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Book - Molavi > Chapter 12 - Bladder > Flashcards

Chapter 12 - Bladder Flashcards

1
Q

What indications or presentations generate bladder biopsies?

A

Hematuria

Abnormal urine cytology

History of neoplasm

Lesion seen on cystoscopy

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2
Q

Describe the normal morphologic appearance of urothelium.

A

5-7 cell thick layer of uniform cells without significant surface maturation. Basal mitoses, surface umbrella cells (pillowy and atypical).

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3
Q

Describe the layers deep to the urothelium.

A

Lamina propria (with vessels, lymphatics, smooth muscle fibers and even fat)

Detrusor muscularis propria

Adventitia or serosa (depending on site)

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4
Q

Describe and distinguish between von brunn’s nests, c**ystitis cystica, and cystitis glandularis

A

Von brunn’s nests are downward invaginations of normal, bland urothelium.

Cystitis cystica is when these nests develop central lumina.

Cystitis glandularis features columnar cell metaplasia.

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5
Q

Where and in whom is squamous metaplasia a common normal variant?

A

In the trigone area of the female bladder

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6
Q

What is the most likely cause of granulomatous cystitis?

Does it merit AFB/GMS staining?

A

Intravesical BCG therapy

Not if the history of BCG treatment is documented

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7
Q

Describe the pathogenesis of schistosoma infection.

A

Parasitic worms extrude their eggs into the bladder wall, causing an intense foreign-body reaction.

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8
Q

What is polypoid cystitis?

What is interstitial cystitis?

A

Polypoid cystitis is similar to an inflammatory polyp and is related to any chronic injury (eg catheters, stones, fistulae)

Interstitial cystitis is a poorly understood disease and a diagnosis of exclusion.

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9
Q

What is the cause, gross and microscopic appearance of malakoplakia?

A

A defective macrophage response to infection, resulting in grossly yellow plaques comprised of sheets of epithelioid histiocytes with Michaelis-Guttman bodies (resembling archery targets).

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10
Q

What is the progression of flat urothelial neoplasia?

Of papillary urothelial neoplasia?

A

Flat: Benign > dysplasia (rarely diagnosed) > carcinoma in situ > invasive carcinoma

Papillary: Papilloma > PUNLMP > LGPUC > HGPUC

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11
Q

What molecular abnormalities underlie the flat and papillary urothelial carcinoma pathways?

A

Flat: p53 loss, 9-, RB loss, INK4a loss, 8p-

Papillary: FGFR3, 9-, INK4a loss

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12
Q

What are the features of urothelial carcinoma in situ?

A

Increased nuclear size (4-5x lymphocytes)

Hyperchromatic nuclei with irregular (“boulder”) outlines

Denuding with clinging cells

*does not need to be full thickness*

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13
Q

How is urothelial dysplasia described and called?

A

Atypia not quite enough to call CIS.

Rarely called, as low-grade is ignored while high-grade is essentially CIS.

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14
Q

Distinguish between the morphologic appearances of papilloma and PUNLMP.

A

Papilloma have normal urothelial lining and are small.

PUNLMPs are thickened with good organization. Exceeding rare mitoses in the basal layer only.

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15
Q

Describe the morphologic appearance of papillary hyperplasia.

A

Undulating wave-like urothelium without true fibrovascular cores.

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16
Q

Distinguish between the morphologic appearance of low and high-grade papillary urothelial carcinoma.

A

Low-grade: Still fairly organized with subtle nuclear atypia. Uncommon mitoses.

High-grade: Very disordered, pleomorphic, full thickness mitoses. Often invasive.

17
Q

What forms of nonurothelial differentiation can be seen in HGPUC?

How much high-grade behavior is required to define the lesion as high-grade?

A

Squamous or glandular

As little as 5% can define the entire lesion as high-grade.

18
Q

What features define urothelial carcinoma invasion?

A

Irregular tongues or cells or single cells pushing into the lamina propria

Desmoplasia (uncommon)

Retraction artifact (stroma away from tumor nests)

Paradoxical differentiation

19
Q

What is paradoxical differentiation?

A

Deep invasive urothelial carcinoma cells can acquire increased pink cytoplasm, mimicking maturing surface cells.

20
Q

What is the most important threshold of bladder invasion?

A

Invasion of the muscularis propria (detrusor muscle).

Biopsies must identify it and determine involvement.

21
Q

How can invasive carcinoma be distinguished from involvement of Von Brunn’s nests?

A

In von Brunn’s nest involvement, the nests are round and even without ragged borders, and appear basophilic with crowding or palisading of the outermost layer of cells.

22
Q

Name and describe 3 mimics of urothelial carcinoma.

A

Inverted papilloma (grows into the LP but the normal urothelium not cross basement membrane)

Reactive urothelial changes (chromatin is evenly blue grey and nuclear contour smooth & oval)

Nephrogenic adenoma (benign proliferation with many appearances…)

23
Q

Describe the morphologic appearance of nephrogenic adenoma.

A

Possibilities include cuboidal cells lining papillae, hobnail cells lining vessel-like structures, small thyroid-like tubules, and tubules mimicking signet ring tumors.

24
Q

Describe the morphologic appearance of nested urothelial cell carcinoma.

A

An invasive urothelial carcinoma made of small bland nests resembling von Brunn’s nests. Look for an infiltrative pattern and architecturally complex pattern of nests.

25
Q

Describe the morphologic appearance of lymphoepithelial-like carcinoma.

A

Resembles normal bladder with raging inflammation and tissue destruction. Malignant cells are often obscured by lymphocytes. Tumor cells have indistinct cytoplasmic borders.

26
Q
A

Normal urothelium

Arrow: Umbrella cells

Arrowhead: Lymphocyte, for size comparison (2-3x smaller)

27
Q
A

Cystitis Glandularis

Arrow: von Brunn’s nest

Asterisk: Lumen with columnar cell metaplasia

28
Q
A

Flat carcinoma in situ.

Arrow: Denuding of urothelium

29
Q
A

Papilloma

Arrow: Umbrella cell

Asterisk: Fibrovascular core

30
Q
A

PUNLMP

Note thickening without atypia

31
Q
A

LGPUC

Arrow: Fibrovascular core

Circle: Disorganized, enlarged cells

32
Q
A

HGPUC

Arrow: Large mitosis

33
Q
A

Invasive urothelial carcinoma

Arrow: Basement membrane, with cells below featuring paradoxical differentiation

34
Q
A

Invasive carcinoma in the detrusor muscle.

Arrow: Cancer

Arrowheads: Detrusor muscle

35
Q
A

Reactive nuclei

Note enlargement and prominent nucleoli with smooth nuclear outline and even chromatin.

36
Q
A

Nephrogenic adenoma, no urothelium

Arrowheads: Multiple tiny tubules in the lamina propria with dark nuclei.

37
Q
A

Lymphoepithelial-like carcinoma.

Arrow: Background of lymphocytes

Arrowhead: Malignant cells

Circle: Atypical mitosis

Book - Molavi (29 decks)

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