Bladder Flashcards
Urothelial carcinoma of the ureter: Main prognostic factors (3).
Stage.
Grade.
Presence of synchronous tumor in renal pelvis.
Malakoplakia: Typical patient.
Woman in her fifth decade.
Malakoplakia: Gross pathology.
Multiple soft, yellow-white, nodular plaques on the mucosa.
Histiocytes of malakoplakia:
A. Name.
B. Location.
C. Appearance.
A. Von Hansemann’s histiocytes.
B. Superficial lamina propria.
C. Abundant eosinophilic granular cytoplasm.
Michaelis-Gutmann bodies of malakoplakia:
A. Location.
B. Composition.
A. Within the histiocytes and in the interstitium.
B. Bacteria encrusted with calcium and iron.
Malakoplakia: Other histopathologic features (2).
Fibrosis.
Acute and chronic inflammation.
Malakoplakia: Putative pathophysiology.
Mononuclear cells cannot degrade bacteria normally.
Clinical associations:
A. Polypoid cystitis.
B. Follicular cystitis (2).
C. Giant-cell cystitis.
A. Indwelling catheter.
B. Bladder carcinoma; urinary-tract infection.
C. None; a pathologic rather than clinical diagnosis.
Polypoid cystitis: Histopathology (2).
Broad fronds covered by benign urothelium.
Edematous, inflamed, congested lamina propria.
Giant-cell cystitis: Histopathology (2).
Atypical large cells with tapering processes; may be multinucleate.
Very few or no mitotic figures.
Granulomatous cystitis secondary to BCG therapy: Gross pathology.
Partial or complete mucosal denudation.
Granulomatous cystitis secondary to BCG therapy: Histopathology (3).
Lamina propria: Noncaseating granulomas surrounded by lymphocytes.
Urothelium: Reactive atypia or denudation.
Granulomatous cystitis secondary to BCG therapy: Special stains.
AFB stain rarely discloses bacteria.
Ureteritis cystica and ureteritis: Histopathology.
Both represent cystic change in von Brunn’s nests.
Ureteritis glandularis: Lined by columnar cells.
Ureteritis cystica:
A. Etiology.
B. Gross pathology.
A. Inflammation.
B. Nodular mucosa secondary to cysts.
Urothelial carcinoma of the ureter: Risk factors (3).
Smoking.
Analgesics.
HNPCC.
Radiation cystitis: Timing (2).
Acute symptoms: 4-6 weeks after radiation.
Later symptoms: Up to 10 years after radiation.
Radiation cystitis: Gross pathology.
Mucosal hyperemia and edema with thick folds.
Radiation cystitis: Earlier histopathology (4).
Lamina propria: Edema and hyperemia.
Urothelium: Atypia with preserved N:C ratio.
Vessels: Dilatation, fibrin deposition.
Stroma: Inflammation, extravasated erythrocytes.
Radiation cystitis: Later histopathology (3).
Lamina propria: Fibrosis.
Urothelium: Ulceration.
Vessels: Myo-intimal proliferation or medial hyalinization.
Hemorrhagic cystitis: Earlier histopathology (2).
Lamina propria: Hemorrhage, congestion.
Urothelium: Regenerative atypia.
Hemorrhagic cystitis: Later histopathology (2).
Lamina propria: Fibrosis.
Urothelium: Hyperplasia with formation of papillae.
Interstitial cystitis: Possible laboratory finding.
Hematuria.
Interstitial cystitis: Possible cystoscopic findings (3).
Petechial hemorrhage.
Linear ulcers.
Mucosal scarring.
Interstitial cystitis: Later gross finding.
Fibrotic and contracted bladder with diminished capacity.
Interstitial cystitis: Early histopathology.
Mucosal microhemorrhages.
Interstitial cystitis: Histopathology of ulcerative phase (3).
Fibroinflammatory infiltrate.
Increase in mast cells.
Hemorrhage, congestion, fibrosis.
Interstitial cystitis: Main differential diagnosis.
Carcinoma in situ must be excluded before interstitial cystitis can be diagnosed.
Cystitis glandularis: Immunohistochemistry.
CK20 highlights the umbrella cells only.
Von Brunn’s nests vs. nested variant of urothelial carcinoma (3).
Von Brunn’s nests:
− Lobular or linear arrangement of nests.
− Flat, noninfiltrative base.
− No cytologic atypia.
Nephrogenic adenoma:
A. Epidemiology.
B. Risk factors (4).
A. Young adults; more frequent in males.
B. Surgery, trauma, calculus, cystitis.
Nephrogenic adenoma: Location in the bladder.
Posterior wall.
Nephrogenic adenoma: Histologic architecture.
May resemble renal tubules or form papillae.
Pink secretions may fill the tubules.
Nephrogenic adenoma: Cytology.
Bland, mitotically inactive “hobnail” cells line the tubules.
Acute and chronic inflammatory cells may infiltrate the stroma.
Nephrogenic adenoma: Pitfall.
Infiltration beyond the lamina propria should not be mistaken for malignant behavior.
Nephrogenic adenoma: Immunohistochemistry (3,2).
Positive: CK7, PAX2, PAX8.
Negative: p63, GATA3 (expressed in invasive urothelial carcinoma).
Nephrogenic adenoma: Putative origin.
Renal tubular cells.
Urothelial hyperplasia: Histopathology.
More layers of cells than in the adjacent, normal urothelium.
Urothelial hyperplasia: Mutation.
May express deletions of chromosome 9.
Urothelial hyperplasia: Rate of progression to urothelial neoplasia.
0%.
Urothelial dysplasia: Histopathology (4).
Loss of polarity.
Nuclear crowding.
Mild nuclear enlargement and atypia.
Urothelial dysplasia: Immunohistochemistry (3).
Aberrant expression of CK20.
Overexpression of p53, Ki-67.
Urothelial dysplasia: Rate of progression to urothelial neoplasia.
5% to 19%.
Urothelial atypia of unknown significance.
Significant atypia in a background of inflammation.
Urothelial carcinoma in situ: Nuclear features (2).
Identical to those of high-grade papillary urothelial carcinoma.
Mitotic figures high in the urothelium.
Urothelial carcinoma in situ: Immunohistochemistry (3).
CK20 and p53 may show full-thickness reaction.
CD44: Negative or limited to the basal layer.
Papillary urothelial hyperplasia: Histopathology (2).
Papillae lined by normal-appearing urothelium.
No branching.
Papillary urothelial hyperplasia: Significance.
May progress to low-grade papillary urothelial carcinoma.
Urothelial papilloma: Typical presentation.
Gross hematuria.
Urothelial papilloma: Histopathology (3).
Branching papillae.
Enlarged, vacuolated umbrella cells.
No mitotic figures, not even in the basal layer.
Urothelial papilloma: Immunohistochemistry.
CK20 highlights the umbrella cells only, as in normal urothelium.
Urothelial papilloma: Significance and management.
May progress to higher-grade disease.
Should be completely excised.
Inverted papilloma: Age range.
May occur at any age; median age is 55 years.
Inverted papilloma: Locations (3).
Trigone.
Neck.
Prostatic urethra.
Inverted papilloma: Presentation.
Hematuria.
Inverted papilloma: Histopathology.
Uniform, anastomosing cords of bland urothelial cells extend into the lamina propria.
Inverted papilloma: Stroma.
Minimal; no inflammation.
Inverted papilloma:
A. Significance.
B. Treatment.
A. Uncertain whether it can progress to low-grade papillary urothelial carcinoma.
B. Resection.
Papillary urothelial neoplasm of low malignant potential: Degree of cytologic atypia.
Minimal or absent.
Papillary urothelial neoplasm of low malignant potential: Immunohistochemistry.
CK20 highlights the umbrella cells only.
Papillary urothelial neoplasm of low malignant potential vs. low-grade papillary urothelial carcinoma.
Low-grade papillary urothelial carcinoma:
− Easily recognizable variation in architectural and cytologic features.
− Mitotic figures are more than rare and can occur at any level.
Low-grade papillary urothelial carcinoma, noninvasive: Immunohistochemistry.
CK20: Negative or focally reactive.
Low-grade papillary urothelial carcinoma, noninvasive: Rate of progression to death.
5%.
High-grade papillary urothelial carcinoma, noninvasive: Immunohistochemistry (2).
CK20 and p16: Strong and diffuse reactivity.
Invasive urothelial carcinoma: Risk factors (5).
Tobacco.
Nitrosamines.
Phenacetin.
Cyclophosphamide.
Schistosomes.
Papillary urothelial carcinoma, noninvasive: Architecture difference between low- and high-grade types.
Low-grade: Papillae are slender and show minimal fusion.
High-grade: Papillae are more fused and may become indistinct.
Papillary urothelial carcinoma: Significance of invasion of fat.
The fat may lie between bundles of muscularis propria rather than outside the bladder.
Invasive papillary urothelial carcinoma: Types of divergent differentiation (2).
Squamous (most common).
Glandular.
Invasive papillary urothelial carcinoma: Histopathology of glandular differentiation.
Tubular or enteric; may secrete mucin.
Invasive papillary urothelial carcinoma, nested variant: Histopathologic significance.
May be misdiagnosed as von Brunn’s nests.
Invasive papillary urothelial carcinoma, nested variant, vs. von Brunn’s nests (2).
von Brunn’s nests:
− Larger.
− Smooth, noninfiltrative deep margin.
Papillary urothelial neoplasm of low malignant potential vs. urothelial papilloma (2).
PUNLMP: Thicker and more crowded urothelium.
Invasive papillary urothelial carcinoma, nested variant: Prognosis.
Death in 4 to 40 months in 70% of patients.
Invasive papillary urothelial carcinoma, large-nested variant: Histopathology (2).
Large nests of deceptively bland cells in a fibrotic stroma.
Often invades muscularis propria.
Invasive papillary urothelial carcinoma, large-nested variant: Surface component.
When present, usually low-grade papillary urothelial carcinoma.
Invasive papillary urothelial carcinoma, micropapillary variant: Histopathology (3).
Surface: Fine papillae and micropapillae.
Invasive component: Minute nests or fine papillae; retraction artifact simulates lymphatic invasion.
Muscle is always invaded.
Invasive papillary urothelial carcinoma, micropapillary variant: Grade.
Always high-grade.
Invasive papillary urothelial carcinoma, lymphoepithelioma-like:
A. Reporting.
B. Treatment.
A. Proportion of lymphoepithelioma-like component should be estimated.
B. Pure lymphoepithelioma-like carcinoma responds to chemotherapy.
Invasive papillary urothelial carcinoma:
A. Cytokeratins (2).
B. Other markers (3).
A. CK7, CK20.
B. CD15, CEA, GATA3.
Mutations associated with invasive papillary urothelial carcinoma:
A. Earlier.
B. Later (4).
A. Loss of 9p.
B. Abnormalities of 17p; aneuploidy involving chromosomes 3, 7, 17.
Invasive papillary urothelial carcinoma: Stages.
T1: Invasion of lamina propria.
T2a: Superficial muscularis propria.
T2b: Deep muscularis propria.
T3: Perivesical soft tissue.
T4: Contiguous organs or tissues.
Villous adenoma: Locations (3).
Urachus.
Dome.
Trigone.
Villous adenoma: Presentation.
Hematuria, occasionally with mucosuria.
Villous adenoma: Significance.
Often accompanied by adenocarcinoma.
Villous adenoma: Histopathology.
The epithelium is similar to that of colonic villous adenoma.
Villous adenoma: Immunohistochemistry (3).
Positive: CK20, CK7, CEA.
Adenocarcinoma of the bladder: Main types.
Non-urachal: About ⅔ of cases.
Urachal.
Non-urachal adenocarcinoma: Presentation.
There is metastatic disease at presentation in 40% of cases.
Non-urachal adenocarcinoma: Risk factors (3).
Non-functioning bladder.
Exstrophy.
Schistosomes.
Urachal adenocarcinoma:
A. Mean age at presentation.
B. Laboratory finding.
A. 50 years.
B. Mucosuria (in 25% of cases).
Non-urachal adenocarcinoma: Locations (2).
Trigone.
Posterior wall.
Non-urachal adenocarcinoma: Cause of false-negative biopsy.
Signet-ring variant has no surface component and infiltrates the bladder wall like linitis plastica.
Urachal adenocarcinoma: Locations (2).
Done of bladder.
Anterior abdominal wall.
Urachal adenocarcinoma: Gross pathology (2).
Mucinous cut surface.
Overlying bladder mucosa may be intact or ulcerated.
Adenocarcinoma of the bladder: Histopathologic patterns (3).
Malignant glands infiltrating the bladder wall.
Pools of mucin containing neoplastic cells.
Signet-ring cells.
Adenocarcinoma of the bladder wall: Precursor lesions (2).
Intestinal metaplasia or adenocarcinoma in situ may be seen with non-urachal carcinomas.
Adenocarcinoma of the bladder: Features that favor urachal origin (4).
Location in dome or anterior wall.
Normal adjacent mucosa.
Location of bulk of tumor within bladder wall.
No evidence of alternative origin, e.g. urothelial carcinoma, cystitis cystica, other adenocarcinoma.
Adenocarcinoma of the bladder: Cytokeratins (2).
Positive: CK20.
Variable: CK7.
Adenocarcinoma of the bladder: Other immunohistochemical stains (3,1).
Positive: CEA, villin (in the enteric type), CDX-2.
Negative: β-Catenin (nuclear staining).
Squamous-cell carcinoma: Risk factors (4).
Schistosomes.
Tobacco.
Calculi.
Indwelling catheters.
Squamous-cell carcinoma: Differential diagnosis.
Urothelial carcinoma with squamous differentiation: Retains some urothelial component.
Squamous-cell carcinoma: Behavior (2).
Local recurrence is more common than metastasis.
Bone is the most frequent site of metastasis.
Small-cell carcinoma: Epidemiology.
Typically occurs in elderly men.
Small-cell carcinoma: Feature favoring origin in the bladder.
Persistence of urothelial component.
Inflammatory myofibroblastic tumor: Presentation.
Gross hematuria.
Inflammatory myofibroblastic tumor:
A. Tumor cells.
B. Inflammatory cells.
A. Myofibroblastic cells in “tissue-culture” pattern.
B. Lymphocytes, plasma cells, sometimes many eosinophils.
Inflammatory myofibroblastic tumor: Other histologic components (2).
Conspicuous network of thin-walled blood vessels.
Edematous or myxoid stroma.
Inflammatory myofibroblastic tumor: Mitotic activity.
Mitotic figures may be many but are not atypical.
Inflammatory myofibroblastic tumor: Immunohistochemistry (2,1,1).
Positive: ALK (⅔ of cases), SMA.
Variable: Cytokeratins.
Negative: Desmin.
Inflammatory myofibroblastic tumor: Gene and its location.
ALK on chromosome 2p23.
Most common sarcoma of the bladder in older adults.
Leiomyosarcoma.
Rhabdomyosarcoma: Epidemiology (2).
Most common bladder tumor in children.
Typically occurs before the age of 5.
Rhabdomyosarcoma: Most common subtypes (2).
Children: Embryonal.
Adults: Pleomorphic.
Rhabdomyosarcoma:
A. Location.
B. Relevance of gross appearance to prognosis.
A. Trigone.
B. Better if exophytic and mostly intraluminal.
Rhabdomyosarcoma: Histopathology (3).
Small round blue cells.
Loose myxoid matrix.
Strap cells may be seen.
Rhabdomyosarcoma: Most helpful immunohistochemical stains.
Positive: Myogenin (myf4) and MyoD1.
Carcinosarcoma / sarcomatoid carcinoma: Risk factors.
Cyclophosphamide.
Radiation.
Carcinosarcoma / sarcomatoid carcinoma: Histological components (3).
Malignant epithelial component.
Malignant mesenchymal component.
Some tumors: Heterologous differentiation.
Histology of components of carcinosarcoma / sarcomatoid carcinoma:
A. Epithelial (3).
B. Mesenchymal.
C. Heterologous.
A. Urothelial, glandular, or small-cell.
B. High-grade spindle-cell.
C. Most commonly osteosarcoma.
Carcinosarcoma / sarcomatoid carcinoma: Cytokeratins.
Reactive in the epithelial component and sometimes in the mesenchymal component.
Metastasis to the bladder: Most frequent primary sites (4).
Breast.
Colon.
Kidney.
Melanoma.
Immunohistochemical stains that support prostatic origin of a metastatic tumor (4).
PSA.
PSAP.
p501s.
NKX3.1.
Immunohistochemical stains that support colonic origin of a metastatic tumor (4).
Villin.
CDX-2.
Urothelial carcinoma of the ureter: Most frequent location.
Lower third of the ureter.
