What is new in Genitourinary Pathology? Recent developments and highlights of the new 2016 World Health Organization classification of tumors of the urinary system and male genital organs
© The Author(s) 2016
Received: 6 July 2016
Accepted: 25 October 2016
Published: 24 November 2016
The recently published 2016 World Health Organization (WHO) Classification of Tumors of the Urinary System and Male Genital Organs stems from the accumulated knowledge and data collected during the last 12 years, since the previous edition of the WHO “blue book” 2004.
The major changes in prostate pathology include the introduction of a novel grading system for prostate cancer (Grade Groups/International Society of Urological Pathology (ISUP) grades 1–5), the recognition of intraductal carcinoma as a new entity, and the terminological changes regarding the neuroendocrine prostatic neoplasms.
In bladder and urothelial tract, within the spectrum of flat and non-invasive lesions, a newly introduced term “urothelial proliferation of uncertain malignant potential” replaced the term “urothelial hyperplasia”, and the term “urothelial dysplasia” was better defined. A category of “invasive urothelial carcinoma with divergent differentiation” was introduced for tumors showing a component of “usual type” urothelial carcinoma combined with other morphologies.
A new WHO/ISUP renal tumor grading system was recommended (Grade 1–4). The definition of renal papillary adenoma was modified and expanded to include papillary neoplasms measuring up to 1.5 cm. Several new epithelial renal tumors were recognized as new entities including: hereditary leiomyomatosis and renal cell carcinoma (RCC) syndrome–associated RCC, succinate dehydrogenase–deficient RCC, tubulocystic RCC, acquired cystic disease–associated RCC, and clear cell papillary RCC.
In testis pathology, intratubular proliferations of testicular germ cell tumors were renamed as “germ cell neoplasia in-situ” (GCNIS), and the testicular neoplasms were divided into two main groups: derived from or unrelated to GCNIS.
A major change in penile pathology was the introduction of a new classification of penile squamous cell carcinoma, based on the presence of human papillomavirus (HPV), which characterizes penile tumor subtypes as HPV-related or non-HPV-related. A similar distinction was introduced for the preneoplastic penile intraepithelial precursor lesion (PeIN) into non-HPV related (differentiated PeIN) and HPV-related types (undifferentiated PeIN). In this review, we provide a summary and highlight the changes in the genitourinary pathology introduced by the 2016 WHO blue book, and we also discuss some recent developments that may impact the practice of genitourinary pathology in the near future.
KeywordsWHO Classification Genitourinary pathology Prostate Testis Bladder Kidney Penis
The recently published 2016 World Health Organization (WHO) Classification of Tumors of the Urinary System and Male Genital Organs stems from the accumulated knowledge and data collected during the last 12 years, since the previous edition of the WHO “blue book” 2004. In this review, we provide a summary of the highlights and the changes in genitourinary pathology introduced by the 2016 WHO blue book, and we discuss some recent developments that may impact the practice of genitourinary pathology in the near future.
Novel prostate adenocarcinoma grading
Over the last half a century, the Gleason grading system has been validated as a fundamental prognostic factor for patient outcome, on biopsy and on radical prostatectomy (RP), including biochemical failure, local recurrence and lymph node or distant metastasis. However, over the last two decades or so, many changes took place, including the introduction of a practice of thin-needle prostate biopsies, first as sextant, and then as systematic and extended prostate biopsies with site specific submission, with introduction and widespread use of immunohistochemistry (IHC), recognition of variants of adenocarcinoma, and the prognostic significance of certain morphologic patterns. These developments led to grading changes by the ISUP in 2005 (ISUP Modified Gleason System 2005)  and in 2014 (ISUP Consensus Conference on Gleason Grading 2014) . The latest modifications from 2014 were incorporated in the WHO 2016 classification of prostate adenocarcinoma, which establishes a novel grading system based on stratification of the Gleason scores in Grade Groups/ISUP Grades 1 to 5, corresponding to Gleason scores ≤6, 3 + 4, 4 + 3, 8 (4 + 4, 3 + 5, 5 + 3) and ≥9 . The Grade Group 1 (Gleason scores ≤6) is the lowest recommended grade as Gleason scores 2–5 are rarely used in the current practice and essentially pertain to the large majority of cases of Gleason score 6. It currently includes well differentiated and slow growing tumors that virtually have no potential of metastasizing and in many circumstances can be handled by active surveillance. It is currently recommended that this new grading system be reported in conjunction with the 2005 ISUP modified Gleason system. A recent study has validated the prognostic significance of the new grading system in a large multi- institutional cohort treated by radical prostatectomy and radiotherapy, using the biochemical recurrence as an outcome measure . In another recent study from the UK, there was a strong correlation between the five grade groups and prostate cancer death .
Glomeruloid glands and all cribriform gland morphologies should be assigned Gleason pattern 4.
Mucinous carcinoma should be graded on the basis of its background growth pattern instead of being classified automatically as pattern 4.
Cribriform morphology has been associated with upgrading at RP when assigned in needle biopsies  and with cancer progression in RP specimens [7, 8], and it should be documented in needle biopsies when present. The current general rules in assigning and reporting Gleason scores in needle biopsy and RP mirror the recommendations from the 2005 ISUP consensus . Although it has been previously recommended to quantify the amount of high grade carcinoma patterns 4 and 5 in needle biopsies and RP specimens, the reporting of percent pattern 4 is inconsistently done in clinical practice. In RP specimens, the amount of high grade component (Gleason patterns 4/5) has been previously confirmed to be an important predictor of survival . However, it is now recommended to quantify the percentage pattern 4 in Gleason score 7 (3 + 4 or 4 + 3), when this is the highest grade in a needle biopsy or RP specimens. For example, a low percentage of pattern 4 in cases considered for active surveillance may influence a clinical decision for these patients to be selected for conservative management .
Intraductal carcinoma has been recognized formally as a new entity in the 2016 WHO classifications, although this term and its morphology have been described previously . It represents an intraepithelial spread or in-situ proliferation of acinar and ductal carcinoma, likely representing a late event in prostate cancer progression. It is defined by intraacinar/intraductal proliferation that may share some morphologic features with high grade prostatic intraepithelial neoplasia (HGPIN), but exhibits a much higher degree of architectural and cytologic atypia. Intraductal carcinoma should not be assigned a Gleason grade. It is rarelyan isolated finding in needle biopsy (0.1–0.3%), and most of the cases are associated with high grade invasive carcinoma both in needle biopsies and RP. The frequency of intraductal carcinomas in RP specimens depends on the grade and the stage of tumors, ranging from 20 to 40% of all RP cases, while it is much lower in needle biopsies (about 3%). The presence of isolated intraductal carcinoma in a needle biopsy should be reported with a comment describing its strong association with high grade and high volume prostatic carcinoma, which likely was not sampled. If this is an isolated biopsy finding without an invasive carcinoma, a recommendation should be given for repeat biopsy, prior to definitive therapy,
New variants of prostatic adenocarcinoma
Two new variants of prostatic adenocarcinoma were included in the new blue book. The microcystic variant is characterized by acini that are 10 times the size of usual small acinar carcinoma, with rounded profiles and flat cell lining. The may show bland cytological features mimicking benign cystic atrophy. The assigned Gleason pattern is 3. Pleomorphic giant cell variant is exceptionally rare variant characterized by giant, bizarre, anaplastic cells with pleomorphic nuclei and lacking a spindle cell component. In some patients there is a history of prior hormonal or radiation therapy. The disease course is very aggressive.
Variants of neuroendocrine tumors of the prostate
Large cell neuroendocrine carcinoma, which is morphologically identical to its counterpart in the lung, has now been included in the 2016 WHO Classification of prostate tumors as a new variant . Almost all cases were associated with hormonal treatment of prostate adenocarcinoma. Small cell carcinoma has been renamed small cell neuroendocrine carcinoma and carcinoid tumor has been now designated as well differentiated neuroendocrine tumor of prostate.
The novel and useful markers for prostate differentiation include prostein (P501S), a plasma membrane protein and NKX3.1, a homeobox-containing transcription factor, both highly sensitive for prostate adenocarcinoma . These markers can be particularly useful in poorly differentiated prostate carcinoma cases demonstrating negative first line prostate markers, such as prostate-specific antigen (PSA) and prostate-specific acid phosphatase (PSAP), to separate them from urothelial carcinoma, for a diagnosis in a metastatic setting, or in tumors in which PSA and PSAP were significantly decreased due to androgen deprivation therapy.
Bladder and urinary tract
Urothelial tumor grading
The new 2016 WHO blue book continued to endorse the classification of urothelial flat and papillary lesions proposed initially by ISUP in 1997, and adopted by the WHO in 2004, given the accumulated evidence comprised in the literature, which recognized its merits and advantages regarding the reproducibility and clinical significance when compared to WHO 1971 classification, which is currently used infrequently [13, 14]. This classification provided uniform grading terminology, based on the observed cytologic and architectural abnormalities, and more specific criteria for various preneoplastic conditions and grades. It also eliminated the ambiguous “transitional” grades (grade 1–2, grade 2–3) and maintained the existence of a category papillary urothelial neoplasm of low malignant potential (PUNLMP), which has a substantial potential for recurrence, but a very small risk of progression .
Urothelial proliferation of uncertain malignant potential
In the diagnostic categories, the novel change is the replacement of the term “urothelial hyperplasia” by the term urothelial proliferation of uncertain malignant potential (UPUMP). This lesion represents a lesion with flat thickened urothelium with minimal or no cytological atypia; undulations are common, but true papillary fronds are lacking. The term is meant to represent the flat counterpart of the papillary urothelial neoplasm of low malignant potential (PUNLMP), which continues to be endorsed. The clinical relevance of UPUMP is not known, although it is possible that it represents a “shoulder lesion”, commonly seen adjacent to true papillary neoplasms. This lesion can also be seen de novo, with uncertain clinical significance.
Invasive urothelial carcinoma with divergent differentiation and urothelial carcinoma variants
Tumors of Müllerian origin
A new category of bladder neoplasms comprise the tumors of Müllerian origin which originate primarily from the bladder wall or the adjacent soft tissues, likely from foci of endometriosis or müllerianosis . It is unlikely that these tumors are of urothelial origin. They typically show tubulocystic, papillary or diffuse morphology. The most common types are clear cell carcinoma and endometrioid carcinoma, both of which share overlapping morphologic and immunophenotypical features with their ovarian counterparts.
Tumors arising in a bladder diverticulum
Another new neoplastic category represents the tumors arising in a bladder diverticulum . About 14% of all bladder diverticula will harbor a malignant tumor and these tumors comprise about 1% of all bladder cancers. About half of the tumors are non-invasive, while the other half are invasive; all tumors are mostly of usual urothelial type. Since the diverticula lack the muscularis propria layer, the pathologic staging system in this setting differs from others carcinomas of the bladder, as pT2 stage does not exist.
Neuroendocrine tumors of bladder
Similar to the prostate, small cell carcinoma has been renamed small cell neuroendocrine carcinoma and carcinoid tumor has been named well differentiated neuroendocrine tumor of bladder. The entity large cell neuroendocrine carcinoma, has now also been included in the 2016 WHO Classification of bladder tumors as a new variant.
Changes pertaining to existing renal tumor types
The ISUP Vancouver consensus conference in 2012 was the basis for the updates of the 2016 WHO renal tumor classification . Multilocular cystic renal cell carcinoma (RCC) has been renamed multilocular cystic renal neoplasm of low malignant potential. These are indolent tumors which resemble low grade clear cell RCC with extensive cyst formation, but without the expansive nodules. Although traditionally papillary RCC has been divided into types 1 and 2, it is becoming apparent that “type 2 papillary RCC” may not constitute a single entity, but rather represent a morphology seen in a variety of neoplasms, including, for example, Xp11 translocation RCC and collecting duct RCC, as acknowledged in the 2016 WHO renal tumor classification. It is conceivable that type 2 papillary RCC is an umbrella category comprising tumors with similar morphology, but distinct molecular backgrounds. In addition, there is papillary RCC with eosinophilic (oncocytic) cytoplasm (oncocytic papillary RCC variant), which is included in type 2 papillary RCC in the new classification, till it is better characterized. The size criterion for papillary adenoma, previously defined as papillary tumor ≤0.5 cm, has been changed and expanded to include all unencapsulated tumors of lower grade with papillary or tubular morphology up to 1.5 cm in size, because they essentially have no metastatic potential. Finding these types of relatively common tumors in potential donor kidneys should not be a contraindication for allograft transplantation. Mixed epithelial and stromal tumors (MEST) has been now been defined to include a broad spectrum of tumors from almost exclusively cystic at one end (cystic nephroma), to tumors that are predominantly solid at the other end (classical MEST). In contrast to adult cystic nephroma, pediatric cystic nephroma represents a distinct entity characterized by DICER1 mutation. Xp11 translocation carcinoma has been renamed MiT family translocation RCC to include not only TFE3 translocation tumors, but also TFEB tumors. Carcinoma of the collecting duct of Bellini has been renamed collecting duct RCC. Carcinoid of the kidney, most of which have poor prognosis, has been renamed well differentiated neuroendocrine tumor of kidney, and placed within the spectrum of renal endocrine tumors, which include small and large cell neuroendocrine carcinomas and paragangliomas (extrarenal pheochromocytoma).
New renal tumor entities
Renal cell carcinomas are subtyped on the basis of their morphologic architectural and cytologic features, anatomic location or the association with specific disease, molecular alterations or familial syndromes. Many unclassified RCC in the past can now be correctly diagnosed or reclassified using the accumulated data and knowledge, along with proper molecular testing, which is increasingly becoming available in selected reference centers.
Several entities are recognized as new RCC subtypes in the WHO 2016 blue book .
Hereditary leiomyomatosis and renal cell carcinoma (RCC) syndrome associated-RCC
Succinate dehydrogenase-deficient RCC
SDH-deficient renal carcinoma represents a distinct and rare renal neoplasm, which is defined by loss of IHC staining for SDHB, which indicates mitochondrial complex II dysfunction [22, 23]. Great majority of SDH-deficient renal tumors demonstrate typical appearances at least focally with uniform low-grade cytology, cytoplasmic vacuoles, eosinophilic or flocculent (not oncocytic) cytoplasm, focal cystic change, and solid to lobulated growth with peripherally entrapped renal tubules (Fig. 4c-d). In tumors exhibiting low-grade nuclear features, metastasis is unusual, but those demonstrating high grade cytology, coagulative necrosis or sarcomatoid transformation, demonstrate potential for metastatic disease, often after a prolonged period. The patients with these tumors also have increased risk of developing paragangliomas and gastrointestinal stromal tumors. Great majority of the reported cases have been associated with germline mutations of the SDH genes.
Tubulocystic RCC is composed of variable-sized cysts, which provide a spongy cut surface on gross examination. The key feature is the morphology of variable-sized tubules and cysts which are lined by a single layer of flat or hobnail cell with prominent nucleoli (ISUP/WHO grade 3) and separated by thin fibrous septa. This is also a rare tumor, which accounts for less than 1% of all kidney tumors. It shows predilection for male patients. Only a small minority of reported cases showed metastatic behavior. As cytogenetic (trisomy 7 and 17, loss of Y) and immunoprofile (CK7, CD10, AMACR all positive) similarities have been found with papillary RCC, they may be related to papillary RCC. Of note, the presence of tubulocystic morphology admixed with other architectural patterns (or areas of dedifferentiation), argues strongly against the diagnosis of tubulocystic RCC and may indicate other tumor type (e.g. FH-deficient RCC).
Acquired cystic disease associated RCC
Acquired cystic disease associated RCC typically arises in end-stage kidneys showing acquired cystic disease, often after prolonged dialysis. Although this is the most common subtype of RCC arising in end-stage renal disease and acquired cystic disease, about 2/3 of epithelial malignancies in end-stage RCC fall into other diagnostic categories. Acquired cystic disease associated RCC demonstrate a morphologic spectrum of cribriform, microcystic and sieve-like growth, with invariable deposits of calcium oxalate crystals, which are characteristic. The cells may show eosinophilic or clear cytoplasm and the nucleoli are prominent. Cytokeratin 7 is typically negative. Most tumors show an indolent behavior.
Clear cell papillary RCC
Clear cell papillary RCC is probably the most common type of the newly recognized entities. It is a low-grade neoplasm composed by clear epithelial cells arranged in tubules or papillae with a linear nuclear alignment away from the basement membrane, with subnuclear vacuoles (piano key appearance). These are indolent tumors that should be distinguished from clear cell RCC. Strong positivity for cytokeratin 7 is a useful tool, as well as CAIX “cup-shaped” reactivity; CD10 is either negative or only focally positive. The stroma may show variable amounts of fibrous or smooth muscle bundles. Renal angiomyoadenomatous tumor (RAT) is another, now obsolete term for this renal tumor. Recent findings indicate that this entity should not be overdiagnosed, because there are cases with mixed features between clear cell papillary RCC and clear cell conventional RCC (both morphologic or by immunophenotype), and there are other similar tumors, characterized by hotspot mutations in TCEB1 [24, 25].
Emerging renal entities
The ISUP 2012 renal tumor classification included a category of emerging renal entities, acknowledging that more data on morphology, immunophenotype and outcome are needed for their formal recognition. This category initially included thyroid-like follicular RCC, ALK rearrangement-associated RCC and SDH-deficient RCC, the latter now recognized as a new type by the WHO. Other emerging tumors include RCC with angioleiomyomatous stroma, some of which show TCEB1 hotspot mutations and may represent a distinct subtype , while some examples are believed to be in the spectrum of clear cell papillary RCC. A category of RCC in neuroblastoma survivors was removed from the 2016 WHO classification, as some of these clearly belong to the MiTF family translocation RCC, and some are difficult to classify .
Eosinophilic, solid and cystic renal cell carcinoma (ESC-RCC) is another emerging entity that has been described recently. ESC-RCC occurs exclusively in female patients with and without associated tuberous sclerosis complex [27, 28]. Most tumors show mixed solid and cystic gross appearance, and on microscopy they demonstrate solid or compact nested growth of eosinophilic cells admixed with cysts lined by with hobnailed cells. A distinctive feature is the presence of coarse cytoplasmic stippling (basophilic granules) and intracytoplasmic globules. Immunostaining typically shows a cytokeratin 20+, cytokeratin7—profile. These tumors demonstrate indolent behavior.
Grading of renal tumors
Grade 1: Inconspicuous or absent nucleoli at x400 magnification.
Grade 2: Nucleoli are conspicuous at x400x magnification and visible but not prominent at x100 magnification.
Grade 3: Nucleoli are conspicuous at x100 magnification.
Grade 4: Extreme nuclear pleomorphism, multinucleated giant cell and/or rabdoid/sarcomatoid morphology.
To date, this system has been validated for clear cell and papillary RCCs. This grading system should not be applied to chromophobe RCC, and has not been validated for other less common tumor types.
Germ cell tumors are now broadly separated into two main groups: derived from GCNIS or unrelated to GCNIS. Those derived from GCNIS share the features of abnormal testicular development in the background, such as impaired spermatogenesis, tubular atrophy, peritubular sclerosis, interstitial expansion, and microlithiasis. These include: seminoma, embryonal carcinoma, yolk sac tumor postpubertal type, trophoblastic tumors, teratoma postpubertal type and teratoma with somatic-type malignancy. Teratoma and yolk sac tumor may belong to both groups (related to or unrelated to GCNIS). Thus, GCNIS-derived tumors are designated postpubertal and those that are unrelated to CGNIS are labeled prepubertal. The new classification also acknowledges that the genetic backgrounds of teratoma and yolk sac tumor are different in its pre- and postpuberal forms and deserves separation into distinct entities. In addition to the presence or absence of GCNIS, prepubertal teratomas and yolk sac tumors lack 12p amplification and do not occur in malformed testes. Prepubertal teratoma and yolk sac tumor, or mixed neoplasm composed by both, share excellent prognosis . Postpubertal teratoma comprises the previous “mature and immature teratoma” categories and demonstrates a metastatic rate of about 30%. The presence or quantification of the dysplastic or immature component does not need to be specified if there are no expansive nodules larger than one low power field (x 4 objective, 5 mm in diameter). In addition to placental site trophoblastic tumor, the genuine non-choriocarcinomatous trophoblastic tumors now include epithelioid trophoblastic tumors and cystic trophoblastic tumors. These are most common in metastatic lesions or post-chemotherapy.
The tumors unrelated to GCNIS are a more heterogeneous group which include spermatocytic tumor (a new term for spermatocytic seminoma), teratoma prepubertal type (including dermoid cyst, epidermoid cyst and monodermal teratoma—well differentiated neuroendocrine tumor), yolk sac tumor prepubertal type, and mixed teratoma and yolk sac tumor, prepubertal type. The low grade neuroendocrine tumor has a metastatic rate that is lower than 15%. They may be pure (~70% of all cases) or mixed with other teratoma components.
Minor changes are introduced in the sex cord-stromal tumor category. Sclerosing Sertoli cell tumor is now included in the Sertoli cell tumor, not otherwise specified, due to the similar genetic background. However, it is recommended that term sclerosing should still be used to designate tumor containing more than 50% hipocellular fibrous stroma, because these have a more favorable prognosis. Intratubular large cell hyalinizing Sertoli tumor is a new entity associated with Peutz-Jegers syndrome which shows a characteristic mutation of STK1 gene. Gonadoblastoma currently remains the sole entity in the mixed germ cell–sex cord–stromal category. In the mesothelial tumor section, the benign mesothelioma category was abolished. Well differentiated papillary mesothelioma is considered to be an indolent variant of mesothelioma. The term cystic mesothelioma no longer exists and those lesions should be considered either as non-neoplastic mesothelial cysts or as variants of conventional mesothelioma.
The 2016 World Health Organization (WHO) Classification of Tumors of the Urinary System and Male Genital Organs reflects an improved understanding and knowledge of the morphologic types and variants of urologic tumors. It also provides novel insights in the molecular and genetic background and biological behavior of the genitourinary neoplasms. It is anticipated that the adoption of the new diagnostic categories and grading systems will increase the diagnostic reproducibility and clinicopathological correlation and prognostication, leading to a better patient care worldwide.
The authors are grateful to Brenda Jensen for her assistance on reference management.
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DAA drafted the manuscript. KT critically reviewed for intellectual content. Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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