B80 Tumors of the urinary bladder and collecting system Flashcards
Etiology and prevalence of bladder cancer
7% of all cancers and 3% of cancer deaths.
more common in men
appear usually after age 50
Risk factors:
- in developing countries is caused by schistosomia hematobium.
- caused by cigarette smoking
- Napthylamine exposure (occupational)
- Chronic cystitis
- cyclophosphamide drugs
- Chromosome 9 tumor suppressor gene mutations.
Types of bladder tumors
Malakoplakia -occurs in the bladder and results from defects in phagocytic or degradative function of macrophages, such that phagosomes become overloaded with undigested bacterial products. Benign but if seen needs to be biopsied to distinguish it from carcinoma.
Polypoid cystitis - Due to inflammation and irritation, the bladder urothelium forms polypoid edmatous structures. Gross morphology can be confused with papillary urothelial carcinoma, and even dimilar histologically.
Brunn nests of urothelium - in the lamina propria, and may form cysts, multple cysts called cystitis cystica.
Squamous metaplasia is possible, especially at the trigone.
Squamous Cell carcinomas ~5% of bladder cancers This type is strongly associated with schistosomiasis.
Most commonly, Urothelial Cell Carcinoma
- Papillary or Flat
- Noninvasive or Invasive
- Low or High grade
- Precursor Urothelial carcinoma in situ.
What are the morphologies of Urothelial Carcinoma?
Benign papilloma: paipllary structures with a well differentiated epithelium and no penetration of the mucosa
In-situ Urothelial carcinoma: in contrast to in situe scc, any dysplasia/malignant cells present in the urothelium represents full blown carcinoma in situ. These cells have enlarge hyperchromic nuclei and some have mitotic figures. There is no 1/3 or 2/3 stipulations.
Low-grade Urothelial Carcinoma: always papillary, and rarely invase, but have frequent recurrence after removal
High-grade Urothelial Carcinoma: Can be either papillary or flat, is invasive
Grade is determined based on the degree of cellular dysplasia in the tumor.
What is the presentation and progression of bladder carcinoma?
First sign is painless hematuria
If it is in the right location urinary tract obstruction occurs
If the tumor is located in a low grade, non-invasive stage, the prognosis is very good, about 75% 5 and 10 year survival, and are treated by resection without chemo.
If it is high grade with deep penetration, 5 year survival drops to less than 20%.
High grade cases with local invasion but no lymph or metastases are are treated by total cystectomy, if there is tumor invasion of the muscularis propria
Advanced stages with metastases are treated with chemo, which is not curative but slows progression.
Unfortunately, all types of urothelial cancer have a high rate of recurrence even after excision and cure.
Metastases go via lymph to the Bone, Lung, and Liver, and via direct infiltration to the peritoneum and prostate.
What is a unique treatment for tumors of the bladder that have a high risk of recurrence?
Introducing into the bladder the Tuberculosis Bacillus strain called Bacille Calmette-Guerin BCG bacteria.
This triggers a granulomatous reaction and stimulates a potent local cellular immunity response, having strong local anti-tumor effects.
What are the tumors of the ureters?
Urothelial cell carcinoma, same risk factors as the bladder type.
Squamous cell carcinoma, rare this type usually occurs in bladder, also much less commonly than urothelial cell carcinoma
Adenocarcinoma - rare, have the same morphology as GI adenocarcinomas, glandular with hyperchromatic hypercellular glandular epithelium. These also occur in the bladder very rarely.
Ureteritis cystica - Small cysts on the ureters, due to glandular metaplasia or from multple Brunn nests. Caused to chronic inflammation and recurrent UTIs
