B5.081 Prework 2: Urinary Tumors

Question 1

histo properties of normal urothelium

Answer 1

well organized with small, round nuclei
4-10 cell layers thick
wider umbrella cells on outermost layer

Question 2

epidemiology of bladder cancer

Answer 2

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

Question 3

risk factors for bladder cancer

Answer 3

smoking

schistosoma, aryl amines, analgesics, cyclophosphamide

Question 4

where can UCC occur?

Answer 4

anywhere lined by urothelial cells

-bladder, renal pelvis, urethra, ureter

Question 5

precursor lesions for UCC

Answer 5

non-invasive papillary urothelial carcinoma

non-invasive flat urothelial carcinoma

Question 6

characterize a non invasive papillary urothelial carcinoma

Answer 6

arise from papillary hyperplasia
can be low or high grade
tumor protrudes into lumen, but doesn’t invade into BM

Question 7

characterize a non invasive flat urothelial carcinoma

Answer 7

AKA carcinoma in situ
no BM invasion
always high grade

Question 8

clinical presentation of UCC

Answer 8

painless hematuria
50% of tumors present with bladder muscle invasion at diagnosis (poor prognosis)
-wont see precursor lesion

Question 9

prognosis of UCC

Answer 9

heavily stage dependent
low grade noninvasive: 98% 10 year survival
high grade invasive: 25% mortality

Question 10

histo appearance of papillary noninvasive low grade UCC

Answer 10

orderly architecture and cytology
evenly spaces
maintain polarity (grow to surface and mature)
cohesive 
minimal nuclear atypia
papillary architecture (thickened)

Question 11

histo appearance of high grade papillary UCC

Answer 11

not cohesive (falling apart)
large, hyperchromatic nuclei
pleomorphism and atypia
frequent mitoses
disordered architecture, loss of polarity
higher risk for invasion and progression

Question 12

histo appearance of carcinoma in situ

Answer 12

flat lesion
not cohesive
hyperchromatic enlarged cells
little cytoplasm

Question 13

risks associated with carcinoma in situ

Answer 13

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

Question 14

invasion and prognosis of UCC

Answer 14

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

Question 15

genetic abnormalities associated with UCC

Answer 15

almost all sporadic
chromosome 9 monosomy
9p21 deletion: tumor suppressor gene p16
17p deletion: tumor suppressor gene p53

Question 16

low grade > invasive carcinogenesis pathways

Answer 16

deletion of tumor suppressor genes on 9p and 9q
leads to superficial low grade papillary tumors
acquire p53 mutations
invasion

Question 17

high grade > invasive carcinogenesis pathways

Answer 17

initial p53 mutation
CIS/ high grade tumors
loss of chromosome 9
invasion

Question 18

at what point is cystectomy required for treatment

Answer 18

muscularis propria invasion

Question 19

squamous cell carcinoma of the bladder

Answer 19

3-7% in US
much higher prevalence in countries with endemic schistosomiasis (Egypt)
chronic bladder infection/irriation

Question 20

histo appearance of squamous cell carcinoma

Answer 20

schistosoma eggs w terminal spine

keratin pearls

Question 21

diagnostic testing for UCC

Answer 21

cystoscopy with biopsy
urine cytology (cant recognize low grade)
FISH testing on urine cytology (for atypical urine cytology)

Question 22

indications for urine cytology

Answer 22

hematuria, follow pts with UCC, pts with high risk factors

NOT for asymptomatic screening

Question 23

sens and spec of urine cytology

Answer 23

25-72% sensitivity, increases w more samples, better for high grade tumors
95-100% specificity

Question 24

treatment of small localized low grade papillary tumors

Answer 24

transurethral resection/biopsy

follow with cystoscopy, urine cytology forever (high risk of recurrence)

Question 25

treatment of CIS, high grade papillary, multifocal tumors, lamina propria invasion

Answer 25

topical immunotherapy
-attenuated strain of tuberculous bacillus
-elicits inflammatory response to destroy tumor
if refractory: radical cystectomy
chemo: metastatic, extravesical invasion