most pathology laboratories, crystals are better
reported from the bench in the fluids laboratory rather than on
Pap-stained cytologic preparations. In cytopathology specimens
being submitted to exclude urothelial carcinoma, the reporting of
crystals may not be necessary unless they obscure cells of interest
and result in a suboptimal specimen.
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 19

Fig. 1.14 Schistosoma haematobium can be present in the urine and speci-
ated by the presence of a terminal spine. Chronic infection induces keratin-
izing metaplasia, which is a major risk factor for the development of squamous
cell carcinoma [Pap stain; high power]

a b

Fig. 1.15 (a) Crushed crystal in the urine. Note the adjacent urothelium,
with may show reactive changes [Pap stain; high power]. (b) A granular cast
formed from luminal contents of renal tubules [Pap stain; high power]

Casts

Various types of casts may be seen in the background and are

typically irrelevant in assessing a cytopathology specimen
(Fig. 1.15b). Like crystals, casts are better reported from the fluids
20 D. B. Allison et al.

laboratory than on cytologic preparations. The presence of casts

does not alter a patient’s pre-test probability for malignancy, and
thus the finding should not be considered reassuring.

Corpora Amylacea

Corpora amylacea can be seen in urinary tract specimens and

most likely enter the urinary stream from the prostate. They are of
no particular consequence and do not need to be noted in the cyto-
pathologic diagnosis.

Other Components

Spermatozoa

Spermatozoa are sometimes seen in patients with retrograde ejac-

ulation secondary to various chronic disease states, such as diabe-
tes. Their presence may be associated with nonspecific urologic
complaints, which are often the reason for UTC specimen sub-
mission. They are usually present in substantial numbers and may
be engulfed by macrophages, resulting in unusual morphologies
(Fig. 1.16a). Because the presence of spermatozoa may provide a
clinical clue to guide patient care, the finding should be reported.

a b

Fig. 1.16 (a) Occasionally, spermatozoa can be found in the urine. Note the
histiocyte at 12 o’clock which has engulfed several spermatozoa. (b) Seminal
vesicle cells with lipofuscin pigment. Note that these cells may appear mark-
edly atypical; however, the presence of pigment is a good indicator of their
origin [Pap stain; high power]
1 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 21

Seminal Vesicle Cells

Seminal vesicle cells may rarely exfoliate into the urinary stream,
and it is thought that this may occur following prostatic massage.
The cells are large, with large amounts of cytoplasm that may be
characteristically pigmented (Fig. 1.16b). In some patients, these
cells may have giant, highly atypical appearing nuclei and give
the impression of malignancy. Clues to help avoid a falsely malig-
nant diagnosis include the presence of cytoplasmic pigment, the
large cell size, and the extreme level of atypia. Spermatozoa may
also be seen in the background or in close contact with these cells,
another helpful clue.

Contaminants

Endometrial Cells

Endometrial cells may contaminate the urinary stream during the

collection of voided urine specimens. The cells have similar mor-
phology to that seen in Pap test specimens. While exact morphol-
ogy and fragment architecture can vary, the cells are often small
with high N/C ratios and dark chromatin. The endometrial clus-
ters are usually three-dimensional and have rounded edges.
Neutrophils may be embedded in the clusters, which may help
distinguish them from clusters of renal tubular cells. The contam-
ination of the urinary stream by endometrial cells is often found in
the context of reported hematuria, which may in fact be blood
from the endometrium rather than from the urinary tract. The
presence of even benign-appearing endometrial cells is abnormal
in women above the age of 45 and should be reported, as well as
the presence of any cytomorphologic features concerning for
endometrial neoplasia (see Chap. 4).
22 D. B. Allison et al.

Suggested Reading
Cox R, Epstein JI. Large nested variant of urothelial carcinoma: 23 cases
mimicking von Brunn nests and inverted growth pattern of noninvasive
papillary urothelial carcinoma. Am J Surg Pathol. 2011;35(9):1337–42.
Guo CC, Fine SW, Epstein JI. Noninvasive squamous lesions in the urinary
bladder: a clinicopathologic analysis of 29 cases. Am J Surg Pathol.
2006;30(7):883–91.
Lane Z, Epstein JI. Polypoid/papillary cystitis: a series of 41 cases misdiag-
nosed as papillary urothelial neoplasia. Am J Surg Pathol. 2008;32(5):758–
64.
Lopez-Beltran A, Luque RJ, Mazzucchelli R, Scarpelli M, Montironi
R. Changes produced in the urothelium by traditional and newer therapeu-
tic procedures for bladder cancer. J Clin Pathol. 2002;55(9):641–7.
Sharifai N, Abro B, Chen JF, Zhao M, He H, Cao D. Napsin A is a highly
sensitive marker for nephrogenic adenoma: an immunohistochemical
study with a specificity test in genitourinary tumors. Hum Pathol.
2020;102:23–32.
Tong GX, Weeden EM, Hamele-Bena D, Huan Y, Unger P, Memeo L, O’Toole
K. Expression of PAX8 in nephrogenic adenoma and clear cell adenocar-
cinoma of the lower urinary tract: evidence of related histogenesis. Am J
Surg Pathol. 2008;32(9):1380–7.
Vakar-Lopez F, Shen SS, Zhang S, Tamboli P, Ayala AG, Ro JY. Muscularis
mucosae of the urinary bladder revisited with emphasis on its hyperplastic
patterns: a study of a large series of cystectomy specimens. Ann Diagn
Pathol. 2007;11(6):395–401.
Volmar KE, Chan TY, De Marzo AM, Epstein JI. Florid von Brunn nests
mimicking urothelial carcinoma: a morphologic and immunohistochemi-
cal comparison to the nested variant of urothelial carcinoma. Am J Surg
Pathol. 2003;27(9):1243–52.
Young RH, Bostwick DG. Florid cystitis glandularis of intestinal type with
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1996;20(12):1462–8.
Urinary Tract Exfoliative
Cytology and Biopsy 2
Specimens: Low-Grade
Urothelial Neoplasms

Derek B. Allison, Carla L. Ellis,

and Christopher J. VandenBussche

 verview of Low-Grade Papillary Urothelial

O
Neoplasms

Low-grade papillary urothelial lesions are typically visualized on

cystoscopy as exophytic growths and are most commonly sampled
by TURBT. The diagnosis of these lesions is mainly based on a
combination of architectural and cytologic features and is divided
accordingly into three main entities: urothelial papilloma, papillary

D. B. Allison (*)
University of Kentucky College of Medicine, Lexington, KY, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 23

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_2
24 D. B. Allison et al.

urothelial neoplasm of low malignant potential (­PUNLMP), and

low-grade papillary urothelial carcinoma (LGPUC). This classifi-
cation is further justified by the rate of recurrence and risk of tumor
progression associated with each entity. More rarely, these tumors
may be flat or raised and show inverted growth patterns, or even
mixed patterns. This chapter will focus on the salient histologic
features of low grade papillary urothelial neoplasms and will be
followed by an updated discussion on the detection of these lesions
on urine cytology specimens.

Exophytic Tumors

Urothelial Papilloma

Urothelial papillomas are relatively rare benign neoplasms which

are more common in younger patients. These rarely recur and
have no risk of progression to higher grade or higher stage lesions.
Urothelial papillomas are characterized by thin papillary fronds
with fibrovascular cores and contain minimal branching (Fig. 2.1).
The lymphatic channels may become dilated and produce larger
bulbous papillae with foam cells found within the cores. The over-
lying urothelium is of normal thickness and shows normal matu-
ration with either no cytologic atypia or limited reactive changes,
particularly when associated with inflammation and edema. As a

a b

Fig. 2.1 Papilloma. (a) Papilloma with central fibrovascular cores contain-
ing focally dilated lymphatics with foamy histiocytes [H&E; medium power].
(b) Papilloma with overlying urothelium of normal thickness and maturation
with a lack of cytologic atypia [H&E; high power]
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 25

result, the urothelial cells are typically monotonous with absent or

inconspicuous nucleoli and may show nuclear grooves, virtually
identical to those seen in normal urothelium. The superficial
umbrella layer may be comprised of enlarged multinucleated
umbrella cells with abundant eosinophilic cytoplasm or promi-
nent vacuolization, masquerading as atypia. However, this change
represents a degenerative type of atypia, and overt cytologic
atypia, by definition, should not be found deeper within the uro-
thelium. Furthermore, mitotic activity should be absent. Urothelial
papillomas can be distinguished from polypoid cystitis by the
presence of longer and thinner papillae that show minimal branch-
ing, which is absent in polypoid cystitis. Urothelial papillomas
also lack the thickened urothelial lining that makes PUNLMP
look distinctive at low magnification.

 apillary Urothelial Neoplasm of Low Malignant

P
Potential (PUNLMP)

PUNLMPs are extremely rare tumors that have a propensity to recur

but rarely result in progression to higher grade or higher stage
lesions. Simply put, PUNLMPs have the same long and thin papil-
lary architecture as urothelial papillomas but can be distinguished by
the presence of a thickened, hyperplastic urothelial lining (Fig. 2.2).
Like papillomas, this urothelial lining, however, shows normal mat-

a b

Fig. 2.2 Papillary urothelial neoplasm of low malignant potential (PUN-

LMP). (a) PUNLMP displaying increased thickness but with bland urothelial
cells [H&E; low power]. (b) PUNLMP showing normal maturation and a
complete lack of cytologic atypia [H&E; high power]
26 D. B. Allison et al.

uration and is comprised of monotonous cells with bland cytologic

features that are virtually indistinguishable from normal urothelium.
In contrast, low-grade papillary urothelial carcinoma shows foci of
architectural disorder in the urothelial lining and more variable cyto-
logic features, such as scattered hyperchromatic cells.

Low Grade Papillary Urothelial Carcinoma

Low-grade papillary urothelial carcinoma (LGPUC) is more com-

mon in older men, and, although recurrence occurs in over half of
patients, disease progression and cancer-related mortality is rare
and occurs in <5% of patients. These tumors are typically well-­
visualized during cystoscopy and are comprised of long, slender
papillary cores that can show a greater degree of branching, as
well as fusion (Figs. 2.3, 2.4, and 2.5). The urothelial lining is
thickened, like PUNLMP; however, there are areas showing a loss
of polarity, resulting in a random distribution of urothelial cells

Fig. 2.3 Early papillary formation in low-grade papillary urothelial carci-

noma [H&E; medium power]
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 27

a b

c d

Fig. 2.4 Low-grade papillary urothelial carcinoma. (a) Low-grade papillary

urothelial carcinoma with central fibrovascular cores seen in cross section
[H&E; low power]. (b) Low-grade papillary urothelial carcinoma with cen-
tral fibrovascular core [H&E; medium power]. (c) Low-grade papillary uro-
thelial carcinoma with smooth and intact basement [H&E; medium power].
(d) Low-grade papillary urothelial carcinoma with complete absence of mat-
uration [H&E; high power]

from the basal layer to the surface. Additionally, there is mild

cytologic atypia, including subtle variations in nuclear size and
shape, minimal nuclear contour irregularity, slightly abnormal
chromatin distribution, and rare scattered hyperchromatic cells.
Overall, the urothelial lining will produce a low-power impres-
sion of monotony and may require scanning at higher magnifica-
tion to appreciate the atypia (Fig. 2.6). In contrast to high-grade
lesions, mitoses are rare and most often limited to the lower half
of the urothelial lining. Overall, low-grade papillary urothelial
carcinomas lack the nuclear pleomorphism, markedly irregular
nuclear contours, diffuse hyperchromasia, abundant mitotic
­figures, and prominent and irregular nucleoli that characterize the
atypia seen in high-grade urothelial carcinomas. On rare occa-
sions, superficial invasion into the lamina propria may be present
28 D. B. Allison et al.

Fig. 2.5 Areas with significant cautery artifact should be disregarded when
grading low-grade papillary urothelial carcinoma [H&E; high power]

a b

Fig. 2.6 Low-grade papillary urothelial carcinoma. (a) Low-grade papillary

urothelial carcinoma with bland nuclei [H&E; high power]. (b) Low-grade
papillary urothelial carcinoma with rare, scattered enlarged, and atypical
nuclei [H&E; high power]

and is characterized by the presence of irregular nests branching

off the basement membrane with an associative stromal response.
If muscularis propria invasion is present, most GU pathologists
consider these lesions to be high-grade urothelial carcinoma by
definition, underscoring the fact that the stage drives the progno-
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 29

a b

Fig. 2.7 Urothelial tract condyloma. (a) Urothelial tract condyloma with
central fibrovascular cores, mimicking the growth pattern of a papillary uro-
thelial lesion [H&E; low power]. (b) Urothelial tract condyloma with classic
HPV-related koilocytic atypia [H&E; high power]

Fig. 2.8 Urothelial tract condyloma showing nuclear positivity with a low-
risk HPV in situ hybridization probe [low-risk HPV in situ hybridization;
high power]

sis in this case. Of note, LGPUC can invade the muscularis muco-
sae and are still considered low grade lesions. Rarely, condyloma
accuminata can extend from the external genitalia into the urethra
and even into the bladder (Figs. 2.7 and 2.8). These lesions also
30 D. B. Allison et al.

display a papillary architecture with a thickened and disorganized

epithelial layer. In contrast to LGPUC or PUNLMP, condylomas
are lined by non-­keratinizing squamous epithelium and display
koilocytic atypia like that seen in low-grade squamous intraepi-
thelial lesions. Due to the difficulty in distinguishing non-keratin-
izing epithelium from urothelium in some cases, paying careful
attention to the nuclear features will result in the correct diagno-
sis.

Tumors with Inverted Growth Patterns

Inverted Urothelial Papilloma

Inverted urothelial papillomas are uncommon low-grade neo-

plasms that rarely recur and do not progress to higher grade or
stage tumors. These tumors are comprised of thin, serpiginous,
and anastomosing trabeculae that grow underneath a normal
­urothelial surface. These cords of tumor are surrounded by clearly
identifiable basement membrane material, are confined to the
lamina propria, and never extend into the muscularis propria.
Inverted urothelial papillomas contain peripherally palisading
basal cells that show a pattern of reverse polarization and, fre-
quent, centrally located spindled cells that may have a stellate
reticulum-like appearance. Cytologic atypia should be absent,
though occasional degenerative type changes may be present. In
some cases, there is a mixed exophytic and endophytic compo-
nent. In general, these tumors have a distinctive low-power
appearance, and a quick high-power search showing a lack of
atypia confirms the diagnosis.

I nverted PUNLMP and Low-Grade Papillary

Urothelial Carcinoma

Inverted PUNLMP shows a similar growth pattern to inverted

urothelial papillomas; however, these neoplasms, by definition,
contain areas of thickened urothelial growth resulting in expanded
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 31

endophytic nests. The urothelial cells lack cytologic atypia and

are otherwise indistinguishable from inverted urothelial papillo-
mas. When architectural distortion and subtle nuclear atypia is
present, a diagnosis of low-grade papillary urothelial carcinoma
should be made. Like inverted urothelial papillomas, these tumors
may show a mix of exophytic and inverted growth patterns. As a
result, it is important not to misinterpret the presence of tumor
cells within the lamina propria as invasion. See Chap. 3 for a dis-
cussion on the patterns of invasion commonly seen in urothelial
carcinomas.

Urine Cytology

Low-grade urothelial neoplasms (LGUN) have significant cyto-

morphologic overlap and cannot be practically distinguished from
one another in urinary tract cytology (UTC) specimens. Thus, the
term LGUN in urinary tract cytology refers to papilloma, papil-
lary urothelial neoplasm of low malignant potential (PUNLMP),
and low-grade papillary urothelial carcinoma (LGUC). Of these,
PUNLMP and LGUC are most commonly found in UTC speci-
mens.
In contrast to high-grade urothelial carcinoma and carcinoma
in situ cells, which tend to be discohesive and readily exfoliate
into the urinary tract, LGUN cells exfoliate less frequently. The
identification of LGUN cells in voided urine specimens is chal-
lenging due to their bland cytomorphology and rarity; however,
the detection of LGUN in voided urine specimens on ancillary
tests supports their natural exfoliation. LGUN lesions are most
frequently seen on washing/barbotage specimens, in which the
neoplastic cells are forcibly exfoliated from the urothelial lining.
LGUN cells tend to be present in tissue fragments rather than
as single discohesive cells, especially in voided urine specimens.
Neoplastic tissue fragments are usually difficult to distinguish
from normal urothelial lining fragments, except in rare instances
in which a fibrovascular stalk is present (Figs. 2.9 and 2.10. The
presence of a fibrovascular stalk is strongly suggestive of a papil-
lary urothelial neoplasm, and the absence of high-grade cytomor-
32 D. B. Allison et al.

a b

Fig. 2.9 Benign-appearing urothelial tissue fragments. (a) Benign-­appearing

urothelial tissue fragments in a patient with a negative cystoscopy. The frag-
ments lack fibrovascular cores, and in the absence of high-grade features,
they could represent benign urothelium or fragments of a low-grade urothelial
neoplasm [Pap stain; medium power]. (b) Benign-appearing urothelial tissue
fragment in a patient with papillary urothelial neoplasm of low malignant
potential (PUNLMP). The cells are monotonous and have bland chromatin.
Since the fragment lacks a fibrovascular core, it could represent benign uro-
thelium or a fragment from the PUNLMP [Pap stain; high power]

a b

Fig. 2.10 Papillary fragments in a specimen from a patient with papillary uro-
thelial neoplasm of low malignant potential (PUNLMP) on follow up. (a, b)
Papillary urothelial fragments in a patient with papillary urothelial neoplasm of
low malignant potential (PUNLMP). While it is likely these are PUNLMP frag-
ments, the absence of fibrovascular cores makes it difficult to distinguish these
from benign urothelial tissue fragments [Pap stain; high power]

phology further suggests LGUN rather than HGUC/CIS

(Figs. 2.11, 2.12, and 2.13). However, a non-representative sam-
ple may miss the high-grade component of a neoplasm containing
both low-­grade and high-grade components.
Cytomorphologically, LGUN cells are usually monomorphic,
with nuclei approximately 1.5 times the size of red blood cells,
regular nuclear borders, hypochromasia, and small nucleoli. The
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 33

a b

Fig. 2.11 Papillary fragments in a specimen from a patient with low-grade

urothelial neoplasm (LGUN) on follow up. (a) A papillary fragment with a
fibrovascular stalk can be seen, with numerous monotonous-appearing neo-
plastic cells in the background [Pap stain; low power]. (b) Low-grade urothe-
lial carcinoma (LGUC). These papillary fragments contain bland urothelial
cells and are connected by a thin vessel [Pap stain; high power]

a b

Fig. 2.12 Papillary fragments in a specimen from a patient with papillary

urothelial neoplasm of low malignant potential (PUNLMP) on follow up. (a)
A long vessel can be seen with numerous bland neoplastic cells attached.
PUNLMPs cannot be distinguished from low-grade urothelial carcinomas
(LGUCs) by cytology alone [Pap stain; low power]. (b) Papillary urothelial
neoplasm of low malignant potential (PUNLMP). The neoplastic cells are
similar in size and have bland chromatin and mostly regular nuclear contours
[Pap stain; high power]

N/C ratios of the cells are around 0.5. Tissue fragments may be
three-dimensional, causing difficulty in assessing these cyto-
morphologic features. In washing specimens, larger and more
numerous tissue fragments are often present, as well as single
cells that have been forcibly removed from these fragments by
the washing procedure. Single cells typically have an eccentri-
34 D. B. Allison et al.

a b

Fig. 2.13 Papillary fragments in a specimen from a patient with papillary

urothelial neoplasm of low malignant potential (PUNLMP) on follow up. (a,
b) A vessel can be seen running through these dark, three-­dimensional frag-
ments. The nuclei are difficult to see but are generally small; it is easier to
discern low N/C ratios at the tissue fragment edges [Pap stain; low power (a),
high power (b)]

Fig. 2.14 Cercariform cells from a patient with low-grade urothelial carci-
noma on follow up. Washing specimens may forcibly exfoliate individual
neoplastic cells from fragments, causing the formation of cytoplasmic tails.
This finding is not entirely specific for low-grade urothelial neoplasms and
can sometimes be seen in high-grade urothelial carcinoma [Pap stain; medium
power]
2 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 35

a b

Fig. 2.15 Cercariform cells derived from a papillary urothelial neoplasm of

low malignant potential (PUNLMP). (a, b) These cells have bland chromatin
and nuclei that are similar in size and shape. Features of high-grade urothelial
carcinoma are not identified [Pap stain; high power]

cally placed nucleus and cytoplasmic tails may be prominent

(Figs. 2.14 and 2.15).
In specimens with suspected LGUN, it is most important to
exclude HGUC/CIS. Even in specimens in which LGUN features
predominate, cells from a high-grade component or a separate
high-grade lesion may be present. A second population of atypical
cells distinctive from the monomorphic LGUN cells should raise
consideration for a diagnosis of AUC, SHGUC, or even HGUC,
using criteria discussed in the HGUC chapter.

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Urinary Tract Exfoliative
Cytology and Biopsy 3
Specimens: High-Grade
Urothelial Carcinoma

Derek B. Allison, Carla L. Ellis,

and Christopher J. VandenBussche

I ntroduction to High-Grade Urothelial

Carcinomas

Bladder cancer is one of the top ten most common cancers world-
wide and has a much higher incidence in men (3–4:1). Despite
representing less than half of all new bladder cancer diagnoses,
almost all cancer-related mortality from bladder cancer is due to
high-grade urothelial carcinoma (HGUC). Most superficially

D. B. Allison (*)
University of Kentucky College of Medicine, Lexington, KY, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 39

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_3
40 D. B. Allison et al.

invasive bladder cancer and, arguably, all of muscle invasive

­bladder cancer are due to HGUC. In general, HGUC is defined by
overt cytologic atypia and can be exophytic, flat, and endophytic,
or show mixed features. There are two forms of noninvasive dis-
ease: high-grade papillary urothelial carcinoma and a flat lesion
referred to as urothelial carcinoma in situ (CIS). Fortunately, most
patients with HGUC are diagnosed with noninvasive (Ta, Tis) or
superficially invasive (involving the lamina propria, T1) disease.
However, this disease often recurs, and one in five patients will
undergo stage progression, while one in eight will die of the dis-
ease. Ultimately, tumor stage is the most important prognostic
factor, and the biopsy results will determine how the patient is
managed; superficial disease is usually treated with intravesicular
therapy, while muscle invasive (T2) disease usually requires
definitive therapy (radical cystectomy or radiation) with or with-
out neoadjuvant chemotherapy. As a result, it is imperative to be
familiar with the common patterns of invasion and the common
pitfalls that result in pathologic over-staging.

 istology of High-Grade Urothelial

H
Carcinoma/Carcinoma In Situ

 oninvasive High-Grade Papillary Urothelial

N
Carcinoma

Noninvasive high-grade papillary urothelial carcinomas are gen-

erally large, exophytic lesions consisting of complex, branching
papillary projections that can fuse and produce a confluent growth
pattern. Occasionally, these tumors can display an inverted growth
pattern, as can also be seen in low-grade neoplasms (see Chap. 2)
or may colonize von Brunn nests (Fig. 3.1a, b), which can mimic
invasion. The architecture of the urothelial lining is markedly dis-
ordered with no evidence of a basal layer, polarity, or maturation.
Most cases show striking nuclear atypia, though some cases may
be relatively bland and show variable cytologic atypia that requires
inspection on high power. All HGUCs show nuclear hyperchro-
masia and most have coarse chromatin, nuclear enlargement (~5–
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 41

a b

Fig. 3.1 Patterns mimicking invasion. (a) Noninvasive HGUC colonizing a

von Brunn nest. Note that these foci are very well-circumscribed and have an
intact basement membrane [H&E; medium power]. (b) Note the well-­
circumscribed nests of tumor cells with an intact basement membrane and a
lack of irregular nests with jagged edges, fingerlike irregular projections, or
single individual cells within the lamina propria [H&E; low power]

6× the size of a lamina propria lymphocyte), significant nuclear

pleomorphism, irregular nuclear contours, variably prominent
nucleoli, and increased mitoses in all layers of the urothelium
(Fig. 3.2a–d).
Rarely, papillary urothelial carcinomas may show mixed fea-
tures of low- and high-grade cytologic atypia. If the high-grade
component comprises ≤5% of the overall cellularity, small data-­
sets suggest these tumors have a similar clinical follow-up as low-­
grade carcinomas. Although there is no consensus regarding this
scenario, a diagnosis of low-grade papillary urothelial carcinoma
with a minor high-grade component is acceptable and used by
many genitourinary pathologists. However, if the component is
>5%, there is consensus to grade these tumors as high-grade
lesions, similarly to how most carcinomas are graded based on the
highest-grade component.

Urothelial Carcinoma In Situ (CIS)

Urothelial CIS is often multifocal and can be difficult to distin-

guish on cystoscopy from areas of inflammation, both of which
are often red and velvety. As a result, these lesions are most often
42 D. B. Allison et al.

a b

c d

Fig. 3.2 Histologic features of HGUC. (a) Note the prominent papillary
architecture comprised of cells with increased N/C ratios, nuclear hyperchro-
masia, abundant mitoses, and significant apoptosis [H&E; medium power].
(b) Note the complete lack of maturation and the significant nuclear pleomor-
phism [H&E; high power]. (c) Note the solid growth pattern and the enlarged
nuclei with coarse chromatin, prominent nucleoli, mitoses distributed
throughout the field, and the presence of an atypical “tripolar” mitosis [H&E;
high power]. (d) Sheets of round to oval tumor cells with coarse chromatin
and markedly irregular nuclear contours [H&E; high power]

sampled via cold-cup biopsy. CIS is a flat lesion (lacking

­fibrovascular cores) defined by the presence of indisputable high-
grade cytologic atypia. Epithelial cell nuclei are often 5–6× the
size of a lamina propria lymphocyte, whereas normal urothelial
cell nuclei are generally only up to 2× the size of a neighboring
lymphocyte. CIS cells can be large and pleomorphic, large and
non-­pleomorphic, or comprised of non-neuroendocrine “small
cells” with significantly increased nuclear-to-cytoplasmic ratios
and other features of high-grade atypia, as discussed above
(Fig. 3.3a, b). CIS cells are extremely discohesive and, as a result,
denudation is common, and a single basal layer of CIS cells may
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 43

a b

c d

Fig. 3.3 Urothelial carcinoma in situ (CIS). (a) CIS nuclei >5× the size of
lymphocytes, irregular chromatin, and increased mitoses [H&E; high power].
(b) CIS displaying a lack of maturation, nuclear enlargement, and significant
hyperchromasia [H&E; high power]. (c) Note the discohesive nature of the
CIS with only a single layer of intact carcinoma displaying significant nuclear
enlargement and hyperchromasia [H&E; high power]. (d) CIS showing a pag-
etoid pattern of spread with an intact overlying umbrella cell layer [H&E;
high power]

be all that remains on biopsy (Fig. 3.3c). To this point, significant

denudation in the absence of diagnostic CIS should be mentioned
in the pathology report with a note recommending correlation
with urine cytology. CIS, however, can show several additional
patterns, including hyperplastic full-thickness urothelial involve-
ment, vaguely nodular growth patterns underlying or overlying
normal urothelium, a “clinging” morphology and pagetoid spread.
As a result, a superficial umbrella layer may remain intact and
should not dissuade from a diagnosis of CIS (Fig. 3.3d). The main
differential diagnosis with CIS is reactive atypia, which is usually
associated with a prominent intraepithelial inflammatory compo-
nent. Although both reactive lesions and CIS may contain intraep-
44 D. B. Allison et al.

ithelial inflammation, the presence of intraepithelial inflammation

should increase the threshold for a diagnosis of CIS. Reactive
atypia mimicking CIS consists of uniformly enlarged urothelial
cells that are roughly 3× the size of a lymphocyte, show a lack of
hyperchromasia, have smooth nuclear borders, and display prom-
inent nucleoli, which can be seen in both lesions. Unfortunately,
reactive urothelium may contain increased mitoses that can also
be found in the superficial portion of the urothelium; however,
atypical mitoses are diagnostic of a high-grade lesion.

Invasive High-Grade Urothelial Carcinoma

Once bladder cancer invades through the basement membrane, it

enters the lamina propria, which contains loose connective tissue,
vessels, and muscularis mucosae. Depending on the location in
the bladder, the proportions of these constituents change. For
example, the lamina propria is thinnest at the bladder neck and
trigone where the muscularis propria sits directly below the uro-
thelial mucosa, and is thickest at the dome. Within the lamina
propria, wisps of smooth muscle are usually present, in a discon-
tinuous or continuous pattern—forming a proper muscularis
mucosae. Occasionally, the muscularis mucosae may be hyper-
plastic and mimic the muscularis propria. Mildly thickened, hap-
hazardly arranged, and wavy muscle bundles in association with
larger caliber vessels and loose connective tissue favor muscularis
mucosae, while thick, compact bundles with the appearance of
“cracking” favor muscularis propria. Due to the importance of
proper staging, the presence or absence of muscularis propria
should be mentioned in all cases of urothelial carcinoma.
Urothelial carcinoma can show several different patterns of
invasion, as well as several different types of stromal responses.
For example, tumor can invade via single cells (microinvasion),
small clusters, irregular nests with jagged edges, or fingerlike
irregular projections (Fig. 3.4a–d). In some cases, the invasive
component may appear morphologically distinct from the overly-
ing urothelium and contain an increased amount of eosinophilic
cytoplasm, a process referred to as paradoxical differentiation.
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 45

a b

c d

Fig. 3.4 Invasive HGUC. (a) Note the small irregular and jagged nature of
the edges of tumor cells invading into the lamina propria with edema [H&E;
high power]. (b) Note the small nests and individual tumor cells invading into
the lamina propria with myxoid change [H&E; high power]. (c) HGUC infil-
trating through the wispy, haphazardly arranged muscularis mucosae of the
lamina propria [H&E; medium power]. (d) HGUC invading through thick
bundles of longitudinal and circumferential muscle, characteristic of the mus-
cularis propria [H&E; medium power]

Alternatively, it may show more striking cytologic atypia. The

stroma may appear desmoplastic, sclerotic, myxoid, or normal. In
other cases, the stroma can be inflammatory or pseudosarcoma-
tous, the latter can mimic sarcomatoid differentiation. Finally,
there may be a significant amount of retraction artifact, which can
mimic lymphovascular invasion (LVI). As a result, strict criteria
for LVI should be applied, which includes the presence of an
unequivocal endothelial lining (may require staining with D2-40
or CD31), tumor attached to the wall of a lumen with blood com-
ponents also noted in the lumen (i.e., neutrophils or red blood
cells), or tumor conforming to the shape of a vascular or lym-
phatic space. Importantly, these findings should be present at the
edges of the tumor and not simply intratumorally.
46 D. B. Allison et al.

Cytology of High-Grade Urothelial Carcinoma

In urinary tract cytology specimens, HGUC refers to urothelial

lesions with high-grade cytomorphology and most often corre-
sponds to HGUC and CIS. UTC cannot distinguish between CIS
and HGUC; furthermore, UTC cannot reliably determine the
presence or absence of invasion. Though some studies have inves-
tigated the cytomorphology of HGUC variants in UTC specimens,
in most instances, variants cannot be reliably identified and a
diagnosis of HGUC without further subclassification is sufficient.
The diagnosis of HGUC in UTC specimens has a high speci-
ficity and sensitivity. HGUC lesions in the upper tract (kidneys or
ureters) are more readily diagnosed in washing specimens as
compared to voided urine specimens. However, studies have not
definitively shown a superiority of washing specimens over
voided urine specimens in the detection of bladder HGUC.
HGUC cells can be quite pleomorphic, and while distinct cyto-
morphologic criteria for diagnosis has been developed by TPS
(Table 3.1), the majority of HGUC cells in a specimen may not
meet these criteria (Fig. 3.5a–c). In degenerated specimens,
HGUC cells are often altered in such a way that most and perhaps
all cells in a specimen may not meet TPS criteria (Fig. 3.5d). For
cells that do not meet the criteria of HGUC, but are concerning for
HGUC, indeterminate categories of TPS may be used (Table 3.1).
The greater threshold is recommended for making a diagnosis on
upper tract specimens, as a diagnosis of HGUC may result in a
definitive surgery without the need for a malignant diagnosis on
an intervening histologic biopsy specimen.
In general, HGUC cells tend to be discohesive, though they
may still form tissue fragments in both voided and washing UTC
specimens (Fig. 3.6a–d). The cytomorphologic features are easier
to assess in single cells, and the absence of single HGUC cells
should cause some hesitance in making an unequivocal diagnosis
of HGUC. HGUC cells are pleomorphic and have coarse/chunky
chromatin and increased N/C ratios (Fig. 3.7a, b). While some
cells have deceiving smooth, round nuclear borders, many cells
will demonstrate nuclear border irregularities (Fig. 3.8). Some
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 47

Table 3.1 TPS 2.0 diagnostic category criteria

Diagnostic category Summary of criteria
Unsatisfactory Voided urine specimens with low volumes and
instrumented urine specimens with low
numbers of urothelial cells
Any specimen with cells meeting the criteria of
AUC, SHGUC, HGUC, or other categories
should be placed in those categories
Negative for high-grade Adequate specimens containing only benign
urothelial carcinoma and nonneoplastic findings that do not meet the
(NHGUC) criteria for other diagnostic categories
Atypical urothelial cells Urothelial cells with increased nuclear-to-­
(AUC) cytoplasmic ratios (above ~0.5) and one form
of the following cytologic atypia:
 Hyperchromasia.
 Coarse/clumpy chromatin pattern.
 Irregular nuclear contours.
Suspicious for high-­ Urothelial cells with high nuclear-to-­
grade urothelial cytoplasmic ratios (above ~0.7) and two of the
carcinoma (SHGUC) following forms of cytologic atypia:
 Hyperchromasia.
 Coarse/clumpy chromatin pattern.
 Irregular nuclear contours.
High-grade urothelial Urothelial cells with high nuclear-to-­
carcinoma (HGUC) cytoplasmic ratios (above ~0.7) and two of the
following forms of cytologic atypia:
 Hyperchromasia.
 Coarse/clumpy chromatin pattern.
 Irregular nuclear contours.
Other The presence of atypical and/or malignant cells
that are not definitively of urothelial origin
Includes carcinoma cells with small cell,
squamous, and glandular differentiation
The atypical/malignant cells may represent a
secondary component of a urothelial carcinoma
48 D. B. Allison et al.

a b

c d

Fig. 3.5 Urine cytology in cases that may not meet TPS criteria for a defini-
tive diagnosis of HGUC. (a) In the center of the field, there is a markedly
atypical urothelial cell with significant nuclear hyperchromasia, nuclear
enlargement, and slightly irregular nuclear contours. However, note the low
N/C ratio which is closer to 0.5 than 0.7. Follow-up in this case showed
HGUC [Pap stain; high power]. (b) Three scattered atypical cells with sig-
nificant nuclear hyperchromasia and irregular nuclear contours but with N/C
ratios <0.7 [Pap stain; high power]. (c) Four markedly atypical cells with
significant nuclear hyperchromasia, irregular nuclear contours, and barely
perceptible coarse chromatin. Note that since at least one of these cells con-
tains an N/C ratio >0.7, this group of cells, which otherwise have similar
cytologic features, can all be counted when determining if this case should
best be interpreted as suspicious for HGUC or positive for HGUC [Pap stain;
high power]. (d) This field shows HGUC with significant degenerative fea-
tures, including multiple pyknotic forms, naked nuclei, and cytoplasmic vac-
uolization. These features may preclude a definitive diagnosis of HGUC [Pap
stain; high power]

cells may have condensed, pyknotic nuclei that appear “ink black”
and in which chromatin detail cannot be assessed (Fig. 3.9).
Nuclei are often enlarged and naked nuclei may be seen in the
background; naked nuclei can be assessed using the same criteria
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 49

a b

c d

Fig. 3.6 Tissue fragments of HGUC. (a) An atypical tissue fragment is pres-
ent, though note the small size of the nuclei and the lack of significant nuclear
hyperchromasia. In a washing specimen, it may be difficult to determine if
this fragment is lesional or an artifact. Despite meeting the criteria for HGUC
by TPS, this case showed HGUC on follow-up [Pap stain; high power]. (b) A
three-dimensional cluster of HGUC with significant nuclear atypia which is
more easily appreciable at the edge. Note the coarse chromatin and the prom-
inent nucleoli [Pap stain; high power]. (c) Tissue fragments and individual
single cells in a background of significant necrosis. In the middle of the field,
there is a “cell-in-cell” pattern, a finding that is often indicative of malignancy
[Pap stain; high power]. (d) Note the large tissue fragments and the presence
of vessels, perhaps suggesting a papillary growth pattern, which may not
always be seen in papillary HGUC by urine cytology. Note that it is the cyto-
logical atypia, however, that must be assessed to make a diagnosis according
to TPS [Pap stain; high power]

as intact cells, except for the N/C ratio (Fig. 3.10). Large, multi-
nucleated giant cells with atypical nuclei may be present and may
have cytomorphologic overlap with large, reactive umbrella cells
seen in benign specimens (Fig. 3.11a, b).
A subset of HGUC will have unusual features, which will be
discussed in greater detail in Chap. 4.
50 D. B. Allison et al.

a b

Fig. 3.7 (a) Note the enlarged markedly irregular nuclei showing hyperchro-
masia, contour irregularity, and coarse chromatin [Pap stain; high power]. (b)
In this case, there is a significant amount of nuclear pleomorphism, including
size and shape variation, as well as differences in the relative amounts of
nuclear hyperchromasia and coarse chromatin [Pap stain; high power]

a b

Fig. 3.8 (a) In some cases, the HGUC may be more monotonous with most
nuclei being round with relatively smooth nuclear contours. Note the diffuse
high N/C ratios and markedly irregular coarse chromatin [Pap stain; high
power]. (b) In other cases, the HGUC may display markedly irregular nuclear
contours and show more anisonucleosis [Pap stain; high power]
3 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 51

Fig. 3.9 Occasionally, HGUC may undergo pyknosis and show “ink black”
nuclei. This process may lower the N/C ratio and precludes evaluation of the
chromatin. In this field, however, there are scattered induvial HGUC cells
with coarse chromatin [Pap stain; high power]

Fig. 3.10 In the center of this field, there is an enlarged and naked nucleus
which is worrisome for HGUC. However, the major differential diagnosis for
this cell would be a degenerated cell infected with BK polyomavirus [Pap
stain; high power]
52 D. B. Allison et al.

Fig. 3.11 Large, multinucleated giant cells with atypical nuclei can be seen
in HGUC and can be very difficult to distinguish from degenerated umbrella
cells [Pap stain; high power]

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Urinary Tract Exfoliative
Cytology and Biopsy 4
Specimens: Other Urothelial
Tract Neoplasms

Derek B. Allison,
Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

The morphologic range of malignant neoplasms of the bladder is

diverse. For example, there are a number of specific histologic
variants of high-grade urothelial carcinoma (HGUC) that can be
challenging to recognize on biopsy and that are important for
clinical management. Furthermore, it is common to have primary
urothelial carcinomas with divergent differentiation, including

D. B. Allison (*)
University of Kentucky College of Medicine, Lexington, KY, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 57

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_4
58 D. B. Allison et al.

squamous, glandular, sarcomatoid, and small cell differentiation.

Additionally, there are several non-urothelial primary carcinomas
of the bladder, including pure squamous cell carcinoma and ade-
nocarcinoma. Finally, there are secondary malignant tumors that
can invade the bladder and, in some cases, mimic a primary lesion.
The focus of this chapter is to provide an overview of the most
common entities that are clinically relevant and that pose a diag-
nostic challenge on biopsy and cytology specimens of the bladder.

Common Variants/Divergent Differentiation

in High-Grade Urothelial Carcinoma

As previously discussed in Chap. 3, invasive HGUCs typically

arise from papillary, flat, or inverted lesions. Once these tumors
invade, they can display a variety of architectural patterns, includ-
ing infiltrative single cells, cords, variably sized nests, and sheets.
There are a few variant patterns, though, that are important to rec-
ognize because they either have clinical significance or are diffi-
cult to distinguish from a benign process. For example, the
micropapillary, plasmacytoid, and sarcomatoid variants predict
early regional and distant metastases and, as a result, are often
treated with neoadjuvant chemotherapy. On the other hand, the
nested and microcystic variants can be extremely bland and mimic
von Brunn nests and cystitis cystica, respectively. Additionally,
other variants worth mentioning include the highly aggressive
giant cell variant (pleomorphic giant cells must comprise at least
20% of tumor), the lipid-rich variant that usually presents at
higher stage (must comprise at least 10% of tumor), and the
lymphoepithelioma-­like variant (no accepted % of tumor require-
ment), which is not EBV-related. Based on limited data, the lym-
phoepithelioma-like variant appears to have a similar or slightly
better clinical course compared to conventional invasive urothe-
lial carcinoma (UC). Divergent differentiation is also fairly com-
mon in HGUCs. For example, as many as 40% and nearly 20% of
HGUCs may have some component of squamous and glandular
differentiation, respectively. Interestingly, small cell differentia-
tion is often seen in the presence of other divergent differentia-
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 59

tion. Moreover, trophoblastic and müllerian ­differentiation may

rarely occur. For all cases displaying a variant of HGUC or diver-
gent differentiation, a percent should be given to each histologic
component. The most common variants and forms of divergent
differentiation are discussed below in further detail.

Micropapillary

The micropapillary variant is a rare but well-recognized and

aggressive form of HGUC that is comprised of small nests of
tumor cells that lack fibrovascular cores, contain peripherally ori-
ented nuclei, and are often surrounded by retraction spaces. In
contrast to the stromal retraction that can be seen in conventional
infiltrating HGUC, single retraction spaces often contain multiple
aggregates of tumor cells in this variant (Fig. 4.1a). These spaces
may mimic lymphovascular invasion (LVI), though true LVI is
common and most of these patients present with high stage dis-
ease. The micropapillary variant usually arises in the background
of a conventional HGUC; however, any micropapillary percent-
age is clinically significant and should be reported. Given the
morphologic overlap between this variant and serous carcinoma
of the ovary, for example, identifying a conventional HGUC com-
ponent can be extremely helpful in ruling out a secondary malig-

a b

Fig. 4.1 Micropapillary urothelial carcinoma. (a) Small infiltrative nests of

tumors cells with peripherally located nuclei, a lack of fibrovascular cores,
and retraction spaces [H&E; high power]. (b) Small, three-dimensional
aggregates of HGUC cells with scalloped edges—findings that can be seen in
cases with micropapillary features on follow-up [Pap stain; high power]
60 D. B. Allison et al.

nancy. If necessary, the immunohistochemical (IHC) staining

pattern is similar to conventional HGUC in that it is generally
positive for GATA3, uroplakin II (specific but not sensitive), CK7,
CK20 (+/−), and p63. Urinary specimens from these patients may
contain a mixture of both conventional HGUC and cells with
micropapillary morphology. These cells typically form small,
three-dimensional fragments with scalloped edges (Fig. 4.1b).
Acinar and/or cribriform-like architecture may be present, as
well, resulting in a glandular appearance. Recognition of this dis-
tinctive morphology, or the recognition of conventional HGUC in
the background of a specimen, can help prevent concern for an
adenocarcinoma. Because many of the features can overlap with
conventional HGUC, it is not recommended (nor is it necessary)
to identify the micropapillary variant of HGUC on urine cytology
specimens.

Plasmacytoid

The plasmacytoid variant is a rare and aggressive entity character-

ized by the presence of single, infiltrating malignant cells with
plasmacytoid features, including eosinophilic cytoplasm with
eccentric round nuclei. Although it is named from its resemblance
to plasma cells, this variant often additionally displays cells with
a mix of rhabdoid and signet ring cell-like features (Fig. 4.2a).
Rarely, the signet ring cell-like component may show intracyto-
plasmic mucin; however, extracellular mucin should be absent, as
its presence would indicate divergent glandular differentiation.
Tumor cells may display a range of atypia from deceptively bland
to clearly malignant, but the most helpful feature should be its
diffusely infiltrative pattern. Interestingly, the stroma is classi-
cally described as being “loose” or edematous and with a myxoid
appearance (Fig. 4.2b). Most patients present at advanced stages
of disease and involvement of the peritoneal surfaces of the
abdominal cavity is not uncommon. A conventional UC compo-
nent is present in approximately half of cases, which can help
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 61

a b

Fig. 4.2 Plasmacytoid urothelial carcinoma. (a) Single infiltrating HGUC

cells with eosinophilic cytoplasm and eccentric nuclei are seen admixed with
signet ring cell-like cells, both of which are consistent with a diagnosis of the
plasmacytoid variant [H&E; high power]. (b) Note the infiltrating plasmacy-
toid urothelial carcinoma cells within this “loose” or edematous stroma,
which is a characteristic finding in this variant [H&E; high power]

confirm a primary lesion. The plasmacytoid variant has a similar

staining pattern as conventional UC with two exceptions: (1) the
plasma cell marker CD138 may be positive and (2) E-cadherin is
lost, similar to lobular carcinoma of the breast. Due to its associa-
tion with a higher rate of recurrence and death, any percentage of
a plasmacytoid UC should be mentioned in the report and is clini-
cally relevant.
Only rare case reports and small case series have reported the
morphology of the plasmacytoid variant in urinary cytology spec-
imens. Generally, the cells are reported to be discohesive and
plasmacytoid. Because conventional HGUC cells are also disco-
hesive and have eccentrically placed nuclei, it is unlikely that
plasmacytoid variant cells can be specifically identified in urinary
cytology. One report has shown that this variant is associated with
urinary tract specimens containing fewer malignant cells, on the
average, than with conventional HGUC. This may be due to the
highly infiltrative nature of this variant as seen in histologic spec-
imens (e.g., the cells migrate into the tissue and not into the lumen
of the bladder and subsequently, the urine). At this time, it is not
recommended, nor is it necessary, to report this variant in a urine
cytology specimen.
62 D. B. Allison et al.

Nested

Nested variant of HGUC is characterized by a proliferation of vari-

ably sized and irregularly distributed nests of tumor cells with
extremely bland cytology that undermine the urothelial surface
(Fig. 4.3a). The nests are typically small, are tightly packed, and

a b

c d

Fig. 4.3 (a) Lower power view of a widely muscle-invasive urothelial carci-
noma with nested and microcystic features. It’s the architectural pattern and
depth of invasion that is the clue to the diagnosis, rather than the degree of
cytologic atypia [H&E; low power]. (b) Irregularly distributed, variably sized
nests of extremely bland cells infiltrating deeply and diffusely within the
lamina propria. In this limited field, the only indication that this may repre-
sent tumor would be the lack of a lobular configuration, which is what one
would expect for von Brunn nests [H&E; medium power]. (c) Large nests of
bland tumor cells deep within the muscularis propria, which rules out non-
invasive urothelial carcinoma with an inverted growth pattern. These findings
are compatible with that which is seen in large nested variant [H&E; medium
power]. (d) Features of microcystic variant are seen in this field, comprised of
extremely bland but irregularly distributed infiltrating nests of tumor cells
with cystically dilated lumens lined by flattened urothelial cells. The major
differential is cystitis cystica; however, the deeply infiltrative and irregular
growth pattern distinguishes this variant from the benign mimic [H&E;
medium power]
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 63

may show an anastomosing and confluent growth pattern. This is

in contrast to von Brunn nests, which are comprised of rounded
nests with a lobular configuration. Desmoplasia, if present, may be
helpful but is often absent in the superficial component.
Additionally, the location of the bland nests can be incredibly help-
ful, as von Brunn nests should not be present deep in the lamina
propria or in smooth muscle. In fact, the nested variant tends to
show more cytologic atypia as the lesion infiltrates more deeply.
One can easily imagine how difficult of a diagnosis this can be on
a TURBT specimen, which lacks orientation in many of the pieces
of tissue, and on a cold cup biopsy, which may be too small, or too
superficial to assess the overall growth pattern and confluence of
the nests. Making matters worse, the nested pattern is most often
seen in isolation without adjacent, easily identifiable conventional
HGUC. Immunostaining with Ki-67 and p53 is generally unhelp-
ful and not recommended because the staining is variable and the
proliferation index can be extremely low and overlap with reactive
and benign proliferative lesions. As a result, a definitive diagnosis
may not be possible and clinical correlation as to whether a mass
was visualized on cystoscopy becomes important for suggesting
additional sampling. In some cases, the nests may be larger (large
nested variant) and may show microcystic change and tubule for-
mation (microcystic variant), which may bring cystitis cystica and
nephrogenic adenoma into the differential (Fig. 4.3b, c). The same
rules for distinguishing a von Brunn nest proliferation can be
applied to ruling out cystitis cystica; however, depending on the
sample, ruling out a nephrogenic adenoma can be difficult.
Features that favor a nephrogenic adenoma would include a mix of
coexisting tubules and papillary structures that are lined by a single
layer of cells which may be hobnailed. Positive immunostaining
with PAX8 and Napsin A can confirm the diagnosis of a nephro-
genic adenoma. Nested variant essentially has the same staining
pattern as conventional HGUC. Interestingly, although muscle-
invasive disease is common at presentation, when matched stage-
for-stage, nested variant has similar outcomes to those seen in
conventional HGUC. Overall, the nested variant indicates a worse
prognosis because of its presentation at higher stage, and this ter-
minology should only be applied to cases with a pure or predomi-
nant component of nested HGUC.
64 D. B. Allison et al.

Because this variant is based on architectural and not cytomor-

phologic change, there are no unique features in urinary tract
specimens.

Sarcomatoid

Sarcomatoid carcinoma is a highly aggressive variant that usually

presents at high stage and is defined as a tumor with elements of
epithelial and mesenchymal differentiation. Sarcomatoid variant
is often associated with a HGUC component and seen alongside
areas of squamous or glandular differentiation. Most commonly,
the sarcomatoid component is comprised of high-grade spindled
and pleomorphic cells, resembling an undifferentiated pleomor-
phic sarcoma (Fig. 4.4). Specific heterologous differentiation can
occur, such as osteosarcoma and chondrosarcoma, and if present,

Fig. 4.4 Sarcomatoid carcinoma comprised of pleomorphic cells with mark-

edly irregular nuclei and abundant dense, eosinophilic cytoplasm—at least
focally imparting a rhabdoid appearance [H&E; high power]
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 65

should be mentioned in the pathology report. IHC may show focal

staining with cytokeratin and, in some cases, GATA3 and p63 will
be retained. The main differential diagnosis is a pseudosarcoma-
tous stromal reaction (PSSR) that can be seen with invasive
HGUC. In contrast to sarcomatoid carcinoma, the atypical mesen-
chymal spindle cells of PSSR show a degenerative type of atypia,
a lack of mitotic activity, and a lack of infiltrative stromal growth
(i.e., simply surrounds the HGUC and does not form an expansile
mass).
The morphology of sarcomatoid HGUC in urinary tract speci-
mens has not been reported in the literature. In the author’s expe-
rience (CJV), urinary tract specimens from these patients often
contain deceivingly bland spindle cells with elongated cytoplas-
mic processes and granular cytoplasm. The cells can be seen sin-
gly as well as in fragments. In many instances, the cells are not
well preserved and have an indistinct chromatin pattern. Due to
the cells’ elongated cytoplasm, they have low N/C ratios. The
cells may resemble reparative/reactive endocervical cells, as seen
on cervical Pap test specimens. Conventional HGUC cells are not
necessarily seen in the background. Because this pattern is not
commonly seen in benign urinary tract specimens, the authors
recommend that spindle cell proliferations in urinary tract speci-
mens be diagnosed as at least “atypical.”

Squamous Differentiation

Squamous differentiation is extremely common and may be focal

or comprise a significant amount of the tumor histology. Due to
the “squamoid” appearance seen in many HGUCs, applying the
term “with squamous differentiation” should usually be limited to
cases with clear intercellular bridges or obvious keratinization
(Fig. 4.5a). The overall significance of squamous differentiation is
unclear; however, there is data that suggests that when present on
biopsy, it is associated with a higher stage and may be less
­responsive to radiation and chemotherapy. With the exception of
pure (100%) squamous cell carcinomas, there is no consensus, to
date, on what percent of a squamous component, if any, should
66 D. B. Allison et al.

a b

Fig. 4.5 Squamous differentiation. (a) In many cases, HGUC shows areas of
squamous differentiation in the form of easily visualized intercellular bridges
or overt keratinization [H&E; medium power]. (b) In the center, there is a
malignant cell with dense blue cytoplasm, characteristic of squamous differ-
entiation. However, also note the presence of conventional single HGUC cells
in the background. On follow-up, it was confirmed that this patient had a
HGUC with squamous differentiation [Pap stain; high power]

lead to differential clinical management. As a result, it is impor-

tant on a biopsy to search carefully for a component showing uro-
thelial differentiation, as any percentage would exclude a
diagnosis of primary (pure) squamous cell carcinoma, which is
generally treated differently. In addition, and for this reason, it is
not suggested to make a diagnosis of pure squamous cell carci-
noma of the bladder on biopsy alone, as bladder biopsies are usu-
ally superficial and limited, and components of an underlying
HGUC may not be present. In this instance, using the term “carci-
noma with squamous differentiation” (see below) is preferred.
In urinary cytology specimens, one component may predomi-
nate, or a mixture of two components may be seen (Fig. 4.5b).
Thus, urinary cytology is not entirely sensitive for detecting squa-
mous differentiation, as conventional HGUC with squamous dif-
ferentiation may be the only finding. When the squamous
component is present, the malignant squamous cells resemble
those seen in Pap test specimens with squamous cell carcinoma.
Cells with densely orange, pink, and/or blue cytoplasm can be
seen in fragments as well as dispersed single cells. “Clinging”
tumor diathesis may be seen, as necrotic debris is usually not well
preserved in urinary tract specimens. The cells are usually pleo-
morphic, with some round forms admixed together with highly
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 67

irregular shapes; some cells will have irregular and rigid cytoplas-
mic extensions. The malignant squamous cells usually have dark,
pyknotic nuclei, causing them to have paradoxically low N/C
ratios. The nuclei in some cells may only faintly stained, resulting
in so-called ghost nuclei. If a conventional HGUC component is
seen together with a squamous cell component, a diagnosis of
“HGUC with squamous differentiation” can be made. If only a
squamous component is seen, the differential diagnosis includes a
primary squamous cell carcinoma or an invasive/metastatic squa-
mous cell carcinoma from the anus, cervix, or lung. Therefore, in
this instance, it is recommended to use terminology such as “car-
cinoma with squamous differentiation.”

Glandular Differentiation

Glandular differentiation is not uncommonly seen and most often

resembles the histology of enteric type adenocarcinoma.
Additionally, the glandular component may be mucinous with
pools of extravasated mucin or comprised of signet ring cells
(Fig. 4.6a, b). It is important to note that the presence of scattered
pseudoglandular spaces in a urothelial carcinoma is not indicative
of glandular differentiation, but care should be taken to look care-
fully for areas that contain well-formed glandular structures and/
or signet ring cells. Well-formed glandular structures or signet
ring cells are required for the diagnosis. As with squamous dif-
ferentiation, it is very important to differentiate pure adenocarci-
noma of the bladder from HGUC with glandular differentiation,
and similarly, to avoid making the diagnosis of pure urothelial
adenocarcinoma on a biopsy alone. Enteric type glands typically
gain positivity with CDX2 and may lose GATA3. Limited data
suggests that HGUC with glandular differentiation may present at
higher stage and show decreased responsiveness to chemotherapy.
As more data is being collected, it is now recommended to include
the percent of glandular differentiation in the report.
Either component may be seen or predominate in cytology
specimens, though usually conventional HGUC cells are seen
along with discohesive malignant cells containing a mucinous
68 D. B. Allison et al.

a b

Fig. 4.6 Glandular differentiation. (a) A case of HGUC with areas, as shown,
with signet ring cell differentiation [H&E; high power]. (b) CDX2 highlights
the underlying signet ring cell component [CDX2 stain; high power]. (c)
Three-dimensional atypical glandular structure, which may indicate glandu-
lar differentiation in a HGUC, a primary adenocarcinoma of the bladder, or
secondary involvement of adenocarcinoma from a separate primary site. In
the absence of a conventional background component of HGUC, further
determination cannot be made on cytology alone [Pap stain; high power]

vacuole, which stains pink on the Pap stain. HGUC cells may
engulf each other, resulting in degenerated cells within malignant
cells; these degenerated cells may resemble mucinous vacuoles.
Additionally, some aggressive forms of HGUC may have intracy-
toplasmic lumina (ICLs) that may resemble mucinous vacuoles.
Three-dimensional atypical glandular structures (Fig. 4.6c) in a
background of HGUC likely indicate a HGUC with glandular dif-
ferentiation. When only the atypical glandular structures are seen,
the differential diagnosis includes an adenocarcinoma (primary to
the bladder, or the invasion or metastasis from outside the urinary
tract) as well as the micropapillary variant of HGUC (see above).
In these instances, a diagnosis in the “Other” category of TPS is
recommended, using terminology such as “carcinoma with glan-
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 69

dular features” or “carcinoma with glandular differentiation.” It is

acceptable that the micropapillary variant of HGUC may be diag-
nosed as such, given its very glandular appearance in urinary tract
specimens.

Small Cell Differentiation

Small cell carcinoma of the bladder is thought to arise from the

urothelium, even though only half of cases show a HGUC compo-
nent or other areas of divergent differentiation. Morphologically,
the small cell component is identical to that seen in other sites,
such as the lung, and is a histologic diagnosis. Briefly, small cell
carcinoma grows in diffuse sheets and is comprised of round cells
with scant cytoplasm and enlarged nuclei with hyperchromatic/
speckled chromatin, increased apoptosis, and frequent mitosis
(Fig. 4.7a, b). Geographic necrosis is common and virtually all
cases present as muscle-invasive disease. IHC is not required but
if performed, the tumor is typically positive for one or more neu-
roendocrine markers (INSM1, synaptophysin, chromogranin,
CD56). Unfortunately, site-specific markers, such as GATA3 and
uroplakin II, are usually lost. As a result, it is important to rule out
secondary involvement of small cell carcinoma from another site,
such as the prostate. Occasionally, small cell carcinoma of the
prostate will show ERG positivity, which can favor a prostatic
origin. However, most cases require clinical and radiographic cor-
relation. When present with a HGUC component, it is important
to mention the presence of any small cell differentiation since 2/3
of patients develop systemic metastases and 5-year survival is
extremely low. As a result, these patients may get treated with
systemic chemotherapy specific for small cell carcinoma.
In cytologic specimens, either the conventional HGUC compo-
nent or the small cell component may predominate. Occasionally,
both components may be seen in the same specimen, in which
case a diagnosis of “HGUC with small cell differentiation” may
be made. Small cell carcinoma usually presents as small-to-­
medium-sized fragments of malignant cells in a background of
dispersed malignant cells (Fig. 4.7c, d). The fragments may con-
70 D. B. Allison et al.

a b

c d

Fig. 4.7 Small cell differentiation. (a) Small cell differentiation in the blad-
der has the same characteristic features as in other primary sites, including
diffuse sheets and single cells with scant cytoplasm and enlarged nuclei with
speckled chromatin. These tumors show abundant mitotic activity, apoptotic
bodies, and geographic necrosis [H&E; high power]. (b) Small cell differen-
tiation is commonly seen alongside other types of divergent differentiation,
such as squamous differentiation [H&E; high power]. (c) In the center, note
that HGUC is present; however, at 3 and 9 o’clock, as well as scattered
throughout the field, a second population of small malignant cells can be seen
with increased N/C ratios, scant cytoplasm, and markedly irregular chroma-
tin, consistent with a component with small cell differentiation [Pap stain;
high power]. (d) Note the single dispersed and central aggregate of markedly
atypical small cells with scant cytoplasm, irregular nuclear contours, and
speckled chromatin, consistent with involvement by a small cell carcinoma
component. Characteristically, the background shows apoptosis and dead/
degenerating malignant cells [Pap stain; high power]

tain necrotic cells which appear as “blue blobs” on Pap stained

preparations; these “blue blobs” may also be seen dispersed in the
background and resemble degenerated neutrophils. “Blue blob”
cells maintain the size of viable small cell carcinoma cells but
lack a nucleus. Viable cells will have minimal cytoplasm, to the
extent that cytoplasm may not be readily visualized. The nuclei
are round and have powdery chromatin with a mixture of granule
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 71

sizes—the “salt and pepper” type chromatin associated with neu-

roendocrine differentiation. In urine specimens, granular necrosis
is often not present on the slide and nuclear molding is minimized.
The malignant cells may be mostly dispersed rather than found in
fragments; in such cases, the cells may seem to be inflammatory
mononuclear cells at low magnification. However, because lym-
phocytosis is an uncommon finding in cytologic preparations, an
impression of lymphocytosis at low magnification should suggest
the possibility of small cell carcinoma.
When a HGUC component is not identified, the malignant
cells may represent a primary small cell carcinoma, which is rare,
or, more commonly, small cell carcinoma arising from the pros-
tate. In the latter situation, patients typically have a history of
prostate cancer with subsequent treatment. Ancillary tests are not
particularly helpful in determining a site of origin. Furthermore,
small cell carcinoma should be identified by assessing cytomor-
phology rather than using ancillary tests. If a pure population of
small cell carcinoma is seen in a urinary tract specimen, TPS rec-
ommends using the diagnostic category of “Other” together with
terminology such as “carcinoma with small cell differentiation.”

 on-urothelial Primary Carcinomas

N
of the Bladder

Primary Squamous Cell Carcinoma

Primary squamous cell carcinoma (SqCC) of the bladder is

extremely rare and represents less than 3% of all bladder tumors.
Like urothelial carcinoma, primary SqCC of the bladder is associ-
ated with smoking and exposure to hazardous chemicals. However,
the main risk factor is actually chronic infection (i.e., Schistosoma
haematobium) and chronic irritation (i.e., long-term indwelling
catheterization). As a result, the incidence is much higher in coun-
tries where Schistosoma haematobium is endemic. Primary SqCC
of the bladder is typically preceded by keratinizing squamous
metaplasia secondary to persistent injury. Consequently, it is
important to recognize and diagnose this process on biopsy, as
72 D. B. Allison et al.

a b

c d

Fig. 4.8 Squamous cell carcinoma of the bladder. (a) Note the presence of
squamous cell carcinoma (SqCC) in situ on the left colliding with adjacent
benign urothelium on the right. Directly adjacent to the SqCC in situ was an
area of keratinizing metaplasia, which typically precedes primary SqCC of
the bladder [H&E; high power]. (b) Invasive SqCC with overlying SqCC in
situ. Note the desmoplastic stromal response in the lamina propria [H&E; low
power]. (c) SqCC with many malignant cells displaying overt keratinization
(deeply red to pink cytoplasm). Follow-up revealed a primary keratinizing
SqCC of the bladder [Pap stain; high power]. (d) Note the markedly atypical
cell with an increased N/C ratio, nuclear hyperchromasia, and the character-
istic orange cytoplasm that is commonly seen in SqCC [Pap stain; high
power]

these patients are at a higher risk of developing an invasive

SqCC. Primary SqCC of the bladder must be comprised com-
pletely of a squamous component with intercellular bridges and
keratinization (Fig. 4.8a, b). Concurrent foci of urothelial carci-
noma in situ may be present. As stated above, biopsy sampling
may be limited, rendering a diagnosis of pure SqCC difficult, and
clinical correlation can be extremely helpful. The presence of
coexisting Schistosoma haematobium eggs, keratinizing metapla-
sia, or squamous CIS suggests a primary process. In some circum-
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 73

stances, it may be prudent to indicate that a urothelial carcinoma

with extensive squamous differentiation cannot be entirely
excluded. Furthermore, clinical correlation is important in exclud-
ing secondary involvement of a SqCC from the anogenital tract,
which can infiltrate to the surface of the bladder and mimic a pri-
mary lesion. In certain circumstances, the performance of HR-­
HPV mRNA in situ hybridization may be helpful in confirming a
secondary process—as primary SqCCs of the bladder are typi-
cally not associated with HPV. Primary SqCC of the bladder typi-
cally presents at a higher stage of disease, and, as a result, is
associated with a worse prognosis compared to conventional
HGUC.
In most instances, primary squamous cell carcinoma in cytol-
ogy specimens cannot be distinguished from HGUC with squa-
mous differentiation or metastatic/invasive squamous cell
carcinoma arising outside the urinary tract (Fig. 4.8c, d). However,
extra-urinary squamous cell carcinomas are typically found in
patients with a known history of malignancy, such as a high stage
cervical squamous cell carcinoma. Squamous cell carcinomas
arising from the cervix or anus may be positive using ancillary
studies for HPV, such as HPV in situ hybridization or p16 immu-
nochemistry. Diffuse cytoplasmic and nuclear positivity for p16 is
strongly associated with HPV-related squamous cell carcinomas
arising from the cervix or anus. These tests may be performed on
cell block material or using additional cytologic preparations.
Primary squamous cell carcinomas and HGUC with squamous
differentiation are generally not positive for HPV, and thus, their
detection would largely exclude a squamous cell carcinoma aris-
ing in the urinary tract. Because HPV-related squamous cell car-
cinomas of the cervix may have decreased or lost HPV expression,
negative test results cannot entirely exclude a cervical or anal
squamous cell carcinoma. Regardless of the site of origin, the
cytomorphology is similar to that described above for the squa-
mous component of HGUC. According to TPS, such s­ pecimens
should be diagnosed under the “Other” category using terminol-
ogy such as “carcinoma with squamous differentiation.”
74 D. B. Allison et al.

Primary Adenocarcinomas

Primary adenocarcinoma of the bladder is extremely rare and is

defined as a purely glandular carcinoma, most commonly due to
persistent intestinal metaplasia as a result of bladder exstrophy,
obstruction, and chronic irritation. Unlike HGUC, primary ade-
nocarcinoma is more likely to present as unifocal disease. Like
glandular divergent differentiation in HGUC, primary adenocar-
cinomas may be of the enteric type and mucinous type or, most
commonly, show features of both (Fig. 4.9a–c). The enteric type

a b

Fig. 4.9 Adenocarcinoma of the bladder. (a) Primary adenocarcinoma of the

bladder with glandular and cribriform spaces filled with mucin and necrosis.
The morphology and immunoprofile are identical to that seen in the colon.
Clinical correlation is always required [H&E; high power]. (b) Primary ade-
nocarcinoma of the bladder with areas showing glands comprised of muci-
nous epithelium. In other areas, mucinous epithelium was present scattered in
pools of extracellular mucin, comprising a significant amount of tumor vol-
ume [H&E; high power]. (c) Urine cytology showing abundant mucin sec-
ondary to a mucinous adenocarcinoma involving the bladder [Pap stain;
medium power]
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 75

mimics colonic type adenocarcinoma both morphologically and

immunohistochemically, most commonly staining with CK20
and CDX2. Importantly, clinical correlation is required to rule
out secondary involvement of adenocarcinoma from the colon.
The mucinous type contains clusters of glandular cells floating
in extracellular mucin and may or may not be associated with
signet ring cells. Overall, primary adenocarcinoma of the blad-
der has a worse prognosis than conventional HGUC and is
treated with radical cystectomy with lymph node dissection.
Secondary involvement by other primaries, such as the cervix,
endometrium, or prostate, can easily be sorted out by IHC and
the morphologic appearance of the lesion undermining a com-
pletely benign urothelial surface. Furthermore, urachal adeno-
carcinomas resemble primary adenocarcinomas of the bladder
morphologically and immunophenotypically. They occur, on
average, a decade earlier than bladder adenocarcinoma and are
usually distinguished by the location of the mass, which is typi-
cally centered in the muscle of the dome or along the anterior
midline of the bladder. These may not extend to the surface of
the bladder and may extend, instead, into the retropubic space
and into the anterior abdominal wall. Overall, though, in many
cases, it may not be possible to distinguish a urachal adenocar-
cinoma from a primary bladder adenocarcinoma, particularly on
biopsy specimen, where the overall architecture cannot be
appreciated.
Primary adenocarcinoma in cytology specimens cannot be
reliably distinguished from HGUC with glandular differentia-
tion or many metastatic/invasive adenocarcinomas arising out-
side the urinary tract. In patients with a known aggressive
adenocarcinoma, involvement by the known malignancy should
be strongly considered over a new diagnosis of a primary blad-
der cancer. Additionally, the micropapillary variant of HGUC
may resemble an adenocarcinoma if conventional HGUC is not
present in the background (see above). According to TPS, ade-
nocarcinomas of unknown origin would be described using ter-
minology such as “carcinoma with glandular features” under the
“Other” category.
76 D. B. Allison et al.

 ther Rare Non-urothelial Tumors

O
and Secondary Malignancies

It is important to keep a broad differential when evaluating biopsy

samples from mass lesions in the bladder, entertaining the idea of
both primary non-urothelial tumors and secondary malignancies.
For example, nephrogenic adenoma (see Chap. 2), leiomyoma,
paraganglioma, inflammatory myofibroblastic tumors, and granu-
lar cell tumors can all occur as primary lesions in the bladder
(Fig. 4.10a, b). When present in this location, the morphologies
and immunophenotypes are identical to those seen in other loca-
tions. Furthermore, secondary malignancies can involve the blad-
der by secondary extension—such as from the prostate,
gynecologic tract, or colon—or may be the result of metastasis,
such as from the breast, stomach, lung, or kidney (Fig. 4.10c, d).
In this setting, clinical correlation and the use of IHC are crucial.
Invasive squamous cell carcinoma in urinary tract specimens
cannot be distinguished from HGUC with squamous cell differen-
tiation (in which the squamous component predominates) and pri-
mary squamous cell carcinoma. As discussed above, ancillary
studies for HPV (HPV ISH and/or p16 immunochemistry) can
indicate an extra-urinary site of origin when positive.
Prostate adenocarcinoma cells may exfoliate into the urinary
stream from the prostate or prostate cancer may invade into the
urinary tract. It is the most common extra-urinary malignancy to
be seen in urinary tract cytology specimens. Prostate adenocarci-
noma cells will usually form small-to-medium-sized fragments in
urinary tract specimens, though single cells may also be seen in
the background. The fragments usually form acinar or cribriform
structures. The cells usually have round nuclei and variable N/C
ratios (Fig. 4.11a, b). In some instances, the cells will retain their
cytoplasm, which may be abundant and have a foamy and/or gran-
ular quality. Prominent nucleoli may be seen, a feature rarely seen
in HGUC. Prostate adenocarcinomas with high N/C ratios and
coarse chromatin may closely resemble HGUC. Furthermore, rare
cases of HGUC may have prominent nucleoli and mimic prostate
adenocarcinoma. While patients usually have a history of
advanced stage prostate cancer by the time it involves the urinary
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 77

a b

c d

Fig. 4.10 (a) Granular cell tumor showing a diffusely infiltrative growth pat-
tern and comprised of relatively monomorphic cells with abundant eosino-
philic, granular cytoplasm, and small-to-medium-sized round nuclei.
Immunohistochemistry revealed S100, SOX10, and CD68 positivity [H&E;
low power]. (b) This TURBT revealed a spindle cell proliferation in a vari-
ably edematous and myxoid background with scattered lymphocytes and
plasma cells. In addition, the haphazard, variably fascicular growth pattern
and lack of overt cytologic atypia were consistent with an inflammatory myo-
fibroblastic tumor [H&E, medium power]. (c) In this field, poorly formed
glands with cells containing abundant amphophilic cytoplasm and prominent
nucleoli can be seen infiltrating through muscularis propria. In some cases, it
can be extremely difficult to differentiate a high-grade prostatic primary,
which can even mimic a surface component, from a primary bladder cancer.
As a result, it is important to keep a prostatic primary in the differential and
to have a low threshold for staining, especially in a sample taken from the
bladder neck [H&E; medium power]. (d) Metastatic ovarian serous carci-
noma to the bladder. Note the benign overlying urothelium. Otherwise, there
can be a significant amount of overlap between micropapillary urothelial car-
cinoma and serous carcinoma of the gynecologic tract. As a result, immuno-
histochemistry is extremely important in patients with a history of malignancy
[H&E; low power]

tract, many patients have a history of prostate cancer, and thus one
must absolutely exclude HGUC in all patients presenting with
hematuria.
78 D. B. Allison et al.

a b

Fig. 4.11 Prostate adenocarcinoma involving the urinary tract. (a) Medium-
sized fragment comprised of cells with finely granular cytoplasm, round
nuclei with crisp nuclear borders, and prominent nucleoli. Follow-up con-
firmed involvement of prostate adenocarcinoma in the bladder [Pap stain;
high power]. (b) Note the presence of a small aggregate, as well as single
individual cells with variable amounts of granular/foamy cytoplasm and
round nuclei with prominent nucleoli. Confirmatory immunostaining is
required to confirm a prostatic primary if there is enough material to make a
cell block [Pap stain; high power]

The presence of malignant cells predominantly in fragments,

especially with an acinar or cribriform architecture, prominent
nucleoli, and/or maintained N/C ratios, should cause consider-
ation for a prostate adenocarcinoma. Ideally, confirmatory immu-
nostains can be performed, where prostate cancer cells will be
positive for NKX3.1 (nuclear stain) and negative for GATA-3
(nuclear stain). The reverse is true for HGUC cells. If confirma-
tory immunostains cannot be performed, a diagnosis of “poorly
differentiated carcinoma” can be made in the “Other” category,
with a note explaining that the differential diagnosis includes
HGUC as well as prostate adenocarcinoma. In these rare instances,
it is wise to discuss the findings with the clinical team.
Rarely, renal cell carcinoma may be seen in urinary tract spec-
imens and is alternatively termed “drop mets.” Patients may pres-
ent with a renal mass that is not clearly localized to the renal
pelvis (which would favor a urothelial carcinoma) versus renal
cortex (which would favor a renal cell carcinoma). Voided urine
specimens may contain at least atypical cells, if not overly
­malignant cells, when an upper tract HGUC is present, but renal
4 Urinary Tract Exfoliative Cytology and Biopsy Specimens… 79

cell carcinoma cells typically do not enter the urinary stream

unless the tumor has invaded into the renal pelvis. The morphol-
ogy of renal cell carcinoma cells varies by subtype, but the most
commonly encountered types are clear cell renal cell carcinoma
as well as papillary renal cell carcinoma. The cells may appear as
small-to-medium-sized tissue fragments with papillary architec-
ture or even as single dispersed cells. The cells typically have low
N/C ratios compared to HGUC and have prominent nucleoli, a
feature not commonly seen in HGUC. The cells usually have
granular cytoplasm. These morphologic features overlap with
those of prostate adenocarcinoma, making the patient’s history
helpful—for instance, does the patient have a renal mass or a his-
tory of prostate or renal cell carcinoma?
Confirmatory immunostains can be helpful, with a panel that
includes PAX-8, NKX3.1, and GATA-3. Nuclear PAX-8 positiv-
ity would be expected in renal cell carcinoma but can also be seen
in some upper tract urothelial carcinomas. Nuclear GATA-3 posi-
tivity would favor HGUC and essentially exclude renal cell and
prostate adenocarcinoma. Melanoma cells can also have abundant
cytoplasm and prominent nucleoli; melanoma cells should dem-
onstrate nuclear positivity for SOX-10 and be negative for PAX-8,
NKX3.1, and GATA-3.
Adenocarcinomas from various sites may also metastasize to
the urinary tract and appear in urinary cytology specimens. These
are rare occurrences. The patient usually has a history of an
aggressive cancer and immunostains may be used to confirm a site
of origin (e.g., nuclear TTF-1 positivity in metastatic lung adeno-
carcinomas). Colorectal adenocarcinoma may directly invade into
the urinary tract and often has distinctive cytomorphologic fea-
tures (e.g., elongated, dark nuclei and abundant necrosis).
However, in the absence of a known extra-urinary malignancy,
one should be cautious in making the first diagnosis of such in a
urinary tract specimen alone. This can be suggested by using the
“Other” category along with terminology such as “carcinoma
with glandular differentiation” with a suggestion that “an extra-­
urinary site of origin cannot be excluded.”
80 D. B. Allison et al.

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Renal Fine Needle Aspiration
and Core Biopsy Specimens: 5
Renal Cell Carcinomas

Patrick C. Mullane, Sara Mustafa,

Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

Fine needle aspiration (FNA) and core biopsies can aid in the
management of select patients with renal lesions. The incidental
detection of renal masses continues to increase due to the

P. C. Mullane (*)
Emory University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]
S. Mustafa
Old Dominion Pathology Associates, Annandale, VA, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 85

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_5
86 P. C. Mullane et al.

expanded use of imaging studies. The management of some renal

masses, especially small lesions less than 5 cm, remains challeng-
ing as many of these tumors are either benign or clinically indo-
lent, and current imaging modalities are often unable to
satisfactorily identify clinically relevant tumors. Current American
Urologic Association (AUA) guidelines recommend considering
biopsy when a mass is suspected to be hematologic, metastatic,
inflammatory, or infectious, with preference of multiple core
biopsies over FNA. Additional indications include active surveil-
lance in patients with a previous diagnosis of renal cell carcinoma
(RCC), providing a histologic diagnosis in patients with suspected
advanced stage disease prior to initiation of systemic therapy, pro-
viding a histologic diagnosis in poor surgical candidates where
RCC is highly suspected prior to ablative therapy, and therapeutic
cyst aspiration.
Interpretation of core biopsies is similar to what is done for
larger resection specimens but is often more challenging due to
the limited amount of lesional material present on the biopsy,
which may preclude the use of immunohistochemical studies. In
addition, the limited sampling by core biopsy may preclude a
definitive diagnosis. Though we will focus on the characteristic
features of renal carcinomas in this chapter and nonrenal-derived
malignancies and benign entities in Chaps. 6 and 7, it should be
stated that the differential for most patients undergoing biopsy
includes malignant and benign neoplasms as well as nonneoplas-
tic findings.

Biopsy Technique and Imaging

Ultrasound- and CT-guided renal biopsies are the preferred meth-

ods for procuring renal specimens. Ultrasound-guided biopsies
can be performed more quickly and require less overhead than
CT-guided biopsies. However, CT-guided biopsies can target
areas inaccessible by ultrasound. When possible, rapid on-site
evaluation for adequacy of the specimen should be performed as
multiple passes may be required. FNA is preferably performed
first with a thin (23–25 gauge) needle, followed by a needle core
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 87

biopsy with a minimum number of two cores. Renal biopsies are

well tolerated and generally safe with few complications. The
most frequent complication is hematoma (4.9%). Other adverse
events include pain (1.2%), gross hematuria (1.0%), and pneumo-
thorax (0.6%). Tumor seeding of the needle tract is now thought
to be a rare to nonexistent occurrence.

Accuracy

Current rates of diagnostic biopsies range from 80% to 90%, with

repeat biopsy leading to a 80% diagnosis rate in patients with an
initial nondiagnostic biopsy. Risk factors for a nondiagnostic
biopsy include a lesion less than 4 cm, lesions with contrast
enhancement less than 20 Hounsfield units on CT, cystic tumors,
left-sided tumors, and skin-to-tumor distances of 10 cm or less.
Biopsies can accurately distinguish between benign and malig-
nant lesions with a sensitivity of 97.5–99.7% and specificity of
96.2–99.1%. Biopsies can also predict histologic subtype with
excellent precision; however, intratumoral heterogeneity and
sampling error may result in discordance between core biopsy and
final resection diagnosis. Despite this, reports of concordance
rates between histology subtype on biopsy and resection diagno-
sis are as high as 96%. Importantly, in patients with multiple renal
masses, the histologic type of one mass does not necessarily cor-
relate with that of the other lesions. Thus, in patients with multiple
renal masses undergoing renal biopsy, all lesions may need to be
sampled. False positives are uncommon but do remain a concern
for biopsy interpretation. Familiarity with normal renal elements
and benign changes on biopsies is therefore imperative for suc-
cessful cytologic assessment (see Chap. 7).

Renal Cell Carcinoma

Renal cell carcinoma (RCC) accounts for over 80% of all renal
malignancies in adults, and cytologic evaluation plays an increas-
ingly important role in their diagnosis and management. Such
88 P. C. Mullane et al.

minimally invasive sampling may be the only diagnostic option

for patients with advanced stage disease, poor surgical candidates,
and for those in which less invasive treatment options (radioabla-
tion, cryotherapy, embolization) are being considered. WHO/
ISUP grading should be performed when possible for clear cell
and papillary RCC, as neoplasm grade can dictate future manage-
ment decisions. However, grade concordance between biopsy and
subsequent resection can vary, with discordance likely secondary
to intratumoral heterogeneity.
The subtyping of these entities has changed with the increased
understanding of molecular alterations in these malignancies. We
discuss the major subtypes of RCC with emphasis on the most
common tumors and their salient differentiating features. It is
treacherous to distinguish between renal cortical carcinomas on
FNA material alone, and a definitive diagnosis typically requires
core biopsy material, often with immunohistochemical studies.
Cell block preparations often do not contain sufficient material to
allow immunohistochemical studies.

Clear Cell Renal Cell Carcinoma

Clear cell renal cell carcinoma (RCC) is the most common sub-
type of RCC, accounting for about 60–70% of all renal cortical
tumors. Though typically detected as a single mass, clear cell
RCC can present as multiple masses. Patients with the autosomal
dominant von Hippel-Lindau (VHL) disease, caused by germline
mutation of the VHL gene on chromosome 3p, frequently present
at a young age (mean 37 years) with multiple clear cell RCCs.

Cytomorphology

Nondiagnostic, bloody aspirates are common due to the vascular

nature of these lesions. Smears show cells with abundant clear to
eosinophilic cytoplasm (Figs. 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8,
and 5.9). Cytoplasmic vacuoles and hemosiderin pigment can be
present (Fig. 5.8). Nuclei are oval, with prominent nuclei
­(consistent with grade), and are eccentrically placed. Low-grade
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 89

Fig. 5.1 Clear cell renal cell carcinoma. This group of oncocytic cells is
evenly arranged in a small sheet and may resemble benign renal tubules.
However, these cells contain very large nucleoli and are in fact malignant
[Diff-Quik; low power]

a b

Fig. 5.2 Clear cell renal cell carcinoma. (a–c) At low magnification, three-­
dimensional fragments are seen. These fragments often contain vessels and
will therefore often appear papillary in nature [Diff-Quik; low power]
90 P. C. Mullane et al.

a b

c d

Fig. 5.3 Clear cell renal cell carcinoma. (a–d) The neoplastic cells may be
individually dispersed as well as attached to vessels. The cells contain vacu-
olated cytoplasm. However, these features can also be seen in other types of
renal cell carcinoma [Diff-Quik; intermediate power]

a b

Fig. 5.4 Clear cell renal cell carcinoma. (a, b) Note the distinct cytoplasmic
borders between the neoplastic cells and the finely vacuolated cytoplasm.
Such features are not found in benign renal cells [Diff-Quik; intermediate
power]

lesions have minimal nuclear atypia and can resemble distal renal
tubular cells, whereas high-grade lesions may appear sarcomatoid
or resemble metastatic high-grade adenocarcinomas (Figs. 5.10,
5.11, and 5.12). Due to the wide variations of morphology seen in
clear cell RCC, the presence of other benign or malignant cells
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 91

Fig. 5.5 Clear cell renal cell carcinoma. This fragment is three-dimensional
which makes the cytomorphology difficult to assess. The carcinoma cells can
be better appreciated along the top edges of the fragment [Diff-Quik; interme-
diate power]

a b

c d

Fig. 5.6 Clear cell renal cell carcinoma. (a–d) CCRCC cells may contain vari-
able amounts of vacuolated cytoplasm. In addition, vessels may be prominently
seen within a fragment – or not seen at all [Diff-Quik; intermediate power]
92 P. C. Mullane et al.

Fig. 5.7 Clear cell renal cell carcinoma. The cells have large amounts of
finely vacuolated cytoplasm. Note the nuclear pleomorphism and irregularities
in nuclear contours, as well as the enlarged nucleoli [Diff-Quik; high power]

a b

c d

Fig. 5.8 Clear cell renal cell carcinoma. (a–d) This CCRCC had cystic areas,
resulting in the presence of pigmented macrophages in the specimen. Some of
the malignant cells also contained cytoplasmic pigment. Pigment-­laden mac-
rophages and carcinoma cells are commonly seen in papillary renal cell carci-
noma, but this finding is not entirely specific [Diff-Quik; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 93

a b

Fig. 5.9 High-grade clear cell renal cell carcinoma. (a, b) The cells are large
and exhibit dramatic nuclear pleomorphism. Some cells contain large nuclei.
In cases such as these, the differential diagnosis is quite broad, and one should
be sure to exclude an extrarenal carcinoma or sarcoma, as well as urothelial
carcinoma, through clinicoradiologic correlation and immunohistochemical
studies [Diff-Quik; high power]

Fig. 5.10 Sarcomatoid renal cell carcinoma. High-grade renal cell carci-
noma may have a sarcomatoid appearance and resemble a high-grade sar-
coma. In this case, many of the malignant cells have a spindle shape and
enlarged, irregular nuclei with irregular, coarse chromatin [Diff-Quik; high
power]
94 P. C. Mullane et al.

a b

c d

Fig. 5.11 Clear cell renal cell carcinoma. (a–d) At intermediate magnifica-
tion on the Pap stain, the nuclei of renal cell carcinomas appear round and
uniform. As a pitfall, this CCRCC contained cytoplasmic pigment (a) and
fragments with papillary architecture (c) – two features typically associated
with papillary renal cell carcinoma [Pap stain; intermediate power]

Fig. 5.12 Clear cell renal cell carcinoma. Small fragments such as these are
difficult to subclassify. However, they are unlikely to represent benign renal
tubular cells given their greatly enlarged nucleoli, which appear red in this
particular specimen [Pap stain; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 95

Table 5.1 Cytomorphologic features that distinguish CCRCC cells from

benign cells
Cell type/lesion Distinguishing features vs. CCRCC
Benign tubular May predominate when lesions are not properly
cells sampled but do not result in hypercellular lesions
May resemble low-grade CCRCC due to the presence
of abundant cytoplasm; may have small nucleoli but
should not have prominent nucleoli
Typically seen as small cellular fragments
Macrophages May predominate in cystic lesions
Possess vacuolated cytoplasm that can mimic CCRCC
Nuclei may appear larger and pleomorphic, but some
will be seen with the classic “kidney bean” shape
Typically will contain cytoplasmic pigment
Will not form true tissue fragments and will be mostly
seen as dispersed cells, though clusters of macrophages
may give the impression of a tissue fragment
Adrenal cortical May demonstrate great cellularity if adrenal tissue is
cells inadvertently sampled
Vacuolated and/or granular cytoplasm may cause
morphologic overlap with low-grade CCRCC or
oncocytic neoplasms
Do not contain prominent/distinctive nucleoli
Naked nuclei in background of granular debris are
common in adrenal cortical smears
Benign renal cyst May contain rare atypical cells indistinguishable from
lining cells low-grade CCRCC
Typically only rare small fragments in a background of
cystic macrophages

may mimic CCRCC on FNA. Table 5.1 provides the main distin-
guishing features from the benign cells, which are often seen in
the background in renal FNA specimens.

Histomorphology

Not all clear cell RCCs have “clear cells” (i.e., clear, vacuolated
cytoplasm), and not all clear cell lesions are clear cell RCCs;
nonetheless, this nomenclature persists for this subtype of RCC
(Figs. 5.13 and 5.14). With that said, clear cell RCCs are c­ omposed
96 P. C. Mullane et al.

a b

c d

Fig. 5.13 Clear cell renal cell carcinoma. (a–d) Small tissue fragments of
renal cell carcinoma may be seen in cell block preparations as well as core
biopsy specimens. The presence of nested carcinoma cells with vacuolated
cytoplasm (a) is characteristic of CCRCC, though the limited nature of small
biopsy specimens often prevents a complete architectural assessment. Immu-
nohistochemistry may allow for a definitive diagnosis [H&E; intermediate
power]

of malignant cells, frequently with clear cytoplasm, arranged in a

myriad of architectural patterns: solid, alveolar, nested, acinar,
microcystic, and macrocystic. High-grade lesions may include
rhabdoid or sarcomatoid morphologies, with minimal or absent
clear cell morphology. A delicate, thin-walled fibrovascular net-
work is present in most lesions, giving a characteristic “chicken-
wire” appearance; very-high-grade or sarcomatoid areas will
often lose this characteristic feature. When the typical features of
clear cell RCC are absent, or when unusual morphologies are
observed, immunohistochemistry is helpful to confirm the diag-
nosis (see Table 5.2) (Figs. 5.15 and 5.16).
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 97

a b

c d

Fig. 5.14 Clear cell renal cell carcinoma. (a–d) Core biopsies may be frag-
mented and contain areas of blood (c). However, these biopsies clearly dem-
onstrate the presence of neoplastic cells and lack of normal renal parenchyma.
The cells have vacuolated cytoplasm and distinct cellular borders [H&E;
intermediate power]

Table 5.2 Immunohistochemical profile of renal cell carcinoma (Pax 8 is

positive in all RCC subtypes below)
RCC subtype Positive IHC Negative IHC
Clear cell CAIX CK7, CD117,
AMACR, 34BE12
Papillary CK7, AMACR CAIX, 34BE12
Chromophobe CK7 (cytoplasmic), CD117 CAIX
(membranous)
Clear cell CAIX (cuplike), CK7 (diffuse) CD117, AMACR,
tubulopapillary 34BE12
Collecting duct INI-1 retained OCT3/4, GATA-3
Medullary INI-1 lost, OCT3/4 GATA-3
MTSC Vimentin, CK7, 34BE12 CAIX
(variable)
MiTF-TFE TFE3/TFEB, cathepsin K, CK7, CD117 in t
translocation HMB-45 in t (6,11), AMACR (6,11), 34BE12
98 P. C. Mullane et al.

Fig. 5.15 Clear cell renal cell carcinoma. Renal cell carcinomas typically
express nuclear PAX-8 which can be useful in excluding metastatic processes
when necessary [PAX-8 immunohistochemical stain]

a b

Fig. 5.16 Clear cell renal cell carcinoma. (a, b) Carbonic anhydrase IX
(CAIX) is not specific to renal cell carcinoma but can help differentiate
between RCC subtypes. CCRCC typically demonstrates a diffuse, cytomem-
branous stain, whereas papillary renal cell carcinoma shows only focal stain-
ing. Chromophobe renal cell carcinoma typically lacks CAIX staining. Clear
cell papillary renal cell carcinoma usually demonstrates a diffuse “cuplike”
membranous staining pattern [CAIX immunohistochemical stain]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 99

Papillary Renal Cell Carcinoma

Papillary RCC is the second most common subtype of RCC,

accounting for 10–15% of RCCs. On histomorphology, papillary
RCCs can be further subtyped based on tumor grade into type 1
and type 2 lesions. The more common type 1 tumors are low
grade and carry an excellent prognosis.

Cytomorphology

Type 1 papillary RCC aspirates classically show cellular frag-

ments with papillary and/or tubular patterns (Figs. 5.17, 5.18, and
5.19). If no fibrovascular core is present, the cells may form small
fragments (Figs. 5.20, 5.21, 5.22, 5.23, 5.24, 5.25, and 5.26). The
neoplastic cells are usually uniform, with minimal nuclear atypia
and scant to moderate amount of cytoplasm, which may be vacu-
olated and mimic CCRCC. Due to their bland nature, they can
appear similar in morphology to benign tubular cells; in well-­
sampled lesions, the neoplastic fragments should be numerous

a b

Fig. 5.17 Papillary renal cell carcinoma. (a, b) While clear cell renal cell
carcinoma can demonstrate fragments with papillary architecture, cellular
PRCC specimens can demonstrate diffuse papillary architecture (a, b) not
seen in clear cell renal cell carcinoma. The papillary projections are better
developed and more bulbous appearing than those seen in clear cell renal cell
carcinoma [Diff-Quik; low power]
100 P. C. Mullane et al.

a b

c d

Fig. 5.18 Papillary renal cell carcinoma. (a–c) The first three panels show
features classically associated with PRCC: vacuolated macrophages, some
with pigment, together with papillary tissue fragments. Note the vacuolation
present in the neoplastic cells, a feature also seen in clear cell renal cell carci-
noma [Diff-Quik; intermediate power]. (d) A sheet of neoplastic cells from a
PRCC. The cells have enlarged nucleoli and are unlikely to represent benign
renal tubular cells. However, it is otherwise difficult to distinguish these cells
from clear cell renal cell carcinoma. Some vacuolated macrophages can be
seen intermingled between the neoplastic cells, however, which may be a
helpful clue [Diff-Quik; intermediate power]

(Fig. 5.27). Hemosiderin in the neoplastic cells as well as in dis-

persed background macrophages is not a common finding, but is
relatively specific when seen together with true papillary frag-
ments (Figs. 5.28, 5.29, 5.30, 5.31, 5.32, and 5.33). Type 2 papil-
lary RCCs show large cells with abundant granular cytoplasm that
can appear eosinophilic to deeply basophilic. The cells may have
pleomorphic and irregular nuclei with conspicuous nucleoli and
thus can resemble CCRCC cells. Diagnostic pitfalls in type I pap-
illary RCCs are that they can appear similar to oncocytoma and
distal tubular cells on FNA. However, the increased cellularity
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 101

a b

c d

Fig. 5.19 Papillary renal cell carcinoma. (a–d) These high power fields
show small fragments of carcinoma cells that contain vacuolated cytoplasm
and irregular nuclei. The nuclei are pleomorphic and large nucleoli. Clearly,
the cells are neoplastic and consistent with a renal cell carcinoma. However,
it would be difficult to definitively classify this as a clear cell renal cell carci-
noma or a papillary renal cell carcinoma using cytomorphologic features in
these fields alone [Diff-Quik; high power]

and identification of papillae favors papillary RCC. Glomeruli can

resemble papillary RCC but will have the characteristic peripheral
capillary loops. The high-grade cells of type 2 lesions can resem-
ble CCRCC and may be near impossible to distinguish on mor-
phology alone.

Histomorphology

Typically, these lesions will have a fibrous pseudocapsule and a

predominant papillary architecture with central fibrovascular
cores (Figs. 5.34, 5.35, 5.36, and 5.37). Segmental tubular and
102 P. C. Mullane et al.

Fig. 5.20 Papillary renal cell carcinoma, solid variant. The solid variant of
PRCC lacks true papillae and may demonstrate spherical structures such as
these on FNA [Diff-Quik; low power]

a b

Fig. 5.21 Papillary renal cell carcinoma, solid variant. (a, b) These fields
from a solid variant of PRCC demonstrate neoplastic cells attached to vessels
as well as singly dispersed in the background. The cells have vacuolated cyto-
plasm. This pattern overlaps with clear cell renal cell carcinoma [Diff-Quik;
low power]

solid patterns are common, so papillae may not be present on

FNA and/or core biopsy sampling. Type 2 tumors, on the other
hand, are less common but are high grade and carry a poor prog-
nosis. Histologically, type 1 tumors will be composed of papillae
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 103

a b

Fig. 5.22 Papillary renal cell carcinoma, solid variant. (a, b) These fields
show papillary fragments with bulbous/spherical projections. Some neoplas-
tic cells are epithelioid, while others appear spindled [Diff-Quik; intermedi-
ate power]

a b

Fig. 5.23 Papillary renal cell carcinoma, solid variant. (a, b) This carcinoma
formed complex three-dimensional structures that formed both acini as well
as papillary projections. While unusual, it is unclear whether any of these
features are specific to the solid variant of PRCC [Diff-Quik; intermediate
power]

a b

Fig. 5.24 Papillary renal cell carcinoma, solid variant. (a, b) The neoplastic
cells have varying degrees of vacuolated and magenta-colored cytoplasm
[Diff-Quik; high power]
104 P. C. Mullane et al.

Fig. 5.25 Papillary renal cell carcinoma, solid variant. This field mimics
clear cell renal cell carcinoma, in which vacuolated cells form nests sur-
rounded by vessels [Diff-Quik; high power]

a b

Fig. 5.26 Papillary renal cell carcinoma, solid variant. (a, b) These fields
demonstrate variation in cytoplasm quality and color among the neoplastic
cells. The appearance is unusual for most renal cell carcinomas and may raise
consideration for uncommon entities [Diff-Quik; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 105

Fig. 5.27 Papillary renal cell carcinoma. In this field, the neoplastic cells
appear monomorphic and form small fragments with fibrovascular cores.
Single neoplastic cells are in the background [Pap stain; low power]

a b

Fig. 5.28 Papillary renal cell carcinoma. (a, b) Neoplastic cells are loosely
cohesive and have eccentrically placed nuclei, some with cytoplasmic tails.
Histiocytes are also seen in the background [Pap stain; intermediate power]
106 P. C. Mullane et al.

Fig. 5.29 Papillary renal cell carcinoma. A sheet of neoplastic cells is seen
in a background of macrophages, some of which are hemosiderin-laden. Note
that distinct cytoplasmic boundaries can be seen, making this a nonspecific
feature for subclassifying renal cell carcinomas [Pap stain; intermediate
power]

a b

Fig. 5.30 Papillary renal cell carcinoma. (a, b) Finely vacuolated neoplastic
cells form fingerlike projections adjacent to thin-walled vessels. Green cyto-
plasmic pigment is seen; it can be difficult to determine whether some cells
are neoplastic or simply macrophages [Pap stain; intermediate power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 107

a b

Fig. 5.31 Papillary renal cell carcinoma. These fields demonstrate the archi-
tectural diversity of PRCC, with (a) showing three-dimensional sheets with
bulbous projections and (b) showing papillary projections [Pap stain; inter-
mediate power]

Fig. 5.32 Papillary renal cell carcinoma. The neoplastic cells are monomor-
phic but form papillary/acinar structures that would not be formed by benign
renal tubular cells. However, such structures may resemble glomeruli, some-
times sampled in FNA specimens [Pap stain; intermediate power]
108 P. C. Mullane et al.

a b

Fig. 5.33 Papillary renal cell carcinoma. (a, b) These fields show papillary
structures containing neoplastic cells with prominent nucleoli. This atypical
architecture as well as the prominent nucleoli suggests this is a neoplasm.
Otherwise, the neoplastic cells have round nuclei, regular nuclear borders,
and minimal pleomorphism [Pap stain; high power]

Fig. 5.34 Papillary renal cell carcinoma, core biopsy. PRCC cells line cores
containing finely vacuolated histiocytes [H&E; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 109

a b

Fig. 5.35 Papillary renal cell carcinoma, core biopsy. (a, b) When neoplastic
areas are well-represented in small biopsy material, distinctive papillary
architecture helps suggest the diagnosis [H&E; intermediate power]

a b

c d

Fig. 5.36 Papillary renal cell carcinoma, core biopsy. (a–d) Fields demon-
strating distinct papillary formations containing neoplastic cells and foamy
histiocytes [H&E; intermediate power]
110 P. C. Mullane et al.

Fig. 5.37 Papillary renal cell carcinoma, solid variant, core biopsy. The solid
variant of PRCC lacks distinctive papillary structures. This may cause some
resemblance to clear cell renal cell carcinoma [H&E; high power]

lined by a single layer of small, more uniform cells with scant

cytoplasm. Type 2 tumors will contain more atypical, high-grade
neoplastic cells with abundant eosinophilic cytoplasm that appear
pseudostratified and overcrowded on papillae. PRCC is typically
positive for CK7 and AMACR and negative for CAIX (Fig. 5.38).

Chromophobe RCC

The third most common subtype of RCC accounts for 3–5% of all
RCC and usually portends an excellent prognosis (mortality less
than 10% and a 5-year disease survival of greater than 90%). Most
tumors are detected incidentally. There is a slight male predomi-
nance and occasionally an association with Birt-Hogg-Dube syn-
drome. Sarcomatoid features and perinephric extension are
associated with worse outcomes.
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 111

a b

c d

Fig. 5.38 Papillary renal cell carcinoma. PRCC is typically positive for
CD10 (a, negative in clear cell papillary renal cell carcinoma), diffusely pos-
itive for AMACR (b, negative in clear cell renal cell carcinoma), and diffusely
positive for CK7 (c, negative in clear cell renal cell carcinoma). (d) MUC1
(EMA) is positive in a cytomembranous pattern in type 1 PRCC and is usu-
ally not expressed (or expressed weakly) in type 2 PRCC

Cytomorphology

Fine needle aspirates of chromophobe RCC show isolated cells

that may sometimes be in small fragments; the cells have thick,
well-defined cellular membranes. The cells are polygonal and
have abundant cytoplasm that may be vacuolated and range from
clear to granular and eosinophilic in consistency (Figs. 5.39, 5.40,
5.41, and 5.42). Well-defined cellular membranes can be seen and
are more apparent in small cellular fragments. The classic feature
of perinuclear clearing is not always present and thus cannot be
relied on to distinguish these cells from the oncocytic cells found
in other neoplasms. The nuclei are pleomorphic and wrinkled,
with irregular borders. Nuclear grooves and inclusions are occa-
sionally present, and binucleation is common.
112 P. C. Mullane et al.

a b

Fig. 5.39 Chromophobe renal cell carcinoma. (a, b) Chromophobe RCC

cells may look oncocytic on cytologic preparations and thus may mimic nor-
mal renal tubular cells or oncocytoma cells. However, nuclear atypia is usu-
ally seen – note in these fields the anisonucleosis and irregular nuclear shapes.
Distinct cytoplasmic borders can be seen and the cytoplasm on Diff-Quik
staining appears moth-eaten [Diff-Quik; intermediate power]

Fig. 5.40 Chromophobe renal cell carcinoma. Note the dramatic anisonucle-
osis as well as distinct nuclear contour irregularities [Diff-Quik; high power]

Chromophobe aspirate smears are less cohesive compared to

other subtypes of RCC, and thus the greatest mimic is oncocy-
toma, which also results in discohesive smears. For this reason,
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 113

a b

Fig. 5.41 Chromophobe renal cell carcinoma. (a, b) At higher magnifica-

tions, an intranuclear pseudoinclusion can be seen, as well as prominent
nucleoli [Diff-Quik; high power]

Fig. 5.42 Chromophobe renal cell carcinoma. On the Pap stain, anisonucle-
osis and prominent nucleoli can still be appreciated. The cytoplasm also has
a moth-eaten appearance but is less distinct than on the Diff-Quik stained
preparations. There is great variation in nuclear size which is not typically
seen in benign renal tubular cells or in oncocytoma [Pap stain; high power]

aspirates of chromophobe RCC and oncocytoma are most likely

to be diagnosed as “oncocytic neoplasms,” with both entities in
the differential diagnosis. The predominant cell of the eosino-
114 P. C. Mullane et al.

philic variant of chromophobe RCC contains densely granular

and eosinophilic cytoplasm, like that of oncocytoma, but careful
assessment for nuclear irregularities can aid in the correct diagno-
sis. The predominant cell of the classic type variant of chromo-
phobe RCC contains abundant clear-to-pale cytoplasm like that of
clear cell RCC. Again, fine attention to nuclear detail should help
distinguish these two subtypes.

Histomorphology

Chromophobe RCCs are typically solid tumors with occasional

areas of scarring. The characteristic histologic features of chro-
mophobe RCC are large, polygonal cells with abundant clear to
eosinophilic cytoplasm and distinct cellular borders (Fig. 5.43).
The “raisinoid” nuclei appear wrinkled with irregular nuclear
contours with occasional binucleation. Copious microvesicles fill
the cytoplasm, and can push cellular structures to the periphery,
resulting in the classic perinuclear halo. The eosinophilic variant
is composed predominantly of intensely eosinophilic cells; how-
ever, no prognostic difference exists between the classic and
eosinophilic variants.

a b

Fig. 5.43 Chromophobe renal cell carcinoma, cell block. (a, b) On the cell
block preparations, areas of perinuclear cytoplasmic clearing can be better
appreciated [H&E; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 115

 lear Cell Tubulopapillary Renal Cell Carcinoma

C
(CCPRCC)

A distinct subtype of RCC, CCPRCC, has an indolent course and

carries a favorable clinical diagnosis. Many cases are associated
with end-stage renal disease and both genders are affected equally.
Distinguishing CCPRCC from conventional CCRCC and papil-
lary RCC is therefore of clinical importance and may affect thera-
peutic management.

Cytomorphology

Fine needle aspirates will be hypocellular and frequently admixed

with blood and cystic components. Clusters of uniform cells with
clear cytoplasm are noted, and nuclei will typically be low grade
and eccentrically placed and have indistinct nucleoli (Figs. 5.44

Fig. 5.44 Clear cell papillary renal cell carcinoma. Clear cell papillary renal
cell carcinoma can have features of papillary renal cell carcinoma and clear
cell renal cell carcinoma [Diff-Quik; intermediate power]
116 P. C. Mullane et al.

Fig. 5.45 Clear cell papillary renal cell carcinoma. In FNA specimens, the
papillary architecture may be the most distinctive feature, resulting in strong
consideration for papillary RCC. Therefore, it can be difficult to exclude
CCPRCC when papillary architecture is present without the use of immuno-
histochemistry [Diff-Quik; high power]

and 5.45). The small, bland-appearing cells of CCPRCC with

clear cytoplasm and low-grade nuclei can appear similar to benign
tubular cells, CCRCC, and PRCC. Compared to benign tubular
cells, CCPRCC cell will be smaller, with more distinct cellular
borders and will lack the granular cytoplasm and prominent
nucleoli. CCPRCC aspirates are less cellular compared to
CCRCC, and the cells will appear much smaller in comparison.
Though papillary architecture is common is CCPRCC, PRCC will
show a predominance of papillae and small fragments containing
cells with more granular cytoplasm and intracytoplasmic hemo-
siderin. If the classic features of either PRCC or CCRCC are not
present diffusely throughout a cellular specimen, or a specimen
lacks hypercellularity, CCPRCC should always remain on the dif-
ferential diagnosis and cannot be excluded without ancillary stud-
ies, with core biopsies being much preferred over cell block
preparations for immunohistochemical studies.
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 117

a b

Fig. 5.46 Clear cell papillary renal cell carcinoma, core biopsy. (a, b)
CCPRCC may be difficult to identify on small biopsy specimens. One clue is
the presence of distinct cytoplasmic borders in a specimen with prominent
papillary architecture [H&E; intermediate power]

Histomorphology

The histologic architecture of these tumors is variable with tubu-

lar, acinar, papillary, nested, and cystic patterns in all reports. The
cells are low grade (WHO/ISUP grades I–II) with clear cytoplasm
(Fig. 5.46). The linearly arranged nuclei are characteristically ori-
ented at the apical aspect of the cell. There is no necrosis or peri-
nephric/vascular invasion. CCPRCC have a distinct
immunohistochemical profile which is also useful for separating
it from CCRCC and PRCC (see Table 5.2), with the basolateral
accentuation of staining with carbonic anhydrase 9 (CA-IX) in a
“cuplike” pattern as a particularly helpful clue (Figs. 5.47 and
5.48).

Collecting Duct Carcinoma

Cytomorphology

Collecting duct carcinoma aspirates are rarely seen on fine needle

aspiration, and thus their cytomorphologic features have only
been rarely described in the literature. CDC can have a dimorphic
pattern, with malignant epithelial and desmoplastic stromal
­components. A neutrophilic predominant inflammatory infiltrate
118 P. C. Mullane et al.

Fig. 5.47 Clear cell papillary renal cell carcinoma. CCPRCC is diffusely
positive for CK7, as is seen in papillary renal cell carcinoma [CK7 immuno-
histochemical stain]

is commonly seen. Fragments may form tubular or papillary con-

figurations.
Collecting duct carcinoma can resemble high-grade CCRCC,
PRCC, and upper tract urothelial cell carcinoma. The high-grade
cytologic features of CDC can be indistinguishable from a high-­
grade CCRCC, so immunohistochemistry is often needed to sepa-
rate the two (see Table 5.2). Sarcomatoid RCC can also have a
similar dimorphic pattern, but the spindled cells of CDC are
benign and lack the overtly malignant spindled component of sar-
comatoid RCC. Although CDC can form papillae-like PRCC, the
cells of PRCC are smaller and more uniform and lack the desmo-
plastic stromal collagen seen in CDC. CDC and upper tract UCC
can both occur in the pelvicalyceal system and can produce
­similarly appearing high-grade cells with papillary and tubular
patterns. However, the desmoplastic connective tissue is unlikely
to be found in UCC.
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 119

Fig. 5.48 Clear cell papillary renal cell carcinoma. CCPRCC demonstrates
cuplike positivity for CAIX rather than complete cytomembranous staining
for CAIX seen in clear cell RCC [CAIX immunohistochemical stain]

Histomorphology

Collecting duct carcinoma is a rare subtype of RCC that is highly

aggressive and arises from the collecting duct epithelium. These
tumors are located in the renal medulla and can extend into the
cortex and the pelvicalyceal system. They are frequently high-­
grade lesions with variable architecture that can include papillary,
tubular, acinar, and solid pattern morphology. The invasive tumor
cells will produce a marked desmoplastic stroma and inflamma-
tory response. The cells are high grade and mitotically active with
eosinophilic and vacuolated cytoplasm, pleomorphic nuclei, and
conspicuous nucleoli. Glandular architecture and intracytoplas-
mic mucin are occasionally observed.
120 P. C. Mullane et al.

Renal Medullary Carcinoma

Renal medullary carcinoma is a rare and aggressive cancer of the

kidney that originates from the terminal collecting ducts and most
frequently affects children and young adult (primarily male and
African American) patients with sickle cell trait or sickle cell
­disease. The average age of these patients is 21 years, and they
often present with disseminated disease at time of diagnosis with
a mean survival of 4 months.

Cytomorphology

Renal medullary carcinoma is rarely encountered on FNA, and its

cytomorphologic features have not been well described in the lit-
erature. Pleomorphic, large, and atypical tumor cells are found
predominantly in loosely cohesive groups, with occasional single
cells. Tumor cells show high nuclear-to-cytoplasmic ratio, and
irregular nuclear membranes with course chromatin and occa-
sional nucleoli are seen. The cytoplasm can be vacuolated or
dense. When vacuoles are present, they can result in eccentrically
placed nuclei with occasional nuclear indentation.
The high-grade and poorly differentiated tumor cells of renal
medullary carcinoma can appear similar to other high-grade car-
cinomas such as urothelial carcinoma, renal cell carcinoma, and
collecting duct carcinoma. Immunohistochemistry on cell block
preparations can be useful to differentiate, as renal medullary
carcinoma is negative for high-molecular-weight keratin, CD10,
and thrombomodulin. Due to the young age of these patients, a
Wilms tumor or malignant rhabdoid tumor could also be enter-
tained, though rhabdoid tumors are usually found in much
younger pediatric patients, and Wilms tumor should contain
some variation of the blastemal, epithelial, and mesenchymal
cellular components.
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 121

Histomorphology

The tumor is medullary based and frequently infiltrates into sinus

fat. Though a variety of growth patterns have been described, the
most common histologic pattern for these tumors is reticular or
cribriforming glands with diffuse areas of poorly differentiated,
high-grade cells. The stroma will be fibrotic or desmoplastic with
vascular proliferation and an inflammatory infiltrate.

Mucinous Tubular and Spindle Cell Carcinoma

Mucinous tubular and spindle cell carcinoma (MTSC) is a rare,

low-grade renal epithelial neoplasm. It occurs more commonly in
female patients and at a wide age range. It is usually asymptom-
atic and detected incidentally.

Cytomorphology

MTSC is rarely encountered on FNA and its cytomorphologic

features are not well-defined in the literature. Fine needle aspi-
rates are usually cellular with loosely cohesive oval-to-spindled
cells associated with abundant, metachromatic myxoid matrix
material. The cells can form sheets, tubules, or pseudo-papillary
structures (Figs. 5.49, 5.50, 5.51, 5.52, 5.53, 5.54, and 5.55).

a b

Fig. 5.49 Mucinous tubular and spindle cell carcinoma. (a, b) MTSC is
rarely seen on FNA but demonstrates a cellular population of monomorphic
neoplastic cells intermixed with magenta-colored matrix material, best seen
on the Diff-Quik stain [Diff-Quik; intermediate power]
122 P. C. Mullane et al.

Fig. 5.50 Mucinous tubular and spindle cell carcinoma. Unless high grade,
the nuclei seen in MTSC are oval-shaped and bland-appearing [Diff-Quik;
intermediate power]

Fig. 5.51 Mucinous tubular and spindle cell carcinoma. The wispy magenta-­
colored matrix can look similar to the matrix seen in pleomorphic adenoma of
the salivary gland [Diff-Quik; high power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 123

Fig. 5.52 Mucinous tubular and spindle cell carcinoma. Single neoplastic
cells may be seen embedded in the matrix material [Diff-Quik; high power]

Fig. 5.53 Mucinous tubular and spindle cell carcinoma. In this field, the
matrix material appears bubblier and thicker [Diff-Quik; high power]
124 P. C. Mullane et al.

a b

Fig. 5.54 Mucinous tubular and spindle cell carcinoma. (a, b) The matrix
material on Pap stain is more indistinct than seen on Diff-Quik. If the matrix
material is not recognized, the cellular fragments may look papillary and
cause consideration for papillary RCC as well as clear cell RCC [Pap stain;
intermediate and high power]

Fig. 5.55 High-grade mucinous tubular and spindle cell carcinoma. This is
an example of a rare high-grade MTSC. The nuclei are more pleomorphic
than seen in the previous examples of low-grade MTSC, and the matrix mate-
rial is minimal in this field. It would be difficult to recognize this as MTSC on
FNA, and the bubbly cytoplasm would likely raise the possibility of a clear
cell RCC [Diff-Quik; intermediate power]
5 Renal Fine Needle Aspiration and Core Biopsy Specimens… 125

Neoplastic cells are monotonous and medium sized with indis-

tinct cell borders with delicate cytoplasm and occasional cyto-
plasmic vacuolization. There is typically mild to moderate cellular
pleomorphism. Nuclei are uniform, with minimal contour irregu-
larity and conspicuous nucleoli.
The spindled cells of MTSCC will resemble the spindled cells
of sarcomatoid variant RCC, but the nuclei will be more monoto-
nous. PRCC can rarely contain predominantly bland spindle cells,
but lacks the amount of myxoid matrix material seen in
MTSC. Mucin-poor MTSCC variants have been described as a
potential pitfall.

Histomorphology

The tumor is characterized by the proliferation of small, com-

pressed, and elongated spindle cells arranged in tubules and sheets
within an abundant myxoid background that appears
­metachromatic after preparation. Scant stromal mucin with an
inflammatory cell presence is variably present. This lesion has a
favorable prognosis, though sarcomatoid variants have been
reported and may be associated with more aggressive behavior.
The myxoid background can show positivity for Alcian blue.

Translocation-Associated Renal Cell Carcinoma

The MiT family of translocation-associated RCCs are a discrete

type of renal carcinoma characterized by the fusion of gene TFE3
on chromosome locus Xp11.2. Xp11 translocation RCC repre-
sents around 40% of pediatric RCC but less than 5% of adult
RCC. Usually, these tumors are more aggressive in adults and
carry a worse clinical prognosis compared to pediatric patients.
126 P. C. Mullane et al.

Cytomorphology

The cytomorphology of this neoplasm has not been well described

in the literature. Fine needle aspirates are moderately to highly
cellular, with variably sized tissue fragments and isolated cells.
Papillary structures can be present with epithelial cells showing
indistinct cell borders with clear-to-eosinophilic and/or granular
cytoplasm. Round-to-oval nuclei with fine chromatin and con-
spicuous nucleoli are identified with occasional psammoma bod-
ies and hyaline nodules. In the absence of these more distinctive
features (psammoma bodies and hyaline nodules), the differential
diagnosis is broad and usually includes both PRCC and CRCC, as
well as other renal cortical neoplasms.

Histomorphology

The morphology of Xp11 translocation RCC overlaps with many

subtypes of RCC. Generally, clear cells arranged in a papillary or
nested growth patterns are seen. Occasionally, cells with more
granular and eosinophilic cytoplasm will be present. A biphasic
morphology with larger, epithelioid cells scattered among smaller,
more hyperchromatic cells arranged around hyalinized material
have also been described. Psammomatous calcification is fre-
quently present.

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Renal Fine Needle
Aspiration and Core Biopsy 6
Specimens: Urothelial
Carcinoma and Other
Nonrenal Malignancies

Patrick C. Mullane,
Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

The breadth of this chapter will focus on malignant neoplasms of

the urothelial tract and nonrenal-derived entities that can involve
the kidney parenchyma. With a few exceptions, nonneoplastic

P. C. Mullane (*)
Emory University School of Medicine, Atlanta, GA, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 129

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_6
130 P. C. Mullane et al.

entities will be covered in Chap. 7. Urothelial carcinoma can be

characterized by malignant transformation of transitional epithe-
lium. It can be exceptionally challenging diagnostically (particu-
larly by cytopathologic examination or small biopsy), as there are
numerous subtypes and divergent histologies in its histopatho-
logic spectrum.
In addition, urothelial carcinoma and nonrenal epithelial-­
derived neoplastic entities can affect the kidney. It is important to
be aware of some of the main entities that can occur, and not be
biased at the microscope by a “kidney biopsy” showing histologic
features atypical of being derived from renal epithelium and stain-
ing negatively for PAX8. This chapter will summarize the cytopa-
thology and corresponding small biopsy histomorphology of
urothelial carcinoma and some of the more common nonrenal
epithelium-derived entities involving the kidney.

Urothelial Carcinoma

Urothelial carcinoma can exist anywhere along the urothelial tract

where transitional epithelium exists. This includes the lining uro-
thelium beginning from the superior most aspect of the renal pel-
vis and extending to all lined sites inferior to this point and
terminating at the distal urethra. As such, urothelial neoplasia can
occur and be sampled (providing cytologic and small biopsy spec-
imens) at any point along this length. The cytologic, immunohis-
tochemical, and histologic features of urothelial carcinoma are
identical irrespective of location. However, some clinical and
pathophysiologic differences exist between the upper and lower
tracts that warrant individual discussion.
Upper tract urothelial carcinoma (UTUC) is any malignant
urothelial growth of the renal calyx, pelvis, or ureter. UTUC
accounts for approximately 5–10% of all urothelial tumors, with
most tumors located in the renal pelvis. UTUC frequently coin-
cides with urothelial carcinoma of the lower tract (LTUC) which
includes the urinary bladder and urethra. Hematuria is the most
common presenting symptom, followed by flank pain. Fifteen
percent of patients can be asymptomatic and diagnosed only after
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 131

incidental lesions are detected on imaging. The gold standard

imaging technique for diagnosis is the CT urogram, where
excreted contrast is used to highlight filling defects or obstruc-
tions of the urinary tract which are suggestive of an upper tract
tumor.
Like in the lower tract, UTUC can be flat (CIS), papillary, or
sessile, and although UTUC and bladder urothelial carcinoma
share many characteristics, certain distinct features of UTUC can
dictate diagnostic and treatment decisions. The muscularis pro-
pria of the upper tract is much thinner than that of the bladder,
increasing the risk of advanced spread of disease. Additionally,
due to the close proximity of the renal parenchyma to the renal
pelvis and proximal ureter, direct invasion into the kidney is more
likely.
UTUC lesions are also more likely to be high grade, represent-
ing about 70% of all tumors.
UTUC can be problematic clinically for it is difficult to surveil
and technically challenging to endoscopically biopsy and resect
the tumor. In fact, up to 25% of upper tract biopsies using ure-
teroscopy result in inadequate tissue for diagnosis. Despite these
limitations, upper tract biopsy and cytology usually forms the
basis for most of the clinical decision-making. The high rates of
recurrence, tumor multi-focality, and concurrent CIS in UTUC
tumors make nephroureterectomy (in which the kidney and ureter
are removed en bloc), the preferred treatment strategy for high-­
grade UTUC.
High-grade UTUC tend to be poorly formed lesions and can
often have an inverted growth pattern. The most common variant
morphology observed is squamous and glandular, though upper
tract lesions can show any of the same variant histologies as
described in the bladder.
Selective upper tract cytology, with urine or washings directly
sampled from the renal pelvis during ureteroscopy, is preferred
over voided cytology due to the higher sensitivity and lower rates
of false negatives. It may be difficult to determine whether a large
renal neoplasm seen on imaging is arising from the pelvis or the
cortex. In such an instance, FNA with core biopsy may be per-
formed rather than a selective urine cytology specimen. The pres-
132 P. C. Mullane et al.

ence of a squamous cell carcinoma component or a population of

discohesive malignant cells with cytoplasmic tails (described
further below) suggests the presence of a urothelial carcinoma
rather than a renal cortical neoplasm such as renal cell carci-
noma; immunohistochemical studies can help further elucidate
this.
Lower tract urothelial carcinoma comprises the remaining,
approximately 90% of urothelial lesions, and most of the above
discussion applies. Lesions of the bladder and urethra are ana-
tomically more accessible for sampling with a lower rate of non-
diagnostic biopsies. This and the well-formed muscularis propria
of the urinary bladder wall (detrusor muscle/muscularis propria)
allow for lesions of the bladder to be sampled at earlier stages of
invasion, most commonly pT2.

Benign Urothelial Tissue

The presence of only benign urothelial tissue on core biopsy

implies that the lesion seen on imaging studies was not sampled.
The corresponding FNA specimen may contain only blood or
scant benign renal elements due to the absence of a sampled
lesion. Benign urothelial tissue is essentially normal in appear-
ance and nonreactive or inflamed. It shows a normal thickness of
6–7 epithelial cell layers of cohesive cells with distinct retention
of the umbrella cell layer. The cells are uniform without enlarged
and/or hyperchromatic nuclei and mitotic figures are typically
absent. A distinct polarity from the basal layers to the umbrella
cell layer is maintained throughout. When used in specific situa-
tions, CK20 stains the umbrella cell layer only.

 ow-Grade Urothelial Neoplasia/Low-Grade

L
Papillary Urothelial Neoplasms

Usually associated with gross or microscopic hematuria, low-­

grade papillary urothelial carcinoma is a papillary lesion that
ranges in size but can be quite large. Because these lesions are
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 133

not invasive, they typically are identified on imaging studies as

based in the renal pelvis and therefore are not typically seen on
FNA or core biopsy. When sampled, their morphologies are sim-
ilar to those described in the Low-Grade Urothelial Neoplasia
chapter.

High-Grade Papillary Urothelial Carcinoma

Histomorphology

High-grade papillary urothelial carcinoma occurs at a mean age

of 65 with a wide range. The most important differences between
low- and high-grade papillary urothelial carcinoma (the main
entities in the differential diagnosis) are as follows: the urothe-
lium in high-grade papillary urothelial carcinoma is more likely
to be thickened, with distinct loss of polarity and occasional spin-
dling of cells. The cytology is mostly abnormal, with markedly
enlarged and hyperchromatic nuclei that stand out at low power
(Figs. 6.1 and 6.2). Occasionally prominent nucleoli can be pres-
ent, and mitotic activity is frequent in all layers of the urothe-
lium. Discohesion is frequent and umbrella cells are typically
absent.

a b

Fig. 6.1 High-grade urothelial carcinoma. (a) Carcinoma cells infiltrate

fibrous tissue. At this power, the nuclei are dark but are mostly round. Feature
of renal cell carcinoma, such as papillary architecture or clear cytoplasm, is
lacking [H&E; intermediate power]. (b) HGUC with plasmacytoid cytomor-
phology. The cells are dicohesive and pleomorphic. The nuclei are eccentri-
cally placed, giving an appearance similar to plasma cells [H&E; high power]
134 P. C. Mullane et al.

a b

Fig. 6.2 GATA-3 positivity in high-grade urothelial carcinoma. (a, b) Cells

of urothelial origin are typically diffusely positive for GATA-3 (nuclear stain-
ing), a finding not seen in renal cell carcinoma. PAX-8, a renal cell carcinoma
marker, can sometimes be positive in upper tract urothelial carcinomas and
cause a diagnostic pitfall [GATA-3 immunohistochemical stain (a and b);
high power]

Cytomorphology

On FNA, HGUC lesions typically yield cellular specimens con-

taining both tissue fragments and dispersed single cells (Figs. 6.3,
6.4, 6.5, 6.6, 6.7, and 6.8). The cells and their nuclei are enlarged
and usually demonstrate the coarse/clumpy chromatin appearance
seen in HGUC cells from urinary tract cytology specimens.
Because the cells are freshly obtained, they are better preserved
and do not demonstrate the same degeneration as seen in urinary
tract cytology specimens. The nuclei may be round with minimal
nuclear contour irregularities in some carcinomas, which nuclear
pleomorphism may be dramatic in others (Fig. 6.8). Prominent
cellular discohesion is a common feature, with the malignant cells
having eccentrically placed nuclei (Fig. 6.5). Cercariform cells
may also be seen, in which the cells possess cytoplasmic exten-
sions; this feature is often also preserved in metastatic HGUC and
can provide a clue to the cells’ origin (Figs. 6.6 and 6.7).
HGUC first diagnosed by FNA are typically large and advanced
lesions. In such lesions, squamous differentiation with keratiniza-
tion may occur. If only these areas are sampled, the findings are
similar to squamous cell carcinoma (described below), which
rarely occurs as a primary (pure) malignancy in the upper tract.
Included in the differential diagnosis is metastatic squamous cell
carcinoma which is very rarely seen in the upper urinary tract.
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 135

Fig. 6.3 High-grade urothelial carcinoma. The malignant cells form a large
fragment and rare discohesive cells are seen in the background. The cells have
high nuclear-to-cytoplasmic ratios with anisonucleosis [Diff-Quik; interme-
diate power]

Fig. 6.4 High-grade urothelial carcinoma with necrosis. The malignant cells
have great variation in nuclear size and shape. Numerous inflammatory cells
are present secondary to tumor necrosis [Pap stain; high power]
136 P. C. Mullane et al.

a b

Fig. 6.5 High-grade urothelial carcinoma. (a, b) This carcinoma’s cells were
predominantly discohesive. Many have plasmacytoid forms and some are
multinucleated [Diff-Quik; high power]

a b

Fig. 6.6 High-grade urothelial carcinoma. (a, b) The presence of numerous

malignant single cells with cytoplasmic tails (cercariform cells) strongly sug-
gests a urothelial origin [Pap stain; high power]

Squamous Cell Carcinoma

Squamous cell carcinoma of the renal collecting system repre-

sents less than 1% of all renal tumors, but 10–20% of pelvic
tumors. The characteristic risk factor is persistent ureteral calculi,
resulting in chronic irritation of the urothelium leading to malig-
nant change. Smoking and other risk factors of pure squamous
cell carcinoma of the urothelial tract apply, particularly in lower
tract lesions. Patients can present with signs and symptoms of uri-
nary obstruction: nausea, vomiting, flank pain, hematuria, fevers/
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 137

Fig. 6.7 High-grade urothelial carcinoma. Cercariform cells may overlap

with the spindled morphology seen in high-grade sarcomatoid renal cell car-
cinomas. However, high-grade urothelial carcinoma may also have a sarco-
matoid appearance [Diff-Quik; high power]

a b

Fig. 6.8 High-grade urothelial carcinoma. (a, b) HGUC can occasionally

demonstrate three-dimensional fragments containing cells with highly pleo-
morphic nuclei. Such morphology may cause concern for a poorly differenti-
ated renal cell carcinoma or involvement by an extrarenal malignancy
[Diff-Quik; high power]
138 P. C. Mullane et al.

chills, and chronic urinary tract infections. Urine cytology, either

voided or collected at time of endoscopy, may show pleomorphic
squamous cells admixed with reactive urothelial cells.

Histomorphology

Pure squamous cell carcinoma of the urinary tract is largely anal-

ogous to squamous cell carcinoma in other sites with one impor-
tant exception, particularly with regard to limited sampling
(Figs. 6.9 and 6.10). Urothelial carcinoma can frequently have
divergent differentiation, most commonly squamous. Limited
biopsy may only sample the squamous differentiation at superfi-
cial surface leaving underlying urothelial carcinoma unsampled.
In addition, many immunohistochemical stains have overlapping
positivity for squamous and urothelial origin, rendering immuno-

Fig. 6.9 Carcinoma with squamous differentiation. Infiltrating squamous

cell carcinoma on renal biopsy often indicates the sampling of a high-grade
urothelial carcinoma with squamous differentiation [H&E; intermediate
power]
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 139

a b

Fig. 6.10 Carcinoma with squamous differentiation. (a, b) Because pure

squamous cell carcinoma of the upper urinary tract is rare, limited biopsies
may require a descriptive diagnosis with an explanatory note

histochemical differentiation between pure squamous cell carci-

noma and urothelial carcinoma difficult.

Cytomorphology

Fine needle aspirates show occasional clusters and scattered pleo-

morphic squamous cells with dense cytoplasm, hyperchromatic
nuclei with irregular contours, course chromatin, and absent to
inconspicuous nucleoli (Figs. 6.11, 6.12, 6.13, and 6.14).
Occasional tadpole cells can be seen, as well as hemorrhagic and
necrotic background. In most instances, these findings represent
the sampling of the squamous component of a high-grade urothe-
lial carcinoma and are best reported as “carcinoma with squamous
differentiation.”

Lymphoma

Lymphoproliferative disorders of the kidney are not unusual.

Most lymphomas involving the kidney will be secondary renal
lymphoma, occurring in the setting of systemic disease and likely
detected after CT surveillance imaging studies. Primary l­ ymphoma
affecting only the kidney is rare, but can occur in specific popula-
tions, notably posttransplant patients. Imaging characteristics
140 P. C. Mullane et al.

Fig. 6.11 Carcinoma with squamous differentiation. The findings are similar
to those seen on the FNA of squamous lesions elsewhere in the body. In the
absence of keratinization, it may be difficult to identify the squamous differ-
entiation, given the expectation of finding either a urothelial or renal cell car-
cinoma [Diff-Quik; intermediate power]

include hypovascular tumors, and patients may develop progres-

sive renal failure if the disease burden is significant. Due to the
wide differential on imaging, which includes infectious processes,
metastasis, urothelial carcinoma, and hypovascular RCC, tissue
diagnosis is often required for clinical management. Even if the
patient has a known diagnosis of lymphoma, it is still often neces-
sary to biopsy the kidney to rule out other causes as their preferred
treatment strategies are quite different. Renal lymphoma tends to
be high grade and aggressive, with large B-cell lymphoma most
frequently reported. Other high-grade tumors include Burkitt
lymphoma and ALL. Low-grade tumors that have been reported
include marginal cell lymphoma, CLL/SLL, and follicular
­lymphoma.
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 141

Fig. 6.12 Carcinoma with squamous differentiation. A small fragment of

carcinoma cells is seen in a background of necrosis. The cells have dense
cytoplasm that appears “Robin’s egg blue” due to the keratinization, which
will appear red or orange in the corresponding Pap stained preparation [Diff-­
Quik; high power]

a b

Fig. 6.13 Carcinoma with squamous differentiation. (a, b) The carcinoma

cells are singly dispersed within a necrotic background. The cells have dense,
red-staining cytoplasm and faintly staining nuclei [Pap stain; high magnifica-
tion]
142 P. C. Mullane et al.

Fig. 6.14 Diffuse large B-cell lymphoma. The lymphoid nature of these
cells is suggested by the condensed blue rim of cytoplasm seen most promi-
nently in the larger cells [Diff-Quik; high power]

Histomorphology

In addition to urothelial carcinoma, the main differential for lym-

phoid aggregates on small biopsy is lymphoepithelioma-like car-
cinoma and large cell lymphoma. It is crucial to have a low index
of suspicion and be aware of the clinical history in either entity.
Immunohistochemical studies (see Table 6.1) can be very helpful
in the distinction between those entities and any renal- or urothe-
lial-derived entities. Large cell lymphoma shows nests or sheets
of cells with large nuclei and multiple nucleoli. It usually lacks
CIS or usual urothelial carcinoma, whereas lymphoepithelioma-
like carcinoma can share cytologic features with lymphoma but
may have associated CIS or associated usually infiltrating urothe-
lial carcinoma.
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 143

Table 6.1 Varying immunohistochemical staining patterns for urothelial

carcinoma, lymphoepithelioma-like carcinoma, and large cell lymphoma
IHC Urothelial Lymphoepithelioma-­
stains carcinoma like carcinoma Large cell lymphoma
Keratins Positive Positive Negative
CD45 Negative Negative Positive
EBV Negative Negative + if associated
immunosuppression
GATA-3 Positive Negative Negative

a b

Fig. 6.15 Wilms tumor. (a, b) The field is filled with numerous small cells
with high nuclear-to-cytoplasmic ratios. The morphology may resemble other
small round blue cell tumors. The diagnosis is often already suggested by the
clinicoradiologic impression [Pap stain (a) and Diff-Quik (b); high power]

Cytomorphology

Fine needle aspirates and cytology specimens can show discohe-

sive and/or monotonous populations of atypical lymphoid cells.
Rare epithelial-like clustering of the atypical lymphoid cells can
be present.
Necrosis and lymphoglandular bodies (anucleate aggregations
of cytoplasm from neoplastic lymphocytes) are more commonly
observed in high-grade tumors. Smears for large cell type lesions
will feature cells with abundant cytoplasm, large nuclei with con-
spicuous nucleoli, and fine chromatin (Fig. 6.15). Small cell type
lesions will feature cells with minimal cytoplasm and small nuclei
with more course and dense chromatin. Normal renal components
are scant. Cell population from low-grade tumors can be indistin-
144 P. C. Mullane et al.

guishable from normal lymphocytes. In these instances, the use of

flow cytometry is critical to identify an atypical clonal population
of lymphocytes.
Inflammatory processes and some epithelial neoplasms will
possess abundant lymphocytes which can appear monotonous.
These reactive lymphocytes, however, should be more
polymorphous without significant nuclear atypia and contain
­
other inflammatory cell types like neutrophils and plasma cells.
Demonstration of a clonal population either through immunohis-
tochemistry or flow analysis is often necessary for a final diagno-
sis.

Wilms Tumor

Also known as nephroblastoma, Wilms tumor is a distinctive

pediatric tumor with 90% of tumors diagnosed before the age of
6. A palpable abdominal mass is often reported and can be accom-
panied by hypertension, proteinuria, or hematuria. Imaging of
nephroblastoma shows a solid, mostly intrarenal mass with archi-
tectural distortion of the collecting system. The etiology is largely
unknown aside from genetic with dysmorphic syndromes like
WAGR and Denys-Drash. Wilms tumors are WT-1 positive.
Epithelial components are positive for cytokeratins. Clinical his-
tory is crucial in the differential between renal/urothelial carci-
noma and this entity.
Given that imaging studies can reliably identify most Wilms
tumors, FNA and other small biopsies are not usually performed
on Wilms tumor.

Histomorphology

These tumors recapitulate renal embryogenesis and will contain

the three major components of undifferentiated blastemal tissue,
mesenchymal tissue, and epithelial tissue. The ratio of the three
components can vary, with biphasic and monophasic appearing
lesions possible. The blastemal tissue is composed of numerous
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 145

small, round, blue, and primitive cells with scant cytoplasm

arranged in various architectural patterns. The patterns include
sheetlike, nodular, trabecular, or basaloid with peripheral palisad-
ing. Mesenchymal tissue is typically composed of spindled cells
with a smooth muscle or fibroblastic appearance. The epithelial
tissue component mimics metanephric structures with tubular and
glomerular structural formation.

Cytomorphology

Blastemal, epithelial, and mesenchymal elements will be seen in

relation to their overall tumoral distribution (Fig. 6.16). However,

Fig. 6.16 Metastatic adenocarcinoma. Lung adenocarcinoma is the most

common metastasis to the kidney. This fragment demonstrates the common
features of most adenocarcinomas: three-dimensionality, nuclear pleomor-
phism, anisonucleosis, high nuclear-to-cytoplasmic ratios, and irregular
nuclear contours. Immunohistochemical studies are often needed to deter-
mine whether this cytomorphology represents renal cell carcinoma, urothelial
carcinoma, or a metastatic process [Diff-Quik; high power]
146 P. C. Mullane et al.

aspirates will often demonstrate a higher blastemal tissue propor-

tion due to its more discohesive nature.

• Blastemal component: sheets to loose clusters of small round

cells with scant cytoplasm and fine chromatin. The cells are
about 2× the size of background lymphocytes.
• Epithelial component: 3D clusters of cells with abundant cyto-
plasm forming acini or corded structures. The primitive glom-
eruli can form clusters and crescents with a semilunar basal
lamina.
• Mesenchymal component: spindled cells with elongated
nuclei. Often arranged in bundles, these cells can often be
found bound to the epithelial cell clusters.

Metastasis

Although metastatic tumors only represent about 2–5% of all

renal masses, the diagnosis of metastatic disease on FNA is not
uncommon. 21% of malignant tumors and 11% of all biopsied
renal neoplasms have been reported to be metastatic in origin. The
histomorphologies for these lesions typically mimic the site of
origin; however, the most common metastatic tumors are lympho-
mas, soft tissue sarcomas, and carcinomas of the lung, colon, con-
tralateral kidney, head and neck, breast, and thyroid. Generally,
metastatic tumors to the kidney are multifocal, bilateral, small,
organ confined, and homogenous, while primary renal cell carci-
nomas are solitary, large, heterogeneous, and occasionally exo-
phytic. In patients with a known nonrenal primary malignancy,
biopsy is typically withheld unless there is significant clinical-
radiographic discrepancy or if the specific diagnosis will impact
clinical management. Immunohistochemistry is critical in most
cases for accurate classification, and individual practices may
vary for preferred work-up, though a useful panel often includes
TTF-1 and Napsin-A for the lung, GATA-3 and ER for the breast,
PSA and NKX3.1 for the prostate, p40 and CK5/6 for squamous
6 Renal Fine Needle Aspiration and Core Biopsy Specimens… 147

cell carcinoma, S-100 and HMB45 for melanoma, and CDX2 for
colorectal.

Cytomorphology

Cytologic specimens show loose but cohesive tissue fragments

with atypical individual cells. Hemorrhage and necrosis are com-
mon. Few, if any, characteristic features of primary renal cell car-
cinoma should be present, particularly cells with abundant foamy,
clear, or granular cytoplasm. Neoplastic cells of metastatic adeno-
carcinoma frequently have scant cytoplasm, high nuclear-to-­
cytoplasmic ratios, minimal cytoplasmic vacuolization,
anisonucleosis, irregular nuclear contours, and nuclear hyper-
chromasia (Fig. 6.16). Small cell carcinoma cells will show
hyperchromatic cells with scant cytoplasm, high nuclear-to-­
cytoplasmic ratio, and nuclear molding with occasional crush arti-
fact.

Sarcomas

Sarcomas of the soft tissue represent a diverse and heterogenous

mix of malignant tumors derived from the embryonic mesoderm.
The majority of renal sarcomas are secondary to renal invasion
from a primary retroperitoneal soft tissue sarcoma and will appear
histologically similar to the original tumor. The most common
primary adult renal sarcoma is leiomyosarcoma and it is thought
to derive from the renal veins. Other reported sarcomas include
synovial sarcoma, malignant fibrous histiocytoma, primitive neu-
roectodermal tumor (PNET), angiosarcoma, hemangiopericy-
toma, and liposarcoma. Primary adult sarcoma is a rare occurrence,
so ruling out the more common spindled cell possibilities of pri-
mary retroperitoneal soft tissue sarcoma, sarcomatoid RCC, and
sarcomatoid urothelial carcinoma is critical.
148 P. C. Mullane et al.

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Renal Fine Needle
Aspiration and Core Biopsy 7
Specimens: Benign Entities
and Nonneoplastic Findings

Sara Mustafa,
Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

As mentioned in Chap. 5, surgical removal for pathologic evalua-

tion has been the standard diagnostic approach for renal masses.
In recent years, this practice has noticeably shifted to the use of
less invasive diagnostic modalities, including image-guided biop-
sies and fine needle aspiration (FNA). Currently, a greater

S. Mustafa (*)
Old Dominion Pathology Associates, Annandale, VA, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 151

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_7
152 S. Mustafa et al.

p­ roportion of renal masses are diagnosed with computed tomog-

raphy (CT) or ultrasound-guided FNA and/or core needle biop-
sies. Published data also corroborates the high technical safety
and diagnostic accuracy of these techniques.
The number of incidentally detectable renal masses, particu-
larly lesions less than 4 cm, has increased dramatically due to the
liberal use of new and improved radiologic imagining. The over-
whelming majority of incidentally found lesions are benign renal
cysts, requiring no further treatment. Additionally, non-neoplastic
conditions infrequently present as mass-like lesions, urging for
precise pre-operative classification and deviating from aggressive
surgical interventions. Selected renal neoplasms have been man-
aged more conservatively, with ablative therapies or partial
nephrectomies, further signifying the utility of pre-surgical clas-
sification. The American Urological Association, therefore, con-
siders the use of renal needle biopsy/FNA, in these cases.
Additional implications encompass metastatic diseases and clini-
cal suspicion for a hematolymphoid process.
This chapter will shed light on key cytomorphologic character-
istics of benign renal neoplasms and non-neoplastic mass-form-
ing lesions. A brief discussion on how to differentiate and work up
benign renal parenchyma from true neoplasms of the kidney is
also included.

Accuracy

Contemporary systematic reviews of renal needle biopsies (spe-

cifically for differentiating benign and malignant conditions)
demonstrated high sensitivity and specificity rates, ranging
between 97.5–99.7% and 96.2–99.1%, respectively. Accurate
histologic subtyping is also achievable, with reported concor-
dance rates of up to 96.0% when compared with surgical resec-
tions. Diagnostic pitfalls, however, hampering such accuracy
include eosinophilic neoplasms (i.e., oncocytomas and hybrid
tumors). Synchronous presentation, whether multiple or bilateral
masses, is also problematic; published data suggests that histol-
ogy may differ between the different masses; therefore, all
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 153

lesions should be sampled when a biopsy procedure is consid-

ered. Intratumoral heterogeneity can also be a factor in biopsies
of single masses.
Nondiagnostic yields vary between 10% and 20%. Two major
factors contributing to lower diagnostic rates are cystic renal
lesions and small masses <4 cm in diameter.
FNA is becoming increasingly important for the oncologic risk
stratification and clinical management of patients with renal
masses. Various studies have reported high sensitivity rates for
FNA, ranging between 62.5% and 79.0%.
Needle biopsies are superior to FNA with regard to histologic
classification. Conversely, FNA allows for an increased likelihood
of specimen adequacy. The combined application of needle biopsy
and FNA significantly improves diagnostic rates when compared
with the use of either technique alone.

Normal Renal Histology

The kidney is considered one of most complicated organs in terms

of development, with a parallel degree of functional complexity. It
resides in the retroperitoneum, in close proximity to multiple
organs, including the duodenal loops, the pancreas, the spleen on
the left, and the liver on the right. Knowledge of neighboring
organs is particularly important when renal biopsy/FNA is per-
formed to avoid diagnostic pitfalls.
The vast majority of sampled elements are from the renal cor-
tex, with more frequent sampling of cells of the proximal tubule.

Histomorphology

The normal (cellular) constituents of glomeruli include Bowman’s

capsule epithelial cells, podocytes, endothelial cells, and mesan-
gial cells. As in any other organ, the vasculature consists of arter-
ies, arterioles, and capillaries, including those specialized
capillary loops of the glomeruli, and those in the medulla where
gas exchange of the kidney occurs.
154 S. Mustafa et al.

The renal tubules comprise 80%–90% of the volume of the

renal cortex. The proximal convoluted tubular cells exhibit abun-
dant eosinophilic and granular cytoplasm with indistinct cytoplas-
mic borders, and a prominent apical brush border. They display
large, oval nuclei with occasional small nucleoli. The distal tubu-
lar cells are conveniently smaller with cuboidal morphology, less
eosinophilic cytoplasm, and small round nuclei.

Cytomorphology

When benign renal elements are present in an FNA specimen,

consider the possibility that the lesion seen on imaging was not
adequately sampled. The presence of only benign renal elements
should be considered a non-diagnostic specimen. A background
of abundant blood may be present. The presence of only benign
elements does not usually result in a highly cellular specimen.
The specimen may consist of only rare glomeruli, renal tubular
fragments, or a mixture of both elements (Figs. 7.1, 7.2, 7.3, 7.4,
7.5, 7.6, 7.7, 7.8, 7.9, 7.10, and 7.11).

1. Glomeruli: Glomeruli form distinctive three-dimensional

structures that appear lobulated. They may become slightly
disrupted and form papillary fragments that can be mistaken

a b

Fig. 7.1 Benign renal elements. (a, b) Small fragments of renal tubules con-
tain varying degrees of granular cytoplasm depending on whether they are
proximal or distal tubules [Pap stain; intermediate power]
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 155

Fig. 7.2 Benign renal elements. A glomerulus is seen in the middle of the
field. Renal tubules are attached [Pap stain; high power]

for papillary RCC. They are composed of a mixture of cells

with both spindled and epithelioid morphologies. Prominent
nucleoli, a feature of RCC, should not be seen. Renal tubular
structures may be attached, one clue to the diagnosis, though
often glomeruli are seen as naked structures. Capillary loops
(usually empty, though occasionally containing red blood
cells) are characteristically identified at the edges of the glo-
merular structures, appearing as rings.
2. Proximal convoluted tubules: These cells represent the most
abundant finding on cytologic aspirates. They form monolay-
ered, cohesive clusters of large cells with deeply stained gran-
ular cytoplasm and indistinct cell borders. The ill-defined cell
borders, in few instances, can simulate a syncytial pattern. The
nuclei are typically large and round with distinct nucleoli that
may exhibit moderate atypia; the latter features recapitulate
the active metabolic function of these cells and are helpful
diagnostic clues. Occasional lipofuscin pigment is commonly
encountered.
156 S. Mustafa et al.

Fig. 7.3 Glomeruli. Glomeruli appear cellular on FNA and may be mistaken
for neoplasms, especially for papillary renal cell carcinoma, given their papil-
lary architecture [Diff-Quik; intermediate power]

a b

Fig. 7.4 Glomeruli. (a, b) Glomeruli are present as distinct structures and
may form attachments with tubules and/or vessels. Empty ringlike structures
at the periphery of the glomeruli are one clue to their correct identification (b)
[Pap stain; low and intermediate powers]

3. Distal convoluted tubules and collecting duct epithelial cells:

These cells typically present as cohesive duct-like aggregates
composed of smaller, cuboidal cells with moderate to scarce
agranular cytoplasm, distinct cellular borders, small nuclei,
and absent nucleoli. Pigment is usually observed.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 157

a b

Fig. 7.5 Glomeruli. (a, b) Glomeruli may unwind or be associated with lym-
phocytes. In these instances, their structure may be disrupted making them
difficult to identify. When a mixture of cell types is present, nonneoplastic
entities should be considered [Diff-Quik; high power]

a b

Fig. 7.6 Glomeruli. (a, b) Note the presence of multiple cell types as well as
the empty rings at the glomerular edges. These empty rings represent capillar-
ies [Pap stain; high power]

4. Others: An additional common finding includes well-defined,

acellular homogenous fragments of stroma, depicting a meta-
chromatic appearance on Diff-Quik stained smears.

Diagnostic Pitfalls

1. Glomeruli: These dense lobular structures, albeit rarely, may

resemble papillae of papillary renal cell carcinoma (PRCC).
The latter, nevertheless, has very distinctive cytomorphologic
features, demonstrated by numerous branching papillae, cel-
lular dissociation, and foamy macrophages. Refer to Chap. 5
158 S. Mustafa et al.

Fig. 7.7 Glomerulus. This glomerulus is slightly disrupted and is surrounded

by benign tubular cells. The background tubular cells have abundant granular
cytoplasm, though they no longer form distinct sheets or tubules. The pres-
ence of background granular debris as well as inflammatory cells may indi-
cate a destructive, yet not necessarily malignant, process occurring in the
kidney [Pap stain; high power]

a b

Fig. 7.8 Glomeruli. (a, b) At high power, both spindled and epithelioid cells
can be identified. It is difficult but not critical to identify each individual cell
type. However, this overall pattern should be recognized so that glomeruli can
be properly identified [Pap stain; high power]
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 159

Fig. 7.9 Renal tubular cells. Renal tubular cells may form small fragments
and sheets as well as larger tubular structures. Some mild nuclear anisonucle-
osis and nuclear contour irregularities may be seen at high power on Diff-­
Quik preparations [Diff-Quik; high power]

a b

Fig. 7.10 Renal tubular cells. (a, b) Benign renal tubular cells are usually
not present in great numbers, a finding seen in neoplastic specimens. They
may have small nucleoli, whereas increased nucleolar size should raise con-
cern for a neoplastic process [Diff-Quik; high power]
160 S. Mustafa et al.

a b

Fig. 7.11 Benign renal parenchyma, core biopsies. (a, b) Normal renal
architecture demonstrating proximal and distal tubules [H&E; intermediate
power]

for a detailed discussion of PRCC. Occasionally, glomeruli

may allude to the presence of a mesenchymal tumor with
­spindle cell morphology, such as an angiomyolipoma. Other
morphologic characteristics in conjunction with ancillary
studies can aid in making such distinctions.
2. Proximal convoluted tubules: Diagnostic challenges may be
encountered when abundant proximal tubular cells are aspi-
rated, simulating a single cell population picture. The cyto-
plasmic granularity may further complicate such occurrences,
creating a broad differential of primary renal neoplasms; this
may include oncocytoma, chromophobe renal cell carcinoma
(CRCC), and PRCC type 2. A helpful diagnostic clue is the
presence of indistinct cellular borders of proximal tubular
cells. Moreover, pigment is typically absent in renal neoplasms
except for when hemosiderin is present in PRCC. Oncocytomas
can be strikingly similar to proximal tubular cells; the well-
defined cellular borders of the former can be of great diagnos-
tic utility. When necessary, immunohistochemistry can be
employed to further assist in rendering an accurate diagnosis.
CD10 and AMACR expression, normally seen in proximal
tubular cells, are absent in oncocytomas.
Clear cell renal cell carcinoma (CRCC) can be readily dis-
tinguished through characteristic cytomorphologic and immu-
nophenotypic features. This entity is further discussed in
Chap. 5.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 161

3. Distal convoluted tubules: The bland nuclei of distal tubular

cells are similar to those of a low-grade clear cell renal cell
carcinoma (CCRCC) or PRCC. However, the cytoplasm of
normal tubular cells is not vacuolated as it often is in low-­
grade clear cell RCCs. Interestingly, PRCC and CCRCC
smears may show basement membrane material, which is usu-
ally present within cellular groups. Conversely, basement
membrane of normal kidney is usually seen in isolation.

Nonneoplastic Conditions

Renal lesions can present as non-neoplastic processes and mimic

true renal neoplasms. A comprehensive list includes benign cysts,
acute pyelonephritis, xanthogranulomatous pyelonephritis, paren-
chymal scar, intrarenal splenules, hematoma, and renal infarcts.

Benign Cysts

Approximately 50% of middle-aged adults have an incidental

renal mass; of those, the overwhelming majority are cysts.
Malignant cysts constitute only a minor subgroup, ~1%–4% of
cases, while the vast majority are benign, acquired, and solitary.
The Bosniak system (see Table 7.1) has been widely utilized
for the risk stratification of renal cysts based on radiologic appear-
ances. Not only does it classify renal lesions, but it also advocates
treatment options for each category. Benign cysts constitute the
main entities of categories I and II. In the past, aspiration of
benign cysts was both diagnostic and therapeutic. Currently, clin-
ical follow-up without surgical intervention is the common prac-
tice; therefore, FNA is seldom performed. The opposite end of the
spectrum represents category IV lesions, which are more likely to
be malignant, and will require resection. Diagnostic challenges
usually arise with the indeterminate categories (IIF and III), and
surgical overtreatment seems to be an inevitable drawback of the
Bosniak system.
162 S. Mustafa et al.

Table 7.1 Bosniak classification of renal cysts by imaging studies. Modified

from “Bosniak classification system of renal cystic masses” by Radiopaedia
(http://www.radiopaedia.org)
Bosniak Imperceptible rounded wall; work-up: none; percentage
I – simple cyst malignant: ~0%
Bosniak Thin (<1) mm septa or thin calcifications (thickness not
II – minimally measurable); non-enhancing high-attenuation (due to
complex proteinaceous or hemorrhagic contents) renal lesions
<3 cm; generally well marginated; work-up: none;
percentage malignant: ~0%
Bosniak Increased number of septa that are minimally thickened
IIF – minimally with nodular or thick calcifications; perceived (but not
complex measurable) enhancement of hairline-thin smooth septa;
perceivable enhancement of the wall; hyperdense cyst
>3 cm diameter, mostly intrarenal (less than 25% of wall
visible); requires follow-up (the “F” in 2F is for
“follow”) with ultrasound/CT/MRI at roughly 6 months;
percentage malignant: ~5%
Bosniak Thick, nodular, multiple septa or wall with measurable
III – enhancement; treatment/work-up: partial nephrectomy or
indeterminate radiofrequency ablation in elderly or poor surgical
candidates; percentage malignant: ~55%
Bosniak Solid mass with a large cystic or a necrotic component;
IV – clearly treatment: partial or total nephrectomy; percentage
malignant malignant: ~100%

Multiple cysts are worthy of mentioning since they share simi-

lar cytologic characteristics to conventional benign cysts. They
can be acquired as a result of long-term dialysis in patients with
end-stage renal disease (acquired cystic disease), or congenitally
develop in patients with adult type polycystic kidney disease.

Histomorphology

The histologic features of benign cystic lesions of the kidney vary

greatly by the etiology of the disease. A full discussion of each
lesion is not included here, as most benign lesions are either not
resected, resected in association, or in the background of neoplas-
tic disease or associated with genetic diseases. Common entities
include renal dysplasia, autosomal dominant and autosomal
recessive polycystic kidney disease, medullary sponge kidney,
simple cortical cysts, and acquired cystic kidney disease.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 163

Cytomorphology

FNA of simple cysts, including multiple cysts, yield clear, pale

straw-colored fluid (Figs. 7.12, 7.13, 7.14, and 7.15). Smears are
mainly composed of macrophages with occasional hemosiderin

Fig. 7.12 Cyst fluid. The FNA of cyst fluid will usually yield macrophages,
which will accumulate pigment from hemosiderin breakdown products over
time [Diff-Quik; high power]

a b

Fig. 7.13 Cyst lining cells. (a, b) Rare fragments of cyst lining cells may be
present upon FNA of a renal cyst. These cells may form medium-sized sheets.
High nuclear-to-cytoplasmic ratios may cause concern for a neoplasm such as
a cystic clear cell RCC [Diff-Quik; high power]
164 S. Mustafa et al.

a b

Fig. 7.14 Cyst lining cells and macrophages. (a, b) Cystic macrophages can
be seen along with small fragments of cyst lining cells [Pap stain; intermedi-
ate and high power]

Fig. 7.15 Cyst lining cells and macrophages. Cyst lining cells may have
nuclear contour irregularities and small nucleoli. However, the fragments are
not present in great numbers and lack other features of renal cell carcinoma.
They are often classified as “atypical” in such specimens due to their unusual
appearance [Pap stain; high power]

pigment. Few bland or mildly atypical epithelial fragments may

be observed, representing cyst lining. They typically have round
nuclei and ill-defined cell borders. The structures form monolay-
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 165

ered sheets with cells that have high nuclear-to-cytoplasmic ratios

but have minimal variation in nuclear size. The nuclei are typi-
cally organized within the sheet. These sheets should not be pres-
ent in great numbers. In rare occurrences, three-dimensional,
laminated, ring-like acellular structures (Liesegang rings) are
encountered.

Renal Abscess/Acute Pyelonephritis

The typical presentation of pyelonephritis is a diffuse pattern.

However, in rare instances, it can be focal and radiologically
mimic a mass lesion. Abscesses, on the other hand, are almost
always localized. Bacterial organisms are the most commonly
encountered etiologic agents in both entities. Pyelonephritis arises
as a complication of an ascending urinary bladder infection caus-
ing inflammation of the renal pelvis and parenchyma.

Histomorphology

Microscopic sections of pyelonephritis will display dense neutro-

phil aggregates, sometimes with visible bacterial colonies. The
tubules and interstitium are affected more commonly with glo-
merular sparing due to the ascending nature of the disease pro-
cess. Biopsy samples can show more localized areas of acute
inflammation, primarily affecting the cortices, with associated
edema. Cortical abscesses may also form. Review of imaging in
association with the biopsy should be undertaken to rule out an
inflammatory process in association with an unsampled mass
lesion.

Cytomorphology

Grossly, aspirates have a cloudy, white-yellow appearance.

Cytologic smears are composed of predominantly neutrophils, with
rare macrophages and degenerated epithelial cells in a necrotic
166 S. Mustafa et al.

background. Reactive atypia of the epithelial cells may be, rarely,

confused with RCC. The scarcity of such cells in a background of
intense inflammation is usually a helpful diagnostic clue.

Xanthogranulomatous Pyelonephritis (XGP)

XGP is a destructive granulomatous inflammatory process that is

typically the result of long-term urinary tract obstruction and
infection. It is believed to result from an atypical and incomplete
immune response to subacute bacterial infections. It usually pres-
ents as a diffuse process on imaging studies (only 10% of cases
are focal), simulating a renal neoplasm. Large staghorn calculi,
centered in the renal pelvis, are associated with the majority of
cases, though deemed a non-specific finding. 70% of patients are
female and urine cultures most commonly show Escherichia coli
and Proteus mirabilis.

Histomorphology

At microscopic examination, renal parenchyma displays xantho-

granulomatous inflammation (mixed histiocytes with foamy cyto-
plasm, neutrophils, lymphocytes, plasma cells, and multinucleated
giant cells). The caliceal mucosa (rarely seen on biopsy) may be
ulcerated and replaced by necrotic debris with inflammatory cells
including neutrophils, lymphocytes, and plasma cells.

Cytomorphology

Aspirates are cellular with varying numbers of single or aggre-

gated lipid-laden (foamy) macrophages, multinucleated giant
cells, and other inflammatory cells including lymphocytes and
plasma cells (Fig. 7.16). An important diagnostic pitfall is that
with aspiration, the dominant macrophages can aggregate and
resemble clusters of clear cell renal cell carcinoma (CCRCC).
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 167

a b

Fig. 7.16 Xanthogranulomatous pyelonephritis. (a, b) These fields contain

vessels and numerous cells, causing concern for a neoplasm. However, the
cells are a mixed population of inflammatory cells, including histiocytes with
foamy cytoplasm, a clue to the correct diagnosis [Diff-Quik; high power]

However, the bean-shaped nuclei of macrophages are rather dis-

tinct from the round nuclei of CCRCC. Immunohistochemistry
can readily assist with this differential.

Renal Infarction

Renal infarction is a rare condition that results from acute disrup-

tion of blood flow in the renal arterial system. It is associated with
various causes, of which cardiogenic events have been the most
commonly encountered. Renal infarcts can be readily diagnosed
on imaging studies, particularly when appropriate clinical and
laboratory correlation is applied. Typical radiologic findings
include single or multiple wedge-shaped perfusion defects involv-
ing the parenchyma. In some instances, renal infarcts may mani-
fest as mass-like lesions, urging for further evaluation. However,
needle biopsy/FNA is seldom performed for this entity.

Histomorphology

Histologic examination displays patchy areas of coagulative

necrosis affecting both the glomeruli and tubules. A rim of hyper-
emic parenchyma usually surrounds the infarcted segment.
168 S. Mustafa et al.

Cytomorphology

Aspirate smears are characterized as being pauci-cellular with a

necrotic background. Reactive cellular changes including atypia,
cytoplasmic vacuolation, and prominent nucleoli can be seen. The
presence of necrotic glomeruli and tubules may suggest the cor-
rect diagnosis. However, reparative/reactive cellular atypia may
be falsely interpreted as malignancy. A conservative approach is
necessary when cytopathologists stumble upon such rare cells,
having repair-like features, in a scanty specimen.

Benign Renal Neoplasms

The clinically relevant benign tumors include angiomyolipoma,

oncocytoma, papillary adenoma, and metanephric adenoma. Care
should be taken on the biopsy and cytologically derived diagnosis
of “benign” renal neoplasms. Sampling error (via location or
quantity) and intratumoral heterogeneity are realistic pitfalls to an
accurate diagnosis. Have a low threshold to “hedge” or be descrip-
tive (i.e., “renal cell neoplasm with oncocytic/clear cell/papillary
features”), use wide immunohistochemical panels, and correlate
with imaging studies in your assessment.

Angiomyolipoma (AML)

Angiomyolipoma is an uncommon benign mesenchymal neo-

plasm composed of variable proportions of mature adipose tissue,
cells with smooth muscle features, and abnormal, thick-walled
blood vessels. It accounts for 1% of all renal tumors, and although
classically associated with tuberous sclerosis (TS), sporadic
AMLs are four- to five-fold more common than TS-associated
AML. It is also more common in females (4:1 ratio in patients
without TS). It is believed to be derived from perivascular epithe-
lioid cells.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 169

Despite being asymptomatic in most cases, these tumors have

a propensity to grow as large masses (>6 cm) and manifest with
abdominal/flank pain or palpable mass. Radiologically, they tend
to be well-circumscribed masses with intratumoral fat on cross-­
axial imaging. In rare instances, AMLs can rupture and lead to
life-threatening retroperitoneal hemorrhage. Most AMLs are
readily characterized on imaging alone due to their characteristic
fatty appearance. Radiologic diagnosis, however, can be defied by
the range of fat content, particularly in cases of “fat-poor AMLs.”
Moreover, owing to their high vascularity, AMLs can be misdiag-
nosed as renal cell carcinoma.

Histomorphology
Microscopic examination of AMLs demonstrates a mixture of
mature adipose tissue, smooth muscle, and tortuous thick-
walled vessels; fat is present in >90% of tumors. The smooth
muscle component can appear as fascicles of spindled cells or
sheets of epithelioid cells with granular cytoplasm. The cells
can appear to “radiate” from vessel walls. Moderate to marked
atypia can be seen in the smooth muscle cells but mitotic activ-
ity is rare. Since AMLs are members of the PEComa family
(tumors originating from perivascular epithelioid cells), the
mesenchymal component (adipose and smooth muscle cells)
will express HMB-45, melan-­ A, SMA, and tyrosinase on
immunohistochemistry. Keratins and other epithelial markers
are negative. Focal nuclear atypia or high cellularity is often
present and is not associated with malignant behavior; however,
the epithelioid variant demonstrates malignant behavior in
25%–33% of cases.

Cytomorphology
Classically, aspirates display variable amounts of adipose, smooth
muscle, and endothelial cells (Figs. 7.17, 7.18, 7.19, 7.20, and
7.21). Because AMLs with high fat content have characteristic
findings on imaging studies, the AMLs seen on FNA usually con-
sist predominantly of the smooth muscle and endothelial (vascu-
170 S. Mustafa et al.

Fig. 7.17 Angiomyolipoma. AMLs are not typically seen on FNA as they
have characteristic radiologic findings. However, this is not true for AMLs
containing only a small amount of fat. In these instances, the FNA often con-
tains cellular fragments that may be mistaken for a renal cell carcinoma. One
clue is the presence of multiple cell types, such as seen here [Diff-Quik; high
power]

lar) components. The smooth muscle spindle cells form tight or

loosely cohesive clusters. These cells have filamentous, stringy
cytoplasm with occasional vacuolation and oval to elongated
nuclei with evenly distributed chromatin and no, or inconspicuous
nucleoli. Naked nuclei are commonly present. Nuclear atypia
within the spindled cell population can be frequently observed;
however, mitoses and necrosis are usually absent. The diagnosis is
predominantly suggested by a mixture of cell types, particularly
when epithelioid and spindled nuclei are seen in the same frag-
ment. The presence of adipose tissue, especially in association
with other cell types, should cause consideration for this diagno-
sis. Confirmatory immunohistochemistry is typically required to
make a definitive diagnosis.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 171

Fig. 7.18 Angiomyolipoma, core biopsy. This biopsy has captured the
smooth muscle component [H&E; intermediate power]

a b

Fig. 7.19 Angiomyolipoma, core biopsy. (a) Epithelioid cells intermixed

with sclerosis. (b) A mixture of epithelioid and spindled cells [H&E; high
power]

Oncocytoma

Oncocytomas are benign lesions accounting for 3–8% of all renal

tumors. They are frequently encountered as an incidental finding
and may present as a large mass, with a median size of 6–8 cm.
They can be bilateral, multicentric, and solid or cystic.
172 S. Mustafa et al.

a b

Fig. 7.20 Angiomyolipoma. The neoplastic cells demonstrate positivity for

cathepsin K (a) and melan-A (b) [cathepsin K and melan-A immunohisto-
chemical stains]

a b

Fig. 7.21 Angiomyolipoma. (a) Focal staining for HMB-45. (b) Diffuse
staining of the smooth muscle component with SMA [HMB-45 and SMA
immunohistochemical stains]

Unfortunately, radiology has limited utility in differentiating

between oncocytoma and renal cell carcinoma (RCC), particu-
larly chromophobe RCC. Both, typically, demonstrate homoge-
nous radiologic features with spoke-wheel enhancement and a
central stellate scar.
Pathologic examination remains the only reliable way to diag-
nose oncocytoma. However, rendering such diagnosis on a small
needle biopsy/FNA is quite challenging to the pathologist, since
many of the defining characteristics of this benign entity are also
seen in RCC. Consequently, up to 31.3% of cases initially diag-
nosed as oncocytomas on biopsy have been subsequently reclassi-
fied as RCC on surgical resections. This highlights the need for
prudence when making a definitive diagnosis of oncocytoma on
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 173

biopsy. Generally, a diagnosis of “oncocytic neoplasm” with a

weighted differential is sufficient. Rare cases are associated with
Birt-Hogg-Dube syndrome.

Histomorphology
Composed of the namesake oncocytes, these polygonal tumor
cells have abundant uniformly granular, eosinophilic cytoplasm
reflecting its rich mitochondrial content. The nuclei are round and
centrally or eccentrically located with conspicuous nucleoli.
Though some lesions may have degenerative changes resulting in
bizarre, atypical nuclei, mitoses are consistently rare. Nests, acini,
tubules, or microcysts of neoplastic cells are orderly arranged and
well circumscribed and lack the trabeculated arrangement of
CRCC. Right-sided lesions, especially when targeting the upper
pole of the kidney, may result in inadvertent liver sampling. The
abundant granular cytoplasm of hepatocytes can be mistaken for
an oncocytoma; hepatocytes can be distinguished by the presence
of lipofuscin, nuclear pleomorphism, and increased cellular size.
Immunohistochemistry is equally helpful in this differential.

Cytomorphology
Smears are highly cellular with abundant dyscohesive cells or
loosely cohesive clusters of monotonous oncocytes (Figs. 7.22,
7.23, 7.24, 7.25, and 7.26). The cells are large and polygonal with

a b

Fig. 7.22 Oncocytoma. (a, b) Benign oncocytic cells contain abundant gran-
ular cytoplasm and small nucleoli. In a limited specimen, these are compati-
ble with oncocytoma, but other oncocytic neoplasms cannot be entirely
excluded [Diff-Quik; intermediate power]
174 S. Mustafa et al.

a b

Fig. 7.23 Oncocytoma. (a, b) Binucleation may occur. The cells may dem-
onstrate anisonucleosis and mild nuclear contour irregularities. However,
many nuclei appear uniformly round [high power; Diff-Quik]

a b

Fig. 7.24 Oncocytoma. (a, b) Cells are often individually dispersed or

loosely cohesive, in contrast to benign renal tubular cells. Distinct nucleoli
are usually present [high power; Diff-Quik]

well-delineated cellular borders and uniformly granular

­cytoplasm. The nuclei are small with fine chromatin and occa-
sional binucleation. Conspicuous central nucleoli can be seen.
See Table 7.2.
Importantly, small biopsy samples containing an oncocytic
population of cells should be signed out with caution. Due to lim-
ited sampling, other oncocytic neoplasms – including malignan-
cies – may appear as a bland oncocytic population on FNA and
even limited tissue biopsy (Fig. 7.27). It is recommended that
such specimens be signed out as “oncocytic neoplasms” with a
note explaining that, while the findings are compatible with onco-
cytoma, such findings may be seen in the limited sampling of
renal cell carcinomas with oncocytic features.
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 175

Fig. 7.25 Oncocytoma. The cells contain numerous cytoplasmic granules

[high power; Pap stain]

a b

Fig. 7.26 Oncocytoma, core biopsy. (a, b) The findings are compatible with
oncocytoma, though small biopsies cannot entirely exclude other processes,
including malignancies, due to limited sampling [high power; H&E]

Papillary Adenoma

These small tumors, arbitrarily defined by a size less than 1.5 cm,
share the same morphologic, immunohistochemical, and cytoge-
netic characteristics of papillary RCC and likely represent the
176 S. Mustafa et al.

Table 7.2 Cytopathologic distinction between common entities

Chromophobe Clear cell
Oncocytoma RCC RCC Papillary RCC
Background Clean Clean Necrotic Foamy
or clean macrophages;
necrosis
Arrangement Dyscohesive Small groups, Large Papillae;
cells; loose isolated cells clusters occasional
clusters isolated cells
Cytoplasm Uniformly Less uniform Abundant Intracellular
granular granularity; foamy, hemosiderin
cytoplasm clear clear to (25%)
Nuclear Thickened cell granular
uniformity borders
Nuclei Uniform Variable size; Round, Small,
irregular nuclear uniform uniform
border rare nuclear
grooves
Nucleoli Rare Variable; may Variable, Inconspicuous
be hard to see prominent
because of in
hyperchromasia high-grade
tumors

a b

Fig. 7.27 Renal cell carcinoma with oncocytic features. (a, b) This FNA was
taken from a renal cell carcinoma and demonstrated predominantly a popula-
tion of oncocytic cells. The nuclei are slightly more pleomorphic than in the
previous figures of oncocytoma. This case demonstrates the difficulty in dis-
tinguishing benign vs. malignant oncocytic populations on small biopsies
alone [high power; Diff-Quik]
7 Renal Fine Needle Aspiration and Core Biopsy Specimens… 177

same tumor biology. Most are asymptomatic and are detected in a

nephrectomy specimen for other reasons or at autopsy.

Histomorphology
They are characterized by cells with scant, amphophilic to baso-
philic cytoplasm, arranged in a tubulopapillary and/or papillary
patterns with or without encapsulation. They have round to oval,
small uniform nuclei without prominent nucleoli. Since the term
“papillary adenoma” is strictly reserved for very small lesions
usually detected at autopsy or kidney resections for other reasons,
this entity is no longer a diagnostic consideration for renal
FNA. Additionally, the prognosis of renal adenomas and low-­
grade papillary RCC of any size is excellent, and therefore mak-
ing such distinction is rather semantic than clinically relevant.

Metanephric Adenoma

Metanephric adenomas are benign tumors that recapitulate dif-

ferentiation toward early embryonic metanephric tubules. It usu-
ally presents as an incidental finding but has a female predominance
and a wide age range. Similar to their age distribution, they can
vary from small to very large lesions. Due to their embryologic-­
like appearance, they can morphologically resemble nephroblas-
toma, yet are known to be genetically unique from these lesions.

Histology
Metanephric adenomas are composed of small primitive cells that
recapitulate early metanephric tubular differentiation. They are
usually well-circumscribed lesions with no capsule and an abrupt
interface with the adjacent, normal renal parenchyma. They are
composed of crowded acini of monotonous, primitive small blue
cells with scant cytoplasm and inconspicuous nucleoli. Slender,
branching tubular structures are frequently seen and may resem-
ble papillary RCC. Psammoma bodies are common and mitosis
should be absent. Immunohistochemistry is positive for WT-1,
178 S. Mustafa et al.

PAX2, PAX8, and CD57. It is negative for AMACR and CK7. The
main differential diagnosis is Wilms’ tumor, where distinction
may be impossible, particularly on biopsy or cytologic specimens.
However, Wilms’ tumor usually has larger cells with more pro-
nounced hyperchromasia and mitoses.

Cytomorphology
Cytologic smears are composed of tight short papillae and loose
sheets with occasional rosettes. The cells are small and round with
minimal cytoplasm, uniform nuclei, and delicate chromatin.
Pseudo-inclusions and nuclear grooves can be present. Psammoma
bodies are frequently seen.

Suggested Reading
Curry NS, Cochran ST, Bissada NK. Cystic renal masses: accurate Bosniak
classification requires adequate renal CT. AJR Am J Roentgenol.
2000;175(2):339–42.
Garstka N, Shariat SF, Remzi M. The evolving role of percutaneous biopsy in
renal masses. Curr Opin Urol. 2018;28(4):364–8.
Jiménez-Heffernan JA, Muñoz-Hernández P, Canca Velasco A, et al. Fine
needle aspiration cytology of the normal kidney: a cyto-histological and
immunocytochemical correlation study. Diagn Cytopathol. 2018;46:482–
8.
Lau HD, Kong CS, Kao C-S. Evaluation of diagnostic accuracy and a practi-
cal algorithmic approach for the diagnosis of renal masses by FNA. Cancer
Cytopathol. 2018;126:782–96.
Sanchez A, Feldman AS, Hakimi AA. Current management of small renal
masses, including patient selection, renal tumor biopsy, active surveil-
lance, and thermal ablation. J Clin Oncol. 2018;36(36):3591.
Scanga LR, Maygarden SJ. Utility of fine-needle aspiration and core biopsy
with touch preparation in the diagnosis of renal lesions. Cancer Cytopathol.
2014;122:182–90. https://doi.org/10.1002/cncy.21371.
Smith AD, Remer EM, Cox KL, et al. Bosniak category IIF and III cystic
renal lesions: outcomes and associations. Radiology. 2012;262(1):152–
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renal mass: FNA or core needle biopsy? Cancer Cytopathol.
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Zhou, et al. High yield pathology: uropathology. Elsevier Saunders
Publishing; 2012.
Adrenal Gland
8
Sara Mustafa,
Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

Fine needle aspiration (FNA)/biopsy of the adrenal gland has

been increasingly utilized in diagnostic modalities; it serves as a
valuable tool in the diagnosis and in differentiating primary adre-
nal lesions from metastatic tumors. Most adrenal lesions are inci-
dentally detected during work-up performed for extra-adrenal
diseases (adrenal “incidentalomas”). While most of these afore-
mentioned “incidentalomas” are found to be benign or non-­
functional neoplasms, a minor subset are metastatic neoplasms of

S. Mustafa (*)
Old Dominion Pathology Associates, Annandale, VA, USA
e-mail: [email protected]
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 179

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_8
180 S. Mustafa et al.

unknown primary, warranting clinical follow up for further inves-

tigation. Moreover, the role of FNA as a screening tool for the
initial evaluation of symptomatic mass lesions and, more impor-
tantly, the confirmation of disease progression through recurrence
or metastasis during cancer staging has been well established in
the literature. Successful application of adrenal gland FNA is not
limited to detecting neoplastic lesions but also that of infectious
diseases and non-neoplastic conditions, allowing for proper clini-
cal management and deviating from unnecessary surgeries.
Core biopsy is not commonly performed for adrenal lesions
and its performance is not well-described in the literature.
Therefore, this chapter will focus primarily on the key cytomor-
phologic characteristics of common adrenal gland lesions encoun-
tered during FNA, differentiating them from mimickers that could
potentially generate diagnostic challenges.

Imaging Techniques

Sampling of adrenal glands via percutaneous image-guided biop-

sies predates that of endoscopic ultrasound (EUS)-guided FNAs,
which has been greatly employed in recent clinical practices. This
colossal shift is attributed to a considerable amount of non-­
diagnostic yields, reported up to 14%, and similarly high adverse
events (0.4–12%) associated with percutaneous routes. In recent
years, EUS-guided FNA/biopsy has been used as a less invasive,
and more accurate, method for sampling the adrenals with fewer
side effects. Additionally, EUS-guided FNA/biopsy is far more
superior to conventional methods in procuring higher sample
yields, which is further enhanced by on-site adequacy evaluation
performed by a cytopathologist, or trained cytotechnologist.
A few studies have illustrated that sampling of the right adre-
nal gland can be rather difficult, particularly when using a percu-
taneous approach. This is due to a retrocaval location in
comparison to its counterpart on the left. This notion, however,
has slowly faded with subsequent studies demonstrating success-
ful sampling of the right adrenal gland via a duodenal approach of
EUS-guided FNA. Subtle and continuous maneuvering of the
needle, to ensure a safe path, may be required to minimize com-
8 Adrenal Gland 181

plications. It is worth mentioning that in the setting of clinical

suspicion of a pheochromocytoma, adrenal gland biopsy should
be avoided to limit risks of hypertensive crises, and even deaths.

Accuracy

Imaging techniques have been successfully used in staging many

diseases. However, technical limitations have been encountered
when dealing with adrenal glands. While relying on imaging char-
acteristics and size can provide some insight into the malignant
potential of identifiable lesions, diagnostic uncertainty still
remains with ample false positive and negative rates. Despite
these challenges, some studies have shown that acquisition of tis-
sue samples via needle biopsies improves sensitivity and specific-
ity at 95% and 100%, respectively, for detecting malignancies.
FNA in particular has an overall sensitivity of 85% and adequacy
rates that vary from 67% to 100%. Adequacy rates are further
improved, with reported rates up to 92%, when immediate assess-
ment is provided.

Normal Anatomy of the Adrenal Gland

Following the discovery of adrenal glands by Eustachius in the

mid-1500s, many studies have emerged describing their embryo-
logic structure and functional vitality as part of the endocrine sys-
tem. Those suprarenal organs are composed of two major
constituents, a cortex and a medulla, with distinct, albeit, interde-
pendent cellular and functional properties.
Utilizing cholesterol as a chief molecule, the adrenal cortex is
specialized in steroid hormone synthesis. It is subdivided into
three zones: the outer zona glomerulosa, which is the site of min-
eralocorticoid production; the central zona fasciculata primarily
responsible for glucocorticoid synthesis; and the inner zona retic-
ularis, which is the site of adrenal androgen formation.
Histologically, adrenocortical cells are arranged in a cord-like
pattern extending from the capsule to the medulla and are embed-
ded within a rich capillary network. The cells of the central zona
182 S. Mustafa et al.

Fig. 8.1 Normal adrenal cortex. Zona glomerulosa is at the top right corner
of the field. Most of the cortex is formed of zona fasciculata which contains
large polyhedral cells with pale-staining, lipid-rich cytoplasm [H & E; high
power]

f­asciculata are distinguished by their rather large and polyhedral

shape as compared to the outer and inner zones, which are mor-
phologically similar, and are predominantly composed of smaller
round cells. A smaller cell type also constitutes the inner zona
reticularis (Fig. 8.1).
The adrenal medulla is a neuroendocrine tissue composed of
unique, postganglionic, sympathetic nervous system neurons
called chromaffin cells. They stimulate fight-or-flight response
through the production of catecholamines, epinephrine, and nor-
epinephrine. The adrenal medulla is located at the core of the
gland with chromaffin cells forming the bulk of it. They are
arranged in clusters, usually around medullary veins, and are mor-
phologically basophilic and columnar in shape. The granularity of
the cytoplasm is reflected by the presence of hormone-containing
8 Adrenal Gland 183

granules. Clusters of sympathetic ganglion cells are also observed

in the adrenal medulla, which are round or polygonal with round
nuclei and distinct nucleoli.

Adrenal Cortex

Infections/Inflammatory Conditions

Infectious processes of the adrenal glands can present as mass-­

like lesions, and radiologically, simulate neoplasms. Tuberculous
adrenalitis is known for such occurrences. The classic presenta-
tion is bilateral gland enlargement with only a few reported cases
of unilateral presentation. Additional imaging features include
preservation of the adrenal gland contour and central low attenu-
ation.
Tissue sections exhibit areas of caseous necrotizing granulo-
mas in the cortex and medulla, composed of Langerhan giant cells
and lymphocytes. Cytomorphologic smears resemble those of tis-
sue sections with necrotizing granulomatous inflammation in a
background of necrosis.
Mycobacterium avium-intracellulare typically affects the
adrenal glands in a clinical setting of disseminated disease amid
immunosuppression. Sheets of histiocytes with abundant intracel-
lular rod-shaped organisms are readily detected with acid-fast
stains.
Fungal organisms, particularly the dimorphic subtypes, have
also been described to involve the adrenal glands. They can be
seen in immunosuppressed as well as immunocompetent patients.
Histologically, the sampled gland is fibrotic with areas of caseat-
ing necrosis and granulomatous inflammation. The organisms are
usually morphologically distinguishable and are further con-
firmed with a Grocott-Gomori methenamine silver (GMS) stain.
The differential diagnosis of infectious agents also includes
viruses, such cytomegalovirus, herpes simplex virus, and HIV.
184 S. Mustafa et al.

Benign Adrenal Cortical Nodules/Adenomas

The vast majority of the incidentally discovered adrenal gland

lesions are nonfunctioning adenomas; only a minority are func-
tional which secrete hormones resulting in endocrine abnormali-
ties. They are usually unilateral, solitary masses and share similar
morphologic characteristics. Moreover, adrenocortical hyperpla-
sia is indistinguishable by morphology from cortical adenomas,
but can be clinically suspected by their bilaterality and multinodu-
lar appearance.
Aspirates usually yield cellular smears with a bubbly, lipid-­
rich background due to the fragile cytoplasmic material; this fea-
ture is seen in almost all benign cortical nodules. Cells can be
individual, form loose aggregates, or in tissue fragments with
transgressing small blood vessels (Figs. 8.2 and 8.3). Cells have
round uniform nuclei and finely vacuolated cytoplasm. ­Occasional

Fig. 8.2 Adrenal cortical adenoma. Cellular smear showing individual cells,
loose aggregates, and tight tissue fragments of cells in a bubbly, lipid-rich
background [Diff-Quik; low power]
8 Adrenal Gland 185

Fig. 8.3 Adrenal cortical adenoma. Abundant scattered bare nuclei [Papani-
colaou stain; low power]

larger cells can be seen but overt atypia, mitosis, and necrosis are
usually absent. Abundant, bare, round to oval nuclei are also com-
monly observed (Fig. 8.4).
Differentiating benign cortical cell proliferation from adreno-
cortical carcinoma is not feasible on small tissue biopsies or
FNA. Certain features, if present, may favor a malignancy; those
include higher nuclear atypia, mitosis, necrosis, numerous intact
isolated cells with less bare nuclei, and lack of bubbly back-
ground. However, accurate evaluation using several established
systems, e.g., Weiss system, require bigger resections. Notably,
metastatic tumors with clear cell features, particularly renal cell
carcinomas, should be considered in the differential. Similarly,
smears tend to have vascular tissue fragments and cells with vacu-
olated cytoplasm. However, they lack the bubbly background and
naked nuclei that are typically seen in adrenal cortical nodules.
Normal cellular mimickers, like benign hepatocytes, may resem-
ble adrenal cortical adenomas, especially those displaying
186 S. Mustafa et al.

Fig. 8.4 Adrenal cortical adenoma. Loose fragment of cells with uniform
round nuclei and vacuolated cytoplasm [Diff-Quik; high power]

o­ ncocytic features. When aspirating the right adrenal gland, hepa-

tocyte contamination should be contemplated.

Benign Cysts

Cystic lesions of the adrenal gland are a heterogeneous group of

uncommon entities. Due to improved imaging modalities, their
detection rates have been noticeably rising in the last decades.
They are usually unilateral, well circumscribed, and have a female
predilection.

Myelolipoma

Myelolipoma is a rare, nonfunctioning, benign tumor. Although

they are classically asymptomatic, they can grow to form large
8 Adrenal Gland 187

a b

Fig. 8.5 Myelolipoma. (a) Mature adipose tissue admixed with hematopoi-
etic cells [Diff-Quik; low power]. (b) Megakaryocytic precursors in the cen-
ter of the field [Diff-Quik; medium power]

masses with associated symptomatology. No definitive cause for

this entity has been identified; however, many reports suggest an
association with chronic conditions such as hypertension, diabe-
tes mellitus, obesity, various types of inflammatory conditions,
and carcinomas. There is a slight male predilection with a ratio of
2:1. Fine needle aspiration or biopsy is the preferred method for
diagnosis.
The characteristic cytologic features include a mixture of
mature adipose tissue fragments or several large fat vacuoles
intermingled with hematopoietic elements. These elements
include granulocytic, erythrocytic, and megakaryocytic precur-
sors (Fig. 8.5a, b).
The presence of extramedullary hematopoietic precursors
should not be confused with extramedullary hematopoiesis. The
latter is rather a systemic condition and occurs at multiple sites
secondary to hematopoiesis failure in the bone marrow; it is typi-
cally devoid of fat tissue.

Adrenal Cortical Carcinoma

A rare but highly aggressive neoplasm, associated with poor prog-

nosis. More than half of tumors are functional owing to aberrant
hormonal secretion. It occurs most commonly in the fourth and
188 S. Mustafa et al.

fifth decades of life, with a slight female predilection. A smaller

peak is noted in the pediatric population. Early detection and
complete surgical resection can improve outcomes, with reported
5-year survival rates varying between 48% and 55%. Most patients
will eventually succumb to the disease.
Arguably, the single most significant predictor of malignancy
on imaging is size, since most adrenocortical carcinomas can
form large masses, more than 6 centimeters, at the time of diagno-
sis. Additional helpful imaging parameters include tumor hetero-
geneity, irregular borders, and evidence of local invasion.
Adrenocortical adenomas and carcinomas may have overlap-
ping features precluding accurate diagnosis on cytologic smears.
Several proposed systems, for making this distinction, have
emerged in the recent years suggesting a potential role for small
biopsy specimens.
The cytomorphologic features of adrenocortical carcinomas
may vary depending on the degree of differentiation. Smears are
highly cellular and composed of discohesive cells, arranged indi-
vidually and in aggregates. Well-differentiated tumors exhibit a
rather bland appearance, typified by uniform cells with vacuolated
cytoplasm, and closely resembling adrenocortical adenomas
(Fig. 8.6). On the contrary, poorly differentiated tumors are easily
identifiable by the striking pleomorphism, increased nuclear to
cytoplasmic ratios, irregularly thickened nuclear membranes,
coarse chromatin, and prominent nucleoli. Bizarre appearing
giant cells, brisk mitosis, and necrosis are common findings
(Fig. 8.7a, b).
Morphologic features on tissue sections tend to recapitulate
those seen on aspirate smears. Among the several scoring systems
devised to assist in histologic diagnosis of adrenocortical carcino-
mas, the Weiss system is the most widely applied. The presence of
three or more of the following criteria – nuclear grade III or IV,
mitotic rate >5 per 50 high-power fields, atypical mitosis, 25% or
fewer clear cells, diffuse architecture, necrosis, or invasion of
sinusoidal structures, venous structures, or tumor capsule –
is associated with malignancy. However, many of those features
are underestimated or not feasible on small biopsy specimens.
8 Adrenal Gland 189

Fig. 8.6 Adrenocortical carcinoma. Loose tissue fragment and single, pre-
dominantly, uniform cells with minimal “bubbly” background. Several cells
are large with nuclear membrane irregularity. Note a mitotic figure at the
bottom right of the field [Diff-Quik; high power]

a b

Fig. 8.7 Adrenal cortical carcinoma. (a) Several cells with large nuclei
[Diff-Quick stain; high power]. (b) Cluster of uniform cells and an individual
larger cell displaying nuclear atypia at the top right corner [Diff-Quick stain;
high power]

Adrenal cells are typically immunoreactive to inhibin, cal-

retinin, synaptophysin, melan A, and CAM5.2. They tend to be
negative for high molecular weight cytokeratins, chromogranin A,
190 S. Mustafa et al.

Fig. 8.8 SF1 immunostain. Strong nuclear reactivity in adrenocortical cells

[Cell block; high power]

and PAX-8. The levels of Ki-67 expression have been demon-

strated to be consistently higher in adrenocortical carcinomas
compared with adrenocortical adenomas. However, some tumors
may exhibit variable expression, and as such, a standardized
accepted threshold has not been established for malignancy
(Fig. 8.8).
Due to the morphologic heterogeneity of adrenocortical carci-
nomas, a wide range of primary and metastatic tumors should be
considered in the differential diagnosis. As previously established
in this chapter, differentiating adrenocortical adenomas from car-
cinomas is problematic and may not be achieved on needle biop-
sies and cytologic smears. Other neoplasms, including
pheochromocytoma, renal cell carcinoma, hepatocellular carci-
noma, clear cell carcinoma of gynecologic origin, malignant mel-
anoma, and large cell carcinoma of the lung, may mimic
adrenocortical carcinomas. Ancillary studies are usually needed
to make such distinctions.
8 Adrenal Gland 191

Adrenal Medulla

Pheochromocytoma

Pheochromocytoma is a rare adrenal neoplasm which

still accounts for the most common primary tumor of the adrenal
medulla. It arises from the chromaffin cells of the paraganglionic
system. The majority of cases are sporadic (> 90%), but those
that are familial usually exist as a component of multiple endo-
crine neoplasia (MEN) syndrome, neurofibromatosis, or VHL
syndrome. It has been called “the 10% tumor,” with approxi-
mately 10% asymptomatic, 10% bilateral, 10% familial, and
10% malignant. About 10% are observed in children, and 10%
occur in extra-adrenal sites. They are usually characterized by
secretion of catecholamines. This secretion can arise suddenly
leading to paroxysmal symptoms. The classic triad of symp-
toms consists of palpitations, headaches, and sweating, and
should be worked up clinically.
The role of needle biopsy and FNA in the preoperative diagno-
sis of pheochromocytoma has been questioned for fear of hyper-
tensive crises and fatal hemorrhage. Although those complications
are rather rare, cytopathologists should still be aware of the cyto-
logic features of pheochromocytoma prompting preventive surgi-
cal intervention in unexpected cases.
The smears are usually cellular with a hemorrhagic background
and cytoplasmic fragments. Cells are distributed singly or form
small loose groups with ill-defined margins between cells (Fig. 8.9).
The neoplastic cells tend to be large, with abundant cytoplasm and
at least moderate nuclear pleomorphism. Nuclei are eccentrically
located, illustrating plasmacytoid cell morphology (Fig. 8.10a, b).
Binucleation and multinucleation, naked nuclei, and intranuclear
pseudoinclusions are common findings. The chromatin is granular
and often has a stippled appearance (Fig. 8.11). Presence of intra-/
extracellular globular bodies with microvesicular content and
smaller neuroendocrine type cells is also commonly noted. Few
published studies alluded to the presence of malignancy when such
small cells are encountered in the absence of hyaline globules and
192 S. Mustafa et al.

Fig. 8.9 Pheochromocytoma. Syncytial group of cells with ill-defined cyto-

plasmic borders in a hemorrhagic background [Diff-Quik; medium power]

a b

Fig. 8.10 Pheochromocytoma. (a) Tissue fragment displaying rosette for-

mation. (b) Neoplastic cells with plasmacytoid appearance and abundant
cytoplasm. Few interspersed smaller neuroendocrine cells are noted [Diff-­
Quik; high power]

sustentacular cells. However, no specific cytomorphologic features

have been proven to ­differentiate between benign pheochromocyto-
mas and their malignant counterparts.
8 Adrenal Gland 193

Fig. 8.11 Pheochromocytoma. Predominantly single cells with nuclear

pleomorphism, bi-/multinucleation and few intranuclear pseudo-inclusions
[Diff-Quik; high power]

Adrenocortical tumors are the main differential for pheochro-

mocytomas. Nevertheless, the former is less pleomorphic, show-
ing a rich lipid background and cytoplasmic microvacuolization.
Renal cell carcinoma is another consideration, particularly the
chromophobe type, which may resemble pheochromocytoma. In
addition to immunocytochemical differences, smears of chromo-
phobe renal cell carcinomas show less cytoplasmic fragility, with
well-preserved cellular limits and greater vacuolization. This
entity is further discussed in Chap. 5. Regarding differentiation
from metastatic tumors, the great majority of patients with adre-
nal metastases have evidence of neoplastic disease elsewhere. In
conjunction with ancillary studies, an accurate diagnosis can be
rendered (Fig. 8.12a, b).
194 S. Mustafa et al.

a b

Fig. 8.12 Pheochromocytoma. (a) Strong immunoreactivity to synaptophy-

sin. (b) Positive chromogranin immunostain [(cell block; low power]

Neuroblastoma

Neuroblastic tumors are derived from primitive neuroectodermal

cells. Nearly 65% of tumors arise in the abdomen, of which half
of the cases are localized to the adrenal medulla. This embryonic
malignancy represents the most common extracranial solid tumor
in childhood, and the majority of cases are diagnosed before the
age of 5. The complexity of those tumors relies on a diverse clini-
cal course, ranging from wide metastatic spread to spontaneous
regression. Sporadic occurrences tend to exceed those harboring
inherent germline mutations. Prognosis correlates with age and
degree of differentiation, and thus, outcomes vary from high rates
of survival to recurrence and mortality.
The pathologic assessment is essential for confirmation.
Recent published data attest to the value of FNA and small biopsy
specimens in the initial work-up, and, perhaps, reaching accurate
interpretation. One limitation, however, is assessing for the degree
of differentiation, which requires complete or thorough sampling.
Histologically, neuroblastomas are exclusively composed of
immature neuroblasts and are Schwannian stroma-poor. Rosette-­
like patterns (Homer-Wright) surrounding a delicate, eosinophilic
neuropil can be seen. Undifferentiated neuroblasts are small to
medium in size, with indiscernible cytoplasm, round nuclei, stip-
pled chromatin, and may have distinct nucleoli. Conversely, the
differentiated cell types show synchronous differentiation of
8 Adrenal Gland 195

nuclei, displaying an increase in size with vesicular chromatin

and prominent nucleoli; the cytoplasm is typically more abun-
dant. Coagulative necrosis, fibrin, and collagen are also common
findings.
Ganglioneuroblastomas, on the other hand, are a composite of
neuroblasts and ganglion cells. They display pockets of cells in
various stages of differentiation and/or neuropil. The ganglion
cells are typically large with distinct cellular borders. Abundant
rough endoplasmic reticulum (Nissl substance) is reflected
through the cytoplasmic granularity of ganglion cells. Nuclei are
eccentrically located with prominent nucleoli.
Ganglioneuromas represent the mature end of the spectrum.
They are mainly composed of ganglion cells in varying distribu-
tion and number, surrounded by Schwann cells. Absence of neu-
ropil is mandatory to exclude a ganglioneuroblastoma.
Cytologic features of neuroblastomas are usually distinct, but
there may be significant morphologic overlap with other small
round blue cell tumors. Aspirations include varying numbers of
individual small, primitive cells with occasional poor to well-­
formed pseudo-rosettes (Homer-Wright rosettes). Tumor cells are
typically embedded in a metachromatic fibrillary background
with delicate cytoplasmic processes representing neurofibrils. The
cells tend to have scanty cytoplasm and round nuclei with granu-
lar “salt and pepper” chromatin and small nucleoli. Occasional
cells with more abundant cytoplasm and eccentric nuclei; and
cells with elongated nuclei and unipolar cytoplasmic extensions
may be present. Foci of nuclear molding can also be observed.
Electron microscopic analysis (although now obsolete), charac-
terizes neurosecretory granules and synaptic vesicles. Depending
on the degree of differentiation, an increasing number of ganglion
cells can be identified.
Neuroendocrine markers, such as synaptophysin, chromo-
granin, and specific neuron enolase (SNE), usually highlight
tumor cells. Additionally, neurofilament proteins as well as glial
fibrillary acidic protein (GFAP) can be helpful. None of those
markers, however, can exclusively label neuroblastomas, particu-
larly when dealing with an undifferentiated subtype. A trendy new
196 S. Mustafa et al.

marker is PHOX2B, assuming its specific role in differentiating

neuroblastomas from other mimickers.
Fluorescence in situ hybridization (FISH)/cytogenetics and
molecular diagnostics have been greatly utilized in the evaluation
of neuroblastic tumors. The significance of such studies is not
only limited to establishing diagnosis but also weighs in the prog-
nostication of such tumors. N-MYC amplification, usually
detected by FISH studies, correlates with unfavorable histology.
Additionally, near-diploid tumors have exceedingly worse events.
Consistent with tumors of neural origin, familial and sporadic
neuroblastomas can express anaplastic lymphoma kinase (ALK1).
Currently, sequencing the kinase domain is being used to detect
this aberration, and attempts to label the active protein; but immu-
nohistochemistry and Western blotting have not been successful.
Although ALK1 has been known as a treatable therapeutic target
in several other tumors, the common mutations observed in neu-
roblastomas appear to show de novo insensitivity to ALK inhibi-
tors. Thus, complementary therapeutic approaches are being
currently studied to overcome poor outcomes associated with this
mutation.
The main differential diagnoses include other small round blue
cell tumors, mainly Ewing sarcoma, primitive neuroectodermal
tumor (PNET), nephroblastoma, and small cell desmoplastic
tumors. Hematolymphoid neoplasms exhibiting similar cytomor-
phology, like Burkitt’s lymphoma, should also be considered.
Batteries of immunohistochemical stains are usually needed for
precise classification.

Metastatic Neoplasms

Owing to a rich sinusoidal blood supply, the adrenal glands are

common sites of metastasis from various organs. The lungs and
breasts account for the vast majority of primary sites, followed by
tumors of the gastrointestinal tract and kidneys (Fig. 8.13a, b).
Hepatocellular and bile duct carcinomas have been encountered
in higher numbers in patients of East Asian descent. While only
2% of incidentally found adrenal lesions represent extra-adrenal
8 Adrenal Gland 197

a b

Fig. 8.13 Metastatic adenocarcinoma. (a) At the bottom right corner is a

tissue fragment composed of neoplastic cells with acinar formation and sev-
eral nuclear grooves. (b) Tumor cells with pleomorphic nuclei infiltrating into
benign adrenal cells [Diff-Quik; high power]

metastasis, the risk may be as high as 50%–75% in patients with

a documented malignancy elsewhere. A unilateral presentation is
more often noted, with the left adrenal gland being commonly
involved. The vast majority of metastatic lesions are asymptom-
atic; with only few reported cases of massive gland destruction
leading to adrenal insufficiency.
The role of current imaging techniques is limited in character-
izing metastasis, therefore emphasizing the importance of tissue
sampling. EUS-guided biopsy/FNA remains to be a safer and far
more effective tool in triaging such cases as compared to tradi-
tional methods.
Morphologic distinction of metastatic tumors from primary
adrenal lesions, particularly adrenocortical adenoma/hyperplasia,
is not a diagnostic dilemma. Few studies, however, have reported
difficulties in discriminating adrenocortical adenomas from small
round blue cell tumors (Fig. 8.14). Renal cell carcinoma is another
entity that could resemble adrenocortical neoplasms (Fig. 8.15)
(refer to adrenocortical adenomas/hyperplasia section). Applying
a PAX-8 immunostain is helpful in establishing renal origin in
these cases.
FNA of poorly differentiated tumor cells encompasses a wide
range of differential diagnoses including adrenocortical carcino-
mas, pheochromocytomas, metastatic carcinomas, and high-grade
lymphomas. Correlation with clinical and radiological data, in
198 S. Mustafa et al.

Fig. 8.14 Metastatic small cell carcinoma. Single cells with scant cytoplasm
and stippled chromatin. Few cells show nuclear molding [Papanicolaou stain;
high power]

Fig. 8.15 Renal cell carcinoma. [Diff-Quik; medium power]

8 Adrenal Gland 199

a b

Fig. 8.16 Metastatic melanoma. (a) Tight tissue fragment of cells with large
nuclei and several prominent nucleoli. (b) Discohesive cells with large, irreg-
ular nuclei and intracytoplasmic melanin pigment [Diff-Quik; high power]

conjunction with appropriate immunohistochemical antibody

panels, is imperative to reach accurate pathologic diagnosis
(Fig. 8.16a, b).

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Fine Needle Aspiration
and Core Biopsy Specimens: 9
Germ Cell Neoplasms

Kimberly S. Point du Jour,

Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

Historically, incisional biopsy of neoplasms within the testicular

parenchyma and paratesticular tissue has not been attempted
because of documented and substantial risk of tumor spread. In
this setting, fine needle aspiration (FNA) biopsy of these lesions
is emerging as an attractive alternative because there is little to no
risk of tumor seeding of the needle tract or increased distant

K. S. Point du Jour (*)

Emory University School of Medicine, Atlanta, GA, USA
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 201

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_9
202 K. S. Point du Jour et al.

metastases with the use of fine (less than 22 gauge) needles.

Notwithstanding, FNA of the testes remains controversial.
­
Benefits of FNA include immediate diagnosis or categorization of
lesions as benign or malignant as well as decreased time to initia-
tion of definitive treatment. Because the majority of scrotal masses
are benign, FNA diagnoses obviate the need for orchiectomy in
many patients. As in other organ systems, tumor heterogeneity
poses a challenge to the pathologist interpreting FNA material;
nevertheless, if a diagnosis of malignancy can be rendered, the
specific components of a neoplasm will be identified on the sub-
sequently resected specimen.
Paratesticular lesions include neoplasms of the genitourinary
(GU) tract proper, soft tissue, and hematopoietic system. Tumors
arise from the spermatic cord, tunica, and epididymis. Benign and
malignant neoplasms, including lipomas, vascular lesions, and
sarcomas, grow from adipose and fibrovascular tissues in this area.
The hematopoietic system is not excluded from the testicle and
paratesticular zone, so any systemic leukemia can involve these
tissues; and lymphoma is not an uncommon occurrence. Common
non-neoplastic lesions of this area of the GU tract consist of cystic
lesions (hydrocele, spermatocele, hematocele) and orchitis
(discussed in Chap. 10). While some of these lesions can be readily
classified radiologically (particularly vascular neoplasms), tissue
diagnosis by FNA is a viable and valuable option.
The FNA and/or small biopsy diagnosis of germ cell neo-
plasms in locations other than the testis or genitourinary tract (i.e.,
mediastinal masses and CNS masses) is made in a similar fashion
to those arising in the genitourinary tract. These lesions are largely
histologically indistinguishable from those arising in the typical
locations, and the access (CT scan guided or ultrasound guided,
etc.) is analogous to the approach to those lesions for any other
diagnosis.
Due to the limited nature of FNA and small biopsy specimens,
not all components of a mixed germ cell tumor may be sampled
(Figs. 9.1, 9.2, and 9.3). Even when present, it may be difficult to
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 203

a b

Fig. 9.1 Mixed germ cell tumor. (a, b) It may be difficult to identify the
various components of a mixed germ cell tumor, even if all components are
present, on a small biopsy specimen. The cells are overtly malignant and
often quite large, which should suggest the possibility of a germ cell tumor in
the proper clinico-radiologic environment [Diff-Quik; intermediate (a) and
high (b) powers]

Fig. 9.2 Mixed germ cell tumor, cell block. The cells seen in the previous
figure are shown in a cell block preparation. Without immunohistochemistry,
it is difficult to know whether the sample contains mixed components or a
pure population of cells [H&E; intermediate power]
204 K. S. Point du Jour et al.

a b

c d

Fig. 9.3 Mixed germ cell tumor. (a) A pankeratin stain is positive in a non-­
seminomatous component, while the seminomatous component is negative.
(b) Oct3/4 shows nuclear positivity in either seminoma or embryonal
carcinoma. (c) AFP highlights a distinct population of yolk sac tumor cells.
(d) CD30 demonstrates cytomembranous staining in a small component of
embryonal carcinoma present in this mixed tumor [immunohistochemical
stains for (a) AE1/AE3, (b) OCT 3/4, (c) AFP, and (d) CD30]

identify all components present in a mixed germ cell tumor in a

small sample using immunohistochemical studies alone.
Correlation with serum markers is recommended. Most impor-
tantly, it should be noted whether the specimen contains a semino-
matous and/or non-seminomatous component, as
non-seminomatous germ cell tumors are less sensitive to radio-
therapy and more likely to metastasize (Figs. 9.4, 9.5, 9.6, 9.7,
9.8, 9.9, 9.10, 9.11, and 9.12). Secondly, the clinical team should
be made aware by documentation in the report that FNA and/or
small biopsy may not have sampled all components and a mixed
germ cell tumor cannot be excluded.
The FNA of germ cell tumors usually occurs in metastatic
lesions, many of which are located in the mediastinum. The dif-
ferential diagnosis often includes lymphoma. While the cytomor-
phologic features of each germ cell tumor type are covered below,
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 205

a b

c d

Fig. 9.4 Seminoma. (a–d) Seminoma usually yields a cellular population of

dispersed large, malignant cells in a background of lymphocytes. The cells
have prominent nucleoli. The background may have a “tigroid” appearance
but this is not necessarily seen and is not necessarily specific for seminoma
[Diff-Quik; intermediate power]

Fig. 9.5 Seminoma. The cells demonstrate anisonucleosis and have a con-
densed rim of blue cytoplasm with cytoplasmic vacuolization. Background
small lymphocytes are seen. This morphology may be mistaken for a lym-
phoma if a germ cell tumor is not suspected [Diff-Quik; high power]
206 K. S. Point du Jour et al.

a b

Fig. 9.6 Seminoma. (a, b) Large, mostly dispersed tumor cells are seen,
many with large nucleoli. Lymphocytes are in the background, though these
may arise from benign lymphoid tissue if a metastasis has been sampled [Pap
stain; high power]

a b

c d

Fig. 9.7 Seminoma, cell block. (a) The tumor cells appear densely packed
and lack their distinctively dispersed nature that was seen on conventional
smears. (b) OCT 3/4 supports the diagnosis of seminoma but may also be
positive in embryonal carcinoma. (c) c-kit staining was weakly positive,
supportive of a seminoma, as embryonal carcinoma is typically negative for
c-kit. (d) Weak yet positive PLAP staining further supported a diagnosis of
seminoma [H&E; intermediate power (a) and immunohistochemical stains
for OCT 3/4 (b), c-kit (c), and PLAP (d)]
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 207

Fig. 9.8 Non-seminomatous germ cell tumor. The field contains numerous
large cells in a background of necrosis and mixed inflammation. The mor-
phology indicates that this is a malignant process but is otherwise nonspecific
[Diff-Quik; low power]

a b

Fig. 9.9 Non-seminomatous germ cell tumor. (a, b) At higher magnification,

large pleomorphic cells with prominent nucleoli and high N/C ratios can be
seen. Lymphocytes can be seen in the background but are outnumbered by
acute inflammatory cells, which may be present secondarily to necrosis [Diff-­
Quik (a) and Pap stain (b); intermediate power]
208 K. S. Point du Jour et al.

a b

Fig. 9.10 Non-seminomatous germ cell tumor. (a, b) Unlike seminoma,

non-seminomatous tumors tend to form three-dimensional tissue fragments
(a) but may also have dispersed cells (b). This morphology mimics adenocar-
cinoma, but many patients are young adults and less likely to have the typical
adenocarcinoma seen in adults [Pap stain; intermediate power]

Fig. 9.11 Non-seminomatous germ cell tumor. Naked nuclei can be seen
with atypical chromatin patterns [Pap stain; high power]

non-seminomatous germ cell tumors usually consist of very large

cells with clumpy chromatin or prominent nucleoli, and hence
their morphology does not significantly overlap with lymphoma.
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 209

a b

c d

Fig. 9.12 Non-seminomatous germ cell tumor, cell block. (a) The morphol-
ogy on cell block matches with that seen in the conventional smears but is
otherwise nonspecific. (b) SALL-4 positivity is useful in establishing the
malignancy as a germ cell tumor, as the stain is both sensitive and specific for
germ cell tumors in the proper setting. (c) Strong positivity for pankeratin
suggests this to be a non-seminomatous germ cell tumor. (d) The tumor cells
lack CD30 staining and thus may represent a non-seminomatous germ cell
tumor other than embryonal carcinoma. In this case, a specific subtype was
never identified [H&E (a); intermediate magnification and immunohisto-
chemical stains for SALL-4 (b), AE1/AE3 (c), and CD30 (d)]

They also tend to form tissue fragments, whereas lymphomas do

not form true tissue fragments. The differential diagnosis may
include thymic carcinoma as well as metastatic adenocarcinoma.
Seminomas may mimic lymphomas and melanomas, as they are
not as large as most non-seminomatous germ cell tumors. They
also have prominent nucleoli and are more dispersed and do not
tend to form tissue fragments. Positive SALL-4 nuclear staining is
specific for most germ cell tumors but may be lacking in some
teratomas.
210 K. S. Point du Jour et al.

Germ Cell Neoplasms

Seminoma

Seminoma is the most common germ cell tumor of the testes and
tends to occur in a slightly older population of men than other
germ cell neoplasms. Aspiration of these tumors typically yields a
cellular specimen with abundant, homogenous, large, and round
cells in loose sheets that are singly dispersed (Figs. 9.4, 9.5, 9.6,
and 9.7). The cells do not tend to form three-dimensional clusters.
The enlarged nucleus is fragile and features a distinct, sizable
nucleolus. Chromatin threads and filaments may be present as an
artifact of preparation. The nuclear to cytoplasmic ratio is
increased and mitotic figures are readily identifiable. A prominent
population of lymphocytes and plasma cells surround tumor cells,
similar to the morphology seen on excision. On Romanowsky-­
type stains, lymphoglandular bodies may be seen as a reflection of
increased lymphocytes within the lesion. If present, this stain also
shows the characteristic tigroid or striped background composed
of glycogen-rich material exuded from the disruption of the cyto-
plasm by the smearing technique. Though necrosis may be seen,
hemorrhage is not conspicuous. Granulomas are a nonspecific
finding that has been described in seminomas as well as benign
lesions such as orchitis, tuberculosis, and epidermoid cysts.
Immunohistochemical stains can be performed on a formalin-­
fixed paraffin-embedded cell block. Malignant cells are positive
for OCT3/4, PLAP, and podoplanin (D2-40).

Spermatocytic Tumor

As of the 2016 WHO classification, the name “seminoma” was

removed from the nomenclature of this tumor type and replaced
with “tumor” for a variety of reasons, some of which are discussed
below. These tumors are seen with much less frequency than clas-
sic seminoma, and are much more common in older men. Three
cell types of varying sizes are identified on smears and the cell
block: small, intermediate, and giant cells. The presence of differ-
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 211

ent cell types imparts a polymorphism not seen in other germ cell
tumors, aiding in the diagnosis. Lymphoglandular bodies, tigroid
substance, and necrosis are usually absent. These tumors also lack
a gynecologic component and are not typically seen outside of the
genitourinary tract. These are useful features to distinguish this
entity from classic seminoma, in addition to the very different
immunohistochemical profile. Cells of a spermatocytic tumor are
positive for SALL4 and CD117. They are negative for OCT3/4,
D2-40, PLAP, glypican-3, alpha-fetoprotein, HCG, CD30, and
cytokeratin.

Embryonal Carcinoma

The submitted material often exhibits high cellularity and abun-

dant three-dimensional groups (Figs. 9.13, 9.14, and 9.15).
Malignant cells are undifferentiated and epithelioid with marked
anaplasia. The cells are large and polymorphic with large nuclei
and multiple prominent, irregular nucleoli. Coarse chromatin and
bizarre mitotic activity is seen. A moderate quantity of cytoplasm
is amphophilic, and cell membranes can be indistinct. Apoptosis
is frequently present. The background often contains swaths of
hemorrhage and necrosis. In a tumor with glandular growth pat-
tern, columnar cells and even cytoplasmic vacuoles may be

a b

Fig. 9.13 Embryonal carcinoma. (a, b) Large, pleomorphic malignant cells

are seen forming three-dimensional structures adjacent to normal benign duo-
denal fragments. The malignant cells have coarse chromatin and minimal
cytoplasm [Diff-Quik; high magnification]
212 K. S. Point du Jour et al.

a b

Fig. 9.14 Embryonal carcinoma. (a, b) On cell block, the malignant cells
can be more clearly seen and match the morphology present on the conven-
tional smears [H&E; intermediate and high magnifications]

a b

c d

Fig. 9.15 Embryonal carcinoma. (a, b) Positive nuclear staining for

SALL-4 identified these cells as arising from a germ cell tumor. (c, d) Cyto-
membranous staining for CD30 suggested that an embryonal carcinoma
component was sampled [immunohistochemical stains for SALL-4 (a, b)
and CD30 (c, d)]

observed. Tumor cells are positive for CD30, OCT3/4, SALL4,

and pancytokeratin. Focal alpha-fetoprotein and/or HCG may be
present, but neoplastic cells are negative for CK20, glypican-3,
alpha-inhibin, and calretinin.
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 213

Yolk Sac Tumor

By definition, yolk sac tumors exhibit a range of growth patterns

(Figs. 9.16, 9.17, 9.18, 9.19, 9.20, 9.21, 9.22, 9.23, 9.24, 9.25, and
9.26). Eleven different histologic subtypes of yolk sac tumor
exist, rendering the diagnosis somewhat difficult (in the absence
of immunohistochemistry – see below) on small biopsies and
aspirate material. Smears and cell blocks generally contain loosely
cohesive epithelioid cells with minimal pleomorphism and clear
to vacuolated eosinophilic cytoplasm. The cells may be innocuous
as to suggest a benign entity; however, three-dimensional clusters
and nuclear overlapping, glomeruloid, or papillary structures
along with occasional larger, immature cells with hyperchromatic
nuclei should raise suspicion. Hyaline globules may be seen as
well as a mucoid background. The differential diagnosis includes
embryonal carcinoma and microcystic Leydig cell tumor. The for-
mer has marked cytologic pleomorphism and frequent mitoses,

Fig. 9.16 Yolk sac tumor. Yolk sac tumors demonstrate a variety of mor-
phologies that have best been described on histology. Thus, cytomorphologic
findings vary depending on the growth pattern [Diff-Quik; intermediate
power]
214 K. S. Point du Jour et al.

Fig. 9.17 Yolk sac tumor. Tumor cells have formed primarily monolayered
fragments with papillary projections [Diff-Quik; intermediate power]

Fig. 9.18 Yolk sac tumor. The cells have high N/C ratio and demonstrate
anisonucleosis. However, the pleomorphism seen is not as dramatic as that
seen in embryonal carcinoma or choriocarcinoma [Pap stain; intermediate
power]
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 215

Fig. 9.19 Yolk sac tumor. The nuclei here are oval and arranged in a disor-
derly fashion. The cytoplasm has a granular/foamy appearance and glandular-­
like formations can be seen. This morphology may mimic a conventional
adenocarcinoma [Diff-Quik; high power]

a b

Fig. 9.20 Yolk sac tumor, cell block. (a) Yolk sac tumor with Schiller-Duval
bodies in a cell block preparation. (b) The cells are positive for AFP [H&E
(a); intermediate magnification; AFP immunohistochemical stain (b)]

while the latter generally has a more uniform cell population with
markedly eosinophilic cytoplasm. Histochemical and immunohis-
tochemical stains are useful to narrow the diagnosis. PAS positive
hyaline globules are present in the microcystic, solid, hepatoid,
216 K. S. Point du Jour et al.

a b

Fig. 9.21 Yolk sac tumor. (a, b) A different case of YST demonstrating tra-
becular, three-dimensional architecture and greater nuclear pleomorphism
than the previous case [Diff-Quik; intermediate power]

Fig. 9.22 Yolk sac tumor. In this YST specimen, the nuclei have a spindled
appearance and consideration may be given to a spindle cell tumor. However,
the nuclei are extremely large compared to the background red blood cells, a
sign that this is a malignant process [Pap stain; high power]

and reticular growth patterns. Cells are positive for cytokeratin,

glypican-3, and SALL4 and negative for CD30, D2-40, OCT3/4,
CD117, HCD, inhibin, and calretinin.
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 217

a b

Fig. 9.23 Yolk sac tumor, cell block. The cells have abundant, vacuolated
cytoplasm and are associated with vessels (a). This appearance resembles
renal cell carcinoma. However, a SALL-4 stain is positive (b), indicating that
this is a germ cell tumor. [H&E (a); intermediate power and SALL-4 immu-
nostain (b)]

a b

Fig. 9.24 Yolk sac tumor in pelvic washing specimen. (a, b) YST tumors
may be seen in pelvic washing specimens. In this case, the cells resembled
glandular cells and could suggest the possibility of a serous carcinoma, endo-
metriosis, or endosalpingiosis [Pap stain; high power]

Choriocarcinoma

The FNA yields a two-cell population of cytotrophoblasts and

syncytiotrophoblasts in a background of hemorrhage and necrosis
(Figs. 9.27, 9.28, 9.29, 9.30, and 9.31). Mononucleated cytotro-
phoblasts are round or polygonal with distinct cell borders, clear
cytoplasm, and inconspicuous nucleoli. Large multinucleated
syncytiotrophoblastic cells contain abundant eosinophilic cyto-
plasm with easily seen vacuoles. Nuclei are bizarre and hyper-
chromatic. Cytoplasm is abundant and blue on air-dried slides or
218 K. S. Point du Jour et al.

Fig. 9.25 Yolk sac tumor in pelvic washing specimen, cell block. On cell
block, this YST had a distinctive growth pattern that could also be seen in an
adenocarcinoma [H&E; intermediate power]

eosinophilic on Papanicolaou stained slides. Trophoblasts exhibit

various characteristic morphologies based on the variant (e.g.,
epithelioid, placental site, monophasic, etc.).
Cytotrophoblasts are positive for SALL4, p63, and GATA3
and negative for CD30, D2-40, and OCT3/4. These tumors tend to
stain intensely with beta-HCG as well, which should be the “go
to” immunohistochemical stain upon detection of syncytiotropho-
blasts, particularly if serum levels of Beta-HCG are elevated in
male patients. While immunohistochemical stains can help with
the differential between neoplastic lesions (especially other germ
cell tumors with syncytiotrophoblasts, such as seminoma), the
main challenge to the diagnosis of choriocarcinoma on FNA or
small biopsy is inadequate sampling despite extensive hemorrhagic
and/or necrosis within the lesion. Non-neoplastic hemorrhagic
lesions within the testes include torsion and trauma, neither of
which tend to be mass forming and are rarely sampled.
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 219

a b

c d

Fig. 9.26 Yolk sac tumor in pelvic washing specimen. The YST cells were
positive for the epithelial marker claudin-4 (a), the germ cell tumor marker
SALL-4 (b), the yolk sac tumor marker AFP (c), and glypican (d), which can
also be positive in choriocarcinoma and some embryonal carcinomas [immu-
nohistochemical stains for claudin-4 (a), SALL-4 (b), AFP (c), and glypican
(d)]

a b

Fig. 9.27 Choriocarcinoma. (a, b) Choriocarcinoma typically yields an

overtly malignant cell population. Depending on the cell types present, cyto-
morphology may vary and different cell populations may be seen [Diff-Quik;
intermediate power]
220 K. S. Point du Jour et al.

a b

Fig. 9.28 Choriocarcinoma. (a, b) The cytomorphologic features of chorio-

carcinoma on FNA are not entirely specific and thus immunohistochemical
studies are useful. Cases may lack the distinctive multinucleated syncytiotro-
phoblasts, though their presence is not specific to choriocarcinoma [Diff-­
Quik; high power]

Fig. 9.29 Choriocarcinoma. Note the enlarged cells with nucleoli that are
larger than background neutrophils. Such morphology should always suggest
the possibility of a germ cell tumor, in the proper clinical setting [Pap stain;
high power]
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 221

a b

c d

Fig. 9.30 Choriocarcinoma with seminomatous component, cell block. The

malignant cells in this cell block preparation (a) were positive for AE1/AE3
(b), beta hCG (c), and negative for OCT 3/4 (d). However, OCT 3/4 was
positive and AE1/AE3 negative in a subset of the tumor cells, indicating the
presence of a seminomatous component [H&E (a); intermediate power and
immunostains for AE1/AE3 (b), HCG (c), and OCT 3/4 (d)]

Teratoma/Malignant Teratoma

The cytologic diagnosis of teratoma is difficult due to sampling

constraints. Primarily, ectoderm, mesoderm, and endodermal
components must be present within the sample, considering all
smears and fixed tissue. An exception to this requirement is mono-
dermal teratoma (e.g., struma, carcinoid, etc.), which may be
diagnosed with the finding of a single cell population (e.g., ­thyroid
follicular cells, neuroendocrine cells, etc.) in the appropriate
radiologic or clinical setting. Another challenge is that small por-
tions of malignant neoplasm (e.g., embryonal carcinoma or semi-
noma) in a mixed germ cell tumor can be missed as well as
malignant teratomatous elements such as immature neuroecto-
derm, adenocarcinoma, or squamous cell carcinoma. False nega-
222 K. S. Point du Jour et al.

Fig. 9.31 Choriocarcinoma, core biopsy. The corresponding core biopsy

contained mostly fibrous tissue with only rare inflammatory cells, making the
cell block preparation much more useful for immunohistochemical studies
[H&E; low power]

tive results from acellular fluid aspirated from cystic areas of a

teratoma are possible. Conversely, false positives occur when
columnar cells are aspirated from herniated bowel or normal
colorectal mucosa.

Sex Cord-Stromal Tumors

Granulosa Cell Tumor

Small, low-grade cells in aggregates and rosette-like follicles are

present in a background devoid of mucin, blood, or glycogen.
Finely granular cytoplasm with indistinct cell borders is present
as well as monotonous, round nuclei and vesicular chromatin.
Nucleoli are not seen. Romanowsky stains show amorphous
metachromatic structures surrounded by palisading tumor cells
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 223

(Call-Exner bodies). Malignant tumors show increased mitoses

and necrosis. The differential diagnosis includes other stromal
tumors as well as mixed germ cell and sex cord-stromal tumors.
Cells of granulosa cell tumors are positive for inhibin, calretinin,
melan-A, smooth muscle actin, and S100. Keratin can be focally
positive, but the cells are negative for germ cell markers.

Leydig Cell Tumor

The aspirate is cellular, with large, monomorphic cells that are

polygonal in shape and contain round nuclei and smooth nuclear
membranes (Fig. 9.32). Cells are present in loose groups and

a b

c d

Fig. 9.32 Leydig cell tumor, core biopsy. The tumor cells have some simi-
larity to hepatocytes, with abundant polygonal cytoplasm and round, mono-
morphic nuclei (a). Cell borders are distinctly seen. The tumor cells are
positive for SF-1 (b) and inhibin (c), indicating this to be a sex cord-stromal
tumor; subclassification of sex cord-stromal tumors mostly depends on mor-
phology. The tumor cells were negative for the germ cell marker SALL4 (d)
[H&E (a); intermediate power and immunostains for SF-1 (b), inhibin (c),
and SALL-4 (d)]
224 K. S. Point du Jour et al.

c­lusters. Intranuclear cytoplasmic inclusions and invaginations

occur. In contrast to granulosa cells, the cytoplasmic borders are
well delineated. Rectangular, eosinophilic crystals (of Renke) are
infrequently observed in the cytoplasm or background of the
smear. Focal atypia in the form of binucleation or nuclear pleo-
morphism can be seen. Uncommonly, the neoplasm exhibits spin-
dle, clear cell, myxoid, or rhabdoid features. Tumors are known to
secrete androgens, but occasionally they secrete estrogen. Tumor
cells are positive for inhibin, calretinin, melan-A, WT1, and ste-
roidogenic factor (SF-1), but are negative for cytokeratin, s100,
and germ cell markers.

Sertoli Cell Tumor

Sertoli cells are cuboidal to columnar and show cytoplasmic tails.

Oval nuclei display conspicuous nucleoli and irregular chromatin.
The cytoplasm is clear to mildly eosinophilic, and vacuoles are
often present. The aspirate may contain hyalinized or vascular
stroma. The cell block can display a tubular or glandular pattern
or rarely, spindled cells. The differential diagnosis includes germ
cell tumors, adenomatoid tumor, or a Sertoli cell nodule, though
the latter entity can only be excluded based on the size of the
lesion. Unlike other sex cord-stromal tumors, these cells are posi-
tive for pancytokeratin as well as inhibin, calretinin, melan-A,
WT1, SF1, and nuclear beta-catenin. Cells are negative for germ
cell markers such as PLAP, D2-40, OCT 3/4, SALL4, alpha-­
fetoprotein, and CD30.

Lymphoma

Hematopoietic tumors secondarily involve the testes, particularly

in older men (typically greater than 60 years of age). Primary
lymphoma is also described in the testes or paratesticular struc-
tures. Diffuse large B-cell lymphoma is the most common pri-
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 225

mary lymphoma of the genitourinary tract, but follicular

lymphoma, extranodal NK/T-cell lymphoma, anaplastic large cell
lymphoma, Burkitt lymphoma, and plasmablastic lymphomas
must be distinguished from germ cell tumors (particularly
­seminoma), chronic orchitis, or metastatic neoplasms. Lymphoma
spares tubular structures as it proliferates within the interstitium.
Aspirates contain abundant atypical lymphocytes that either are
monotonous (low-grade lymphoma) or contain cleaved, non-­
cleaved, multilobated, or immunoblastic morphology depending
on the specific entity. FNA provides minimally invasive medium
for procurement of material for ancillary studies.
Immunohistochemical stains for CD45, CD20, CD70a, PAX5,
CD5, CD10, D138, kappa, and lambda are useful for characteriza-
tion of lymphocytes. Separating specific pass(es) to designate
material for flow cytometry is an even more efficient way to pro-
vide at least a general characterization of a lymphoma or leuke-
mia, as well as liberal use of hematopathology consultation. The
main differential diagnosis is a seminoma, which has an immuno-
histochemical pattern that can differentiate the two lesions (see
above).

Lipoma/Liposarcoma

This paratesticular neoplasm shows adipocytic differentiation and

is found in older men as a variably sized scrotal mass. The aspi-
rate may be acellular and consist of oily material that barely sur-
vives processing. While tissue fragments can show the
characteristic cells with their nucleus flattened to the edge by a
single, large, fat vacuole, single cells are rarely seen.
Atypical lipomatous tumor (well-differentiated liposarcoma)
is generally a larger lesion and is the most common sarcoma of
the paratesticular region. It arises from primitive mesenchymal
cells and not from lipomas. Lipoblasts are present and have a
scalloped nuclear border that is indented by multiple well-defined
cytoplasmic lipid droplets. These are best appreciated on the
226 K. S. Point du Jour et al.

Romanowsky stain. Mitoses may be identified. Mature adipose

tissue is also present, but the adipocytes are varied in size and
shape and are traversed by fibrous bands. In addition, atypical
cells are present and have enlarged, hyperchromatic nuclei. High-­
grade pleomorphic cells and dedifferentiated (leiomyosarcoma-
tous, chondrosarcomatous) components may be present.
Immunohistochemical stains for s100 and MDM2 are positive,
and desmin, myoD1, myogenin, and smooth muscle actin are
negative. Fluorescence in situ hybridization for the MDM2 ampli-
fication is a useful tool to distinguish well-differentiated liposar-
coma from benign lipomatous tumors or higher-grade sarcomas.

Adenomatoid Tumor

Adenomatoid tumors are infrequently seen tumors that can occur

in the male and female genital tract as well as in extragonadal
sites and are the most common paratesticular neoplasm. The most
common “specific” site is the epididymis, though they grow along
the tunica albuginea, spermatic cord, and ejaculatory ducts. They
have the potential to enlarge substantially and even infiltrate to
form intratesticular nodules.
On smears and cell blocks, the tumor cellularity is generally
high. Cohesive clusters, monolayered sheets, naked nuclei, and
few isolated cells are present. In contrast to the central nucleus
with prominent nucleolus of a seminoma, adenomatoid tumor
cells display an oval, eccentric nucleus and inconspicuous nucleo-
lus. Binucleation may be present, and pseudonuclear inclusions
have been described in cytologic preparations in two cases. The
cytoplasm may contain a paranuclear vacuole. While scant stro-
mal fragments may be present, mitoses, lymphocytes, and a
tigroid background are typically absent. Adenomatoid tumors
arise from mesothelial cells and retain their immunohistochemi-
cal staining pattern. Cells are positive for pancytokeratin,
­calretinin, WT-1, D2-40 and Alcian blue, while negative for MOC
31, BerEP4, CEA, SALL4, and 34betaE12.
9 Fine Needle Aspiration and Core Biopsy Specimens: Germ Cell… 227

Mesothelioma

The tunica vaginalis testis is lined by mesothelium, and testicular

mesothelioma accounts for a very small percentage of testicular
lesions as well as mesothelioma diagnoses. Asbestos exposure is
a known risk factor of primary malignant gonadal mesothelioma.
Cytologically, cells of mesothelioma show nuclear atypia, cellular
pleomorphism, and complex architectural pattern formation (in
contrast to the flat monotonous, sheets formed benign mesothelial
cells). The majority of mesotheliomas are pure epithelial malig-
nancies, but various growth patterns may be observed on an ample
cell block. These include papillary, tubulo-papillary, glandular,
and solid/poorly differentiated. The benign differential diagnosis
includes mesothelial hyperplasia and adenomatoid tumor.
Malignant entities that enter the differential include primary or
metastatic carcinomas or sarcomas.
Mesothelioma of the gonads expresses identical immunohisto-
chemical markers as tumors from the pleura and peritoneum.
Cells are positive for pancytokeratin, EMA, calretinin, podoplanin
(D2-40), thrombomodulin, and WT1. Cells are negative for
BER-­EP4, claudin-4, and MOC-31. Loss of normal immunostain-
ing for methylthioadenosine phosphorylase (MTAP) and/or
BRCA-­associated protein 1 (BAP-1) is a marker of malignancy.

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Miscellaneous Lesions
of the Genitourinary System 10
Kimberly S. Point du Jour,
Christopher J. VandenBussche,
and Carla L. Ellis

Introduction

This chapter will focus on the fine needle aspiration and small
needle core biopsy analysis of various nonneoplastic testicular
and paratesticular lesions, as well as a brief review of other mis-
cellaneous benign lesions of the genitourinary system.

K. S. Point du Jour (*)

Emory University School of Medicine, Atlanta, GA, USA
C. J. VandenBussche
The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
e-mail: [email protected]
C. L. Ellis
Department of Pathology, Northwestern University, Chicago, IL, USA
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature 231

Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7_10
232 K. S. Point du Jour et al.

Testes and Paratesticular Tissue

Cystic lesions of the testis and paratesticular region are seldom

biopsied for diagnostic purposes. However, when performed,
FNA of scrotal lesions comprised of paratesticular tissue are usu-
ally benign (approximately 50% of specimens). Below is a sum-
mary of the most common cystic lesions of the testis and
paratesticular tissue, detailing their cytological and histopatho-
logic findings.

Hydrocele

An accumulation of serous fluid between the parietal and visceral

layers of the tunica vaginalis surrounding the testicle or along the
spermatic cord. Aspiration of hydrocele contents is both diagnos-
tic and therapeutic. The clear or pale yellow-tinged fluid is pauci-
cellular. Mesothelial cells and macrophages are typically found
with occasional lymphocytes and rare neutrophils. Lymphoma
has been found in association with a hydrocele and diagnosed
based on cellular fluid contents. Seminoma has also been
described. If encountered on a biopsy, fragments of the hydrocele
wall would show mesothelium lined fibrous connective tissue,
often with a chronic inflammatory infiltrate, fibrosis, and squa-
mous metaplasia.

Spermatocele

A spermatocele is a cystic dilatation of the efferent ductule, prox-

imal rete testis, or head of the epididymis. As the name implies,
spermatozoa are found within the aspirate along with phagocytic
macrophages (spermatophages) and proteinaceous debris
(Figs. 10.1, 10.2, and 10.3). Atypical, large, pigmented, and
polygonal cells may be seen and are thought to represent seminal
vesicle epithelium or reactive myofibroblasts. Ciliated cells within
the aspirated fluid have also been reported. Biopsy tissue will
10 Miscellaneous Lesions of the Genitourinary System 233

a b

Fig. 10.1 Spermatocele. (a, b) FNA of spermatocele shows numerous

mature spermatozoa in a background of proteinaceous debris. Large macro-
phages may be present and may engulf spermatozoa [Pap stain; intermediate
and high powers]

a b

Fig. 10.2 Spermatocele. (a, b) In this separate specimen, spermatozoa can

be seen intermixed with red blood cells and degenerating “blue blob” material
[Pap stain; high power]

show cystic ­tissue lined by simple epithelial cells. The main entity
in the differential diagnosis is a hydrocele, which will not show
mature spermatozoa in the cystic contents.

Hematocele

FNA of scrotal lesions that occur after significant trauma can

reveal bright red fluid composed of mainly intact red blood cells.
Alternatively, a cystic, chocolate-like aspirated fluid would con-
tain hemosiderin-laden macrophages and deteriorating blood
234 K. S. Point du Jour et al.

Fig. 10.3 Spermatocele, cell block preparation. On cell block, spermatozoa

are best recognized by their bullet-shaped nuclei which are significantly
smaller than surrounding cells (compared to the red blood cells in this field)
[H&E; high power]

components. Biopsy tissue would reveal similar findings as a

spermatocele, with or without hemosiderin-laden macrophages.

Orchitis/Epididymitis

Acute or chronic inflammation is seen; and granulomatous lesions

are not uncommon within the scrotum. A multitude of organisms
may infect the paratestes. Reactive and reparative cells display
mild atypia. Spermatic granulomas, which are protective reac-
tions to sperm, have been described. Biopsy of a sperm granuloma
reveals extensive acute inflammation in the early stages and
chronic granulomatous inflammation with fibrosis in the later
stages. The differential diagnosis includes malignancy, particu-
larly since tumors in this region may arise in association with
10 Miscellaneous Lesions of the Genitourinary System 235

necrosis as well as chronic/granulomatous or acute inflammation.

Generally speaking, FNA or biopsy material from this region
showing prominent acute or chronic inflammation should be care-
fully analyzed for organisms with a low threshold for special or
immunohistochemical staining.

Infertility

FNA is a minimally invasive procedure with few complications

and has been shown to be adequate at identifying all cell types in
the spectrum of spermatogenesis. Among men with non-
obstructive azoospermia, FNA material can differentiate men
with Sertoli cell-only syndrome from those with maturation
arrest, hypospermatogenesis, and/or normal spermatogenesis
with elongated ­ spermatids and/or spermatozoa. Despite this
capability, testicular biopsy remains the gold standard for
evaluation of infertility and can definitively differentiate between
the above lesions and cell types with enhanced diagnostic
accuracy. The main advantage to biopsy is to clearly define the
testicular alterations contributing to infertility and distinguish
between obstructive and non-obstructive etiologies. A few
definitions merit acknowledgment here:

• Hypospermatogenesis. All stages of spermatogenesis are pres-

ent, but to reduced and/or variable degrees, some tubules
potentially showing a Sertoli cell-only pattern or tubular base-
ment membrane sclerosis.
• Maturation arrest. Complete arrest of spermatogenesis at a par-
ticular stage, with no mature spermatids (Fig. 10.4).
• Germ cell aplasia. Sertoli cells only, no germ cells of any “age”
of spermatogenesis (Fig. 10.5).
• Tubular and interstitial fibrosis. Thickening of the tubular
basement membrane and increased interstitial fibrosis. This
can be seen with and without a Sertoli cell-only pattern and/or
maturation arrest.
236 K. S. Point du Jour et al.

a b

c d

e f

Fig. 10.4 Maturation arrest. (a–f) Seminiferous tubules show partial matura-
tion, with some cells showing early spermatogenesis and no mature sperma-
tids [H&E; intermediate and high power]

Macrophages are normally found within interstitial tissues and

are not present within the seminiferous tubules. However, macro-
phages with ingested spermatozoa have been reported in FNA
cytology of testes in a background of normal spermatogenesis.
Normal or hypospermatogenesis identified in an FNA biopsy
when no sperm are found on semen examination can help confirm
the diagnosis of obstructive azoospermia.
10 Miscellaneous Lesions of the Genitourinary System 237

a b

c d

Fig. 10.5 Germ cell aplasia (Sertoli cell-only syndrome). (a–d) Seminifer-
ous tubules with no evidence of spermatogenesis [H&E; intermediate and
high power]

Penile Lesions

Fine needle aspiration of penile lesions is rare, as these are usually

diagnosed by incisional biopsy. Though squamous cell carcinoma
is the most common primary malignancy of the penis, there are
reports of primary urothelial carcinoma and even malignant
peripheral nerve sheath tumors identified on smears and/or cell
block material obtained by FNA. In addition, the penis is an
unusual location for metastatic tumors despite the abundant vas-
cularity for its size. The commonest primary tumors arise from
the prostate and urothelium, but rectosigmoid, renal, and lung car-
cinomas have also been reported. Lymphoma has also rarely been
seen in this location. Benign entities such as glomus tumors and
schwannomas are also encountered within the glans penis and
238 K. S. Point du Jour et al.

corpora and as periurethral masses infrequently. Nonneoplastic

mass forming entities within the penis and scrotum that could be
subject to fine needle aspiration include lipogranuloma,
­lymphangioma, scrotal calcinosis, extra-mammary Paget disease,
and granulomatous inflammation from foreign material. All of
these entities are histologically identical to these lesions in other
organs.

Prostate

As the field has evolved, particularly with the prognostic and

diagnostic preeminence of the Gleason scoring system and impor-
tance of grade group determination, urologists have shifted toward
the use of 18 gauge needle core biopsies (CNB) procured using
automated biopsy devices. These biopsies are usually obtained
under ultrasound or, at some institutions, with MRI guidance to
detect worrisome nodules well before they are clinically palpable.
While FNA of prostate nodules was performed in the past and
described in the literature, CNB of the prostate has become the
standard of practice, and most pathologists trained within the past
three decades have rarely diagnosed prostatic lesions or neo-
plasms on cytology specimens. A full discussion on Gleason pat-
terns, diagnostic grade groups, perineural invasion, extraprostatic
extension, intraductal spread of invasive prostate adenocarci-
noma, and various subtypes of non-acinar prostate adenocarcinoma
is beyond the scope of this chapter; however, it is important to
note that in most cases, receipt of a fine needle aspiration of a
prostatic nodule or lesion should warrant suspicion for lesions
other than typical prostate adenocarcinoma, because as mentioned
above, CNB is the gold standard for evaluation of prostate cancer
and prostate nodules. Due to the lack of modern cytologic
correlates, the discussion of prostate CNB is beyond the scope of
this textbook.
10 Miscellaneous Lesions of the Genitourinary System 239

 on-prostatic Infections and Inflammatory

N
Conditions

Infrequently, fine needle aspiration biopsy of a mass in the genito-

urinary tract reveals infection mimicking a neoplastic process. For
example, tuberculous epididymo-orchitis has been described as a
manifestation of the extrapulmonary tuberculosis disease spec-
trum with the prominent finding of caseating granulomatous
inflammation. In a study of FNA biopsy of 40 palpable epididymal
nodules in a developing country, 38 cases were nonneoplastic. In
this series, 14 cases were confirmed tuberculous granulomatous
inflammation, 10 were cystic nodules (described above), and 5
were nonspecific inflammation. Interestingly, filarial infection
accounted for 3 cases of palpable masses of the epididymis.
Careful review of the patients’ travel history can be of benefit.
Xanthogranulomatous inflammation affects the testicle as well
as the prostate, bladder, and epididymis. It is a rare, destructive
inflammatory process with the microscopic finding of lipid-laden
macrophages, lymphocytes, giant cells, and necrosis.
Xanthogranulomatous inflammation is influenced by dysregulation
of the immune system and lipid metabolism. The differential
diagnosis includes bacterial orchitis, malakoplakia, and neoplasms.
Malakoplakia is an uncommon lesion resulting from defects in
phagocytic or degradative functions of histiocytes in response to
bacteria. It is most common in the genitourinary tract, especially
the bladder, and is seen most frequently in women, older, and
immunosuppressed patients. Rare reports exist in the literature in
which these lesions were identified on FNA, but they are seen
most often on bladder biopsies. Cystoscopic lesions are multifo-
cal, soft, yellow-brown plaques that resemble hematologic lesions
involving the bladder. They most commonly involve the trigone.
Histologically, clusters of foamy epithelioid histiocytes are noted
with undigested bacteria (usually E. coli or Proteus spp.) are seen
(Fig. 10.6). These Michaelis-Gutmann bodies are PAS positive,
and positive staining of calcium deposits with von Kossa can be
seen as well. The histiocytes are CD68 and CD163 positive
(Figs. 10.7 and 10.8).
240 K. S. Point du Jour et al.

Fig. 10.6 Malakoplakia of the bladder. A cluster of histiocytes with promi-

nent Michaelis-Gutmann bodies [H&E; high power]

Fig. 10.7 Malakoplakia of the bladder. Positive CD68 (histiocytic marker)

staining [CD68 immunohistochemical stain]
10 Miscellaneous Lesions of the Genitourinary System 241

Fig. 10.8 Malakoplakia of the bladder. The cluster of histiocytes demon-

strates extensive staining for calcium deposits [von Kossa special stain]

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Index

A myelolipoma, 186, 187

Acute pyelonephritis, 165 adrenal medulla
Adenocarcinoma of the bladder, 74 neuroblastoma, 194–196
Adenomatoid tumors, 226 pheochromocytoma, 191,
Adrenal cortex, 182 193
adrenal cortical carcinoma, 187, anatomy of, 181–183
188, 190 imaging accuracy, 181
benign adrenal cortical nodules/ imaging techniques, 180
adenomas, 184–186 metastatic neoplasms, 196, 197,
benign cysts, 186 199
infections/inflammatory Adrenocortical carcinoma, 189
conditions, 183 Angiomyolipoma, 168–172
myelolipoma, 186, 187 Atypical lipomatous tumor, 225
Adrenal cortical adenoma, 184–186 Atypical urothelial cells (AUC), 47
Adrenal cortical carcinoma,
187–190
Adrenal gland B
adrenal cortex Bacteria, 16
adrenal cortical carcinoma, Benign adrenal cortical nodules/
187, 188, 190 adenomas, 184–186
benign adrenal cortical Benign cysts, 161, 162, 186
nodules/adenomas, acute pyelonephritis, 165
184–186 cytomorphology, 163
benign cysts, 186 histomorphology, 162
infections/inflammatory renal infarction, 167, 168
conditions, 183 XGP, 166

© The Editor(s) (if applicable) and The Author(s), under exclusive 243
license to Springer Nature Switzerland AG 2022
C. J. VandenBussche, C. L. Ellis (eds.), Genitourinary System
Cytology and Small Biopsy Specimens, Essentials in Cytopathology
29, https://doi.org/10.1007/978-3-030-87875-7
244 Index

Benign renal elements, 154, 155 Contaminants, endometrial cells, 21

Benign renal neoplasms, 168 Core biopsies, 85, 86
angiomyolipoma, 168–170 Corpora amylacea, 20
metanephric adenomas, 177, 178 CT guided renal biopsies, 86
oncocytoma, 171–173, 176 Cyst fluid, 163
papillary adenoma, 175, 177 Cyst lining cells, 163, 164
Benign renal parenchyma, 160 Cystitis cystica, 8, 9, 58
Benign urothelial tissue, 132 Cystitis glandularis, 8, 9
Biopsy, technique and imaging, 86, 87 Cystoscopy, 1
Birt-Hogg-Dube syndrome, 173 Cytomegalovirus (CMV), 17
BK polyomavirus, 16, 17
BK polyomavirus cytopathic effect,
17 D
Bladder cancer, 39 Decoy cells, 17
Blue blob cells, 70 Diffuse large B-cell lymphoma, 142
Bosniak system, 161, 162 Distal convoluted tubules, 156, 161

C E
Carcinoma in situ (CIS), 2 Embryonal carcinoma, 211, 212
Carcinoma with squamous Endometrial cells, 21
differentiation, 138–141 Epididymitis, 234
Cercariform cells, 134 Exfoliated acellular components
Choriocarcinoma, 217–222 casts, 19
Chromophobe renal cell carcinoma corpora amylacea, 20
(RCC), 112–114 crystals, 18
cytomorphology, 111, 112 Exophytic tumors
histomorphology, 114 low grade papillary urothelial
Clear cell papillary renal cell carcinoma (LGPUC), 26,
carcinoma, 116–118 27, 30
Clear cell renal cell carcinoma PUNLMP, 25
(CRCC), 88–92, 94, urothelial papilloma, 24, 25
96–98, 160
cytomorphology, 88
histomorphology, 95 F
Clear cell tubulopapillary renal cell Fine needle aspirates and cytology
carcinoma (CCPRCC) specimens, 143
cytomorphology, 115 Fine needle aspiration (FNA), 85,
histomorphology, 117 151, 181, 191, 235
Collecting duct carcinoma non-prostatic infections and
cytomorphology, 117, 118 inflammatory conditions,
histomorphology, 119 239
Collecting duct epithelial cells, 156 of penile lesions, 237, 238
Index 245

Florescent in-situ hybridization cytology of, 46, 47, 49

(FISH), 196 definition of, 40
Fungus, 16 GATA-3 positivity in, 134
glandular differentiation, 67, 69
histologic features of, 42
G invasive high-grade urothelial
Ganglioneuroblastomas, 195 carcinoma, 44, 45
Geographic necrosis, 69 micropapillary varient, 59, 60
Germ cell aplasia, 235, 237 with necrosis, 135
Germ cell neoplasms, 202, 204, 209 nested variant, 62–64
choriocarcinoma, 217, 218 non-invasive high-grade
embryonal carcinoma, 211 papillary urothelial
seminoma, 210 carcinomas, 40, 41
spermatocytic tumor, 210, 211 non-urothelial primary
teratoma/malignant teratoma, carcinomas of bladder
221 primary adenocarcinoma, 74,
yolk sac tumors, 213, 215 75
Ghost nuclei, 67 primary squamous cell
Glandular differentiation, 67–69 carcinoma (SqCC), 71, 73
Glial fibrillary acidic protein non-urothelial tumors and
(GFAP), 195 secondary malignancies,
Glomerulus, 154, 156–158 76, 78, 79
Gomori-methenamine silver (GMS) patterns mimicking invasion, 41
stain, 183 plasmacytoid variant, 60, 61
Granular cell tumor, 77 sarcomatoid carcinoma, 64, 65
Granulomatous inflammation, 13 small cell differentiation, 69, 71
Granulosa cell tumors, 222 squamous differentiation, 65–67
tissue fragments of, 49
urothelial CIS, 41–44
H High grade UTUC, 131
Hematocele, 233 High-grade mucinous tubular and
Hematopoietic tumors, 224 spindle cell carcinoma,
Hemosiderin, 100 124
Herpes simplex virus (HSV), 17 HSV cytopathic effect, 18
High grade clear cell renal cell Hydrocele, 232
carcinoma, 93 Hypospermatogenesis, 235
High grade papillary urothelial
carcinoma
cytomorphology, 134 I
histomorphology, 133 Incidentalomas, 179
High grade urothelial carcinoma Infertility, 235, 236
(HGUC), 57, 133, Inflammatory conditions, 183
135–137 Intracytoplasmic lumina (ICLs), 68
246 Index

Intravesicular Bacillus Calmette- M

Guérin (BCG) therapy, 12 Macrophages, 164, 236
Invasive high-grade urothelial Malakoplakia, 239
carcinoma, 44, 45 Malakoplakia of the bladder, 240,
Invasive squamous cell carcinoma, 241
76 Malignant teratoma, 221
Inverted growth patterns tumors Maturation arrest, 236
inverted PUNLMP, 30 Mesothelioma, 227
inverted urothelial papillomas, Metanephric adenomas, 177, 178
30 Metaplasia, 10, 11
Metastasis, 146
cytomorphology, 147
K Metastatic adenocarcinoma, 145,
Kidney biopsy, 130 197
Metastatic melanoma, 199
Metastatic neoplasms, 196, 197, 199
L Metastatic small cell carcinoma, 198
Leydig cell tumor, 223 Micropapillary urothelial
Lipoma, 225, 226 carcinoma, 59
Liposarcoma, 225, 226 Mimic lymphovascular invasion
Low grade urothelial neoplasms (LVI), 45
(LGUN), 24, 26–28, Mixed germ cell tumor, 203, 204
30–33, 132 Mucinous tubular and spindle cell
diagnosis, 23 carcinoma (MTSC),
cercariform cells from a patient 121–124
with, 34 cytomorphology, 121
exophytic tumors histomorphology, 125
low grade papillary urothelial Muscularis propria, 4
carcinoma (LGPUC), 26, Myelolipoma, 186, 187
27, 30
PUNLMP, 25
urothelial papilloma, 24, 25 N
tumors with inverted growth Negative for high grade urothelial
patterns carcinoma (NHGUC), 47
inverted PUNLMP, 30 Nephroblastoma. See Wilms tumor
inverted urothelial Nephrogenic adenomas, 11, 12
papillomas, 30 Neuroblastoma, 194–196
urine cytology, 31, 32, 35 Neutrophils, 21
Lower tract urothelial carcinoma, Non-invasive high-grade papillary
132 urothelial carcinomas, 40,
Lymphoma, 224, 225 41
cytomorphology, 143, 144 Non-neoplastic findings
histomorphology, 142, 143 contaminants, endometrial
Lymphoproliferative disorders, 139 cells, 21
Index 247

exfoliated acellular components O

casts, 19 Oncocytoma, 171–174, 176
corpora amylacea, 20 Oncoytoma, 175
crystals, 18 Orchitis, 234
micro-organisms
bacteria, 16
BK polyomavirus, 16, 17 P
fungus, 16 Pap test, 21
HSV and CMV, 17 Papillary adenoma, 175, 177
protozoa, 18 Papillary renal cell carcinoma
normal histology and cytology, (PRCC), 99–107, 109,
2–5 157
parabasal-type urothelial cytomorphology, 99, 100
cells, 6, 7 histomorphology, 101
renal tubular cells, 8 Papillary urothelial
squamous cells, 5 carcinomas, 41
umbrella cells, 7, 8 Papillary urothelial neoplasm of low
reactive changes malignant potential
metaplasia, 10, 11 (PUNLMP), 23–25, 32,
nephrogenic adenomas, 11, 34
12 cercariform cells derived from,
polypoid cystitis, 12 35
treatment-related cystitis, Parabasal-type urothelial
12–15 cells, 6, 7
von Brunn nests, cystitis Paratesticular lesions, 202
cystica, and cystitis Penile lesions, 237, 238
glandularis, 8, 9 Pheochromocytoma, 191–194
seminal vesicle cells, 21 Plasmacytoid urothelial carcinoma,
specimen procurement, 1, 2 61
spermatozoa, 20 Polypoid cystitis, 12
Non-prostatic infections and Primary adenocarcinoma, 74, 75
inflammatory conditions, Primary squamous cell carcinoma
239 (SqCC), 71, 73
Non-seminomatous germ cell tumor, Prostate, 238
207–209 Prostate acinar adenocarcinoma, 78
Non-urothelial primary carcinomas Prostate adenocarcinoma, 79
of bladder Prostate adenocarcinoma cells, 76
primary adenocarcinoma, 74, 75 Protozoa, 18
primary squamous cell Proximal convoluted tubules, 155,
carcinoma (SqCC), 71, 160
73 Pseudocarcinomatous stromal
Non-urothelial tumors and atypia, 15
secondary malignancies, Pseudosarcomatous stromal reaction
76, 78, 79 (PSSR), 65
248 Index

R benign renal neoplasms, 168

Renal abscess. See Acute angiomyolipoma, 168–170
pyelonephritis metanephric adenomas, 177,
Renal biopsies, 87 178
Renal cell carcinoma (RCC), 78, oncocytoma, 171–173, 176
86–88, 198 papillary adenoma, 175, 177
CCPRCC diagnostic pitfalls, 157, 160
cytomorphology, 115 non-neoplastic conditions, 161
histomorphology, 117 normal renal histology, 153
chromophobe renal cell cytomorphology, 154
carcinoma histomorphology, 153, 154,
cytomorphology, 111, 112 157
histomorphology, 114 Renal infarction, 167, 168
clear cell renal cell carcinoma Renal medullary carcinoma
cytomorphology, 88 cytomorphology, 120
histomorphology, 95 histomorphology, 121
collecting duct carcinoma Renal tubular cells (RTCs), 8, 159
cytomorphology, 117, 118
histomorphology, 119
mucinous tubular and spindle S
cell carcinoma (MTSC) Sarcomas, 147
cytomorphology, 121 Sarcomatoid carcinoma, 64, 65
histomorphology, 125 Sarcomatoid renal cell carcinoma,
with oncocytic features, 176 93
papillary renal cell carcinoma Schistosoma haematobium, 19
cytomorphology, 99, 100 Seminal vesicle cells, 21
histomorphology, 101 Seminoma, 205, 206, 210
renal medullary carcinoma Sertoli cell tumor, 224
cytomorphology, 120 Sertoli cell-only syndrome, 237
histomorphology, 121 Sex cord-stromal tumors
translocation associated RCCs granulosa cell tumors, 222
cytomorphology, 126 Leydig cell tumor, 223
histomorphology, 97, 126 Sertoli cell tumor, 224
Renal fine needle aspiration and Small cell differentiation, 69–71
core biopsy specimens, Spermatocele, 232–234
152 Spermatocytic tumor, 210, 211
accuracy, 152, 153 Spermatozoa, 20
benign cysts, 161, 162 Squamous cell carcinoma
acute pyelonephritis, 165 cytomorphology, 139
cytomorphology, 163 histomorphology, 138
histomorphology, 162 Squamous cell carcinoma of the
renal infarction, 167, 168 bladder, 72
XGP, 166 Squamous cells, 5
Index 249

Squamous differentiation, 65–67 low grade urothelial neoplasia/

Squamous metaplasia, 10 low grade papillary
Suspicious for high grade urothelial urothelial neoplasms, 132
carcinoma (SHGUC), 47 lymphoma, 142–144
metastasis, 146, 147
sarcomas, 147
T squamous cell carcinoma, 138,
Teratoma, 221 139
Testes and paratesticular tissue Wilms tumor, 144, 145
hematocele, 233 Urothelial carcinoma in situ (CIS),
hydrocele, 232 40–44
orchitis/epididymitis, 234 Urothelial condyloma, 29
spermatocele, 232 Urothelial papilloma, 23–25
Translocation associated renal cell
carcionoma
cytomorphology, 126 V
histomorphology, 97, 126 von Brunn nests, 8, 9, 58, 63
Transurethral resection of a bladder
tumor (TURBT), 2, 12,
63 W
Treatment-related cystitis, 12–15 Well differentiated liposarcoma, 225
Tubular and interstitial Wilms tumor, 143, 144
fibrosis, 235 cytomorphology, 145
histomorphology, 144

U
Ultrasound guided biopsies, 86 X
Umbrella cells, 7, 8 Xanthogranulomatous inflammation,
Upper tract urothelial carcinoma 239
(UTUC), 130, 131 Xanthogranulomatous
Urinary tract cytology (UTC), 2 pyelonephritis (XGP),
Urine cytology, 31, 32, 35 166, 167
Urothelial carcinoma, 44, 130–132
benign urothelial tissue, 132
high grade papillary urothelial Y
carcinoma, 133, 134 Yolk sac tumors, 213–219