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BLADDER TUMOURS, PapillaryUC , Polypoidcystitis , Nephrogenic adenoma ,…
BLADDER TUMOURS
BIOPSY TYPES
CUP BIOPSY:
- Evaluate mucosal abnormalities
- Less artefacts with better cellular preservation
- Not optimal for staging
TURBT:
- Evaluates tumor
- More artefacts (tangential sectioning, fragmentation, thermal)
- Optimal for staging
IS THE BIOPSY NORMAL?
- Thickness varies on distension of bladder
- Up to 7 cells thick
- Basal, intermediate and superficial (umbrella) cells
- Umbrella cells can undergo marked reactive changes
- Denudation is common
KEY QUESTIONS:
- Is the biopsy abnormal/neoplastic?
- Is it papillary, flat, inverted (endophytic)?
- Have I excluded pseudotumors/mimics?
- What's the previous Hx?
- Previous Rx for cancer?
- What did the cystoscopy show?
TUMOR TYPES
PAPILLARY
- Well-defined, slender and frequently branching fibrovascular cores
- Papillae are lined by multilayered epithelium
PAPILLOMA
- No atypia
- Discrete papillary structures with central fibrovascular cores with hierarchical branching pattern but without fusion
- Papillae appear to float above the urothelial surface due to transverse sectioning of branching papillae
- Papillae usually slender with scant stroma around fibrovascular cores
- May have large papillae with marked stromal edema or cystitis cystica-like invaginations
- Papillary structures are lined by urothelium of normal thickness and cytology; often with prominent umbrella cell layer
- Umbrella cells may show cytoplasmic vacuolization and degenerative atypia
- There should be no marked cytologic atypia, increased thickness of the urothelium or increased mitotic/apoptotic figures
PAPILLARY UROTHELIAL NEOPLASM OF LOW MALIGNANT POTENTIAL (PUNLMP)
- Orderly arrangement of cells within papillae
- Minimal architectural abnormalities and minimal atypia, regardless of cell thickness
- Reduced cytoplasmic clearing compared to normal epithelium
- Neoplastic cells may extend down the stalk onto adjacent flat urothelium
- Mitotic figures, if present, are usually confined to the basal layer
LOW GRADE UROTHELIAL CELL CARCINOMA (LGUCC)
- Polarity more maintained than high-grade
- Resemble normal urothelial cells more than HG UCC
HIGH GRADE UROTHELIAL CELL CARCINOMA (HGUCC)
- Loss of polarity
- At least focally severe atypia
- Hyperchromasia
- If high-grade component >5% = High-grade UCC
- If high-grade component <5% = Currently no consensus, often listed as predominantly low-grade
FLAT
- Categorized based on degree of cytological and architectural atypia
- IHC stains:
1) CK20
2) CD44
3) p53
4) Ki-67
DYSPLASIA
- Mild and moderate cytological and architectural atypia
- Subjective diagnosis - not really used unless suspicious lesion that doesn't meet all criteria for CIS
CIS
- High grade non-invasive process
- Do not need full-thickness cytological atypia
- Major criteria:
1) Loss of polarity with significant nuclear crowding
2) Significant nuclear enlargement (4-5 x underlying stromal cells)
3) Hyperchromatic/lumpy chromatin pattern
4) Irregular nuclear membrane
- Minor criteria:
1) Cytoplasmic eosinophilia
2) High N:C ratio
3) Cellular discohesion
4) Angiogenesis at the base
5) Thickness
UROTHELIAL PROLIFERATION OF UNCERTAIN MALIGNANT POTENTIAL (UPUMP)
- A flat lesion that appears more undulating
- Previously known as urothelial hyperplasia
- Thickened urothelium with minimal to no cytological atypia
- Although undulations, no true papillary fronds
- Most frequent in patients with Hx of prior carcinoma of adjacent to papillary lesions
- Likely lateral extension ('shoulder lesion') of a papillary neoplasm
- May be seen de novo and in this setting the clinical relevance is unknown
- High incidence of chromosome 9 deletions and lesser but significant FGFR3 abnormality
INVERTED (ENDOPHYTIC)
INVERTED UROTHELIAL PAPILLOMA
- Smooth surface with minimal to absent exophytic component
- Lesion circumscription with smooth base
- No obvious infiltration and no/minimal cytologic atypia
- Can be divided into two subtypes:
1) Trabecular (classic) type
2) Glandular type
INVERTED PUNLMP
- Similar to the exophytic onem, inverted PUNLMP is composed of large and mild irregular trabeculae, increased thickness and presence of central umbrella cells
- There is mild atypia and rare mitoses
- Urothelium has maintained polarity
INVERTED LOW-GRADE UCC
- Can be confused with inverted papilloma
- Large and moderate irregular trabecular with inconsistent size
- Mild to moderate cytologic atypia
Degree of cellularity
- Loss of polarity
INVERTED HIGH-GRADE UCC (+/- INVASION)
- Can be confused with inverted papilloma
- Ragged interface with features of invasion
LARGE NESTED UCC
- Looks like proliferative von Brunn's nests but there is no clear epidermal-stromal interface
- Appears disordered
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