B5.081 Prework 2: Urinary Tumors Flashcards
histo properties of normal urothelium
well organized with small, round nuclei
4-10 cell layers thick
wider umbrella cells on outermost layer
epidemiology of bladder cancer
7% of all cancers M:F 3:1 almost all are sporadic 95% epithelial (rest are mesenchymal) -90% UCC -also have squamous cell carcinoma or adenocarcinoma or other rare variants
risk factors for bladder cancer
smoking
schistosoma, aryl amines, analgesics, cyclophosphamide
where can UCC occur?
anywhere lined by urothelial cells
-bladder, renal pelvis, urethra, ureter
precursor lesions for UCC
non-invasive papillary urothelial carcinoma
non-invasive flat urothelial carcinoma
characterize a non invasive papillary urothelial carcinoma
arise from papillary hyperplasia
can be low or high grade
tumor protrudes into lumen, but doesn’t invade into BM
characterize a non invasive flat urothelial carcinoma
AKA carcinoma in situ
no BM invasion
always high grade
clinical presentation of UCC
painless hematuria
50% of tumors present with bladder muscle invasion at diagnosis (poor prognosis)
-wont see precursor lesion
prognosis of UCC
heavily stage dependent
low grade noninvasive: 98% 10 year survival
high grade invasive: 25% mortality
histo appearance of papillary noninvasive low grade UCC
orderly architecture and cytology evenly spaces maintain polarity (grow to surface and mature) cohesive minimal nuclear atypia papillary architecture (thickened)
histo appearance of high grade papillary UCC
not cohesive (falling apart) large, hyperchromatic nuclei pleomorphism and atypia frequent mitoses disordered architecture, loss of polarity higher risk for invasion and progression
histo appearance of carcinoma in situ
flat lesion
not cohesive
hyperchromatic enlarged cells
little cytoplasm
risks associated with carcinoma in situ
multifocality common
can spread to ureters and urethra
if untreated, high risk of progressing to muscle invasion
hard to detect on cystoscopy: no mass, just erythema
invasion and prognosis of UCC
80% of high grade are invasive
10% of low grade are invasive
advanced tumors can invade through bladder into prostate, ureters, retroperitoneum
metastases: lymph nodes, liver, lungs, bone marrow
genetic abnormalities associated with UCC
almost all sporadic
chromosome 9 monosomy
9p21 deletion: tumor suppressor gene p16
17p deletion: tumor suppressor gene p53
low grade > invasive carcinogenesis pathways
deletion of tumor suppressor genes on 9p and 9q
leads to superficial low grade papillary tumors
acquire p53 mutations
invasion
high grade > invasive carcinogenesis pathways
initial p53 mutation
CIS/ high grade tumors
loss of chromosome 9
invasion
at what point is cystectomy required for treatment
muscularis propria invasion
squamous cell carcinoma of the bladder
3-7% in US
much higher prevalence in countries with endemic schistosomiasis (Egypt)
chronic bladder infection/irriation
histo appearance of squamous cell carcinoma
schistosoma eggs w terminal spine
keratin pearls
diagnostic testing for UCC
cystoscopy with biopsy
urine cytology (cant recognize low grade)
FISH testing on urine cytology (for atypical urine cytology)
indications for urine cytology
hematuria, follow pts with UCC, pts with high risk factors
NOT for asymptomatic screening
sens and spec of urine cytology
25-72% sensitivity, increases w more samples, better for high grade tumors
95-100% specificity
treatment of small localized low grade papillary tumors
transurethral resection/biopsy
follow with cystoscopy, urine cytology forever (high risk of recurrence)
treatment of CIS, high grade papillary, multifocal tumors, lamina propria invasion
topical immunotherapy
-attenuated strain of tuberculous bacillus
-elicits inflammatory response to destroy tumor
if refractory: radical cystectomy
chemo: metastatic, extravesical invasion
