Lower urinary tract lesions Flashcards
What are the layers of the bladder?
- Mucosa
- Urothelium
- Lamina propria
- Discontinuous muscularis mucosa
- Muscularis propria
- Adventitia
- Serosa at dome
- When we have a cancer that is infiltrating and reaches the MUSCULARIS PROPRIA the treatment is cystectomy which is the complete removal of the bladder while if it only reaches the MUSCULARIS MUCOSA we can remove the tumor alone sparing the bladder
What are the causes of acute and chronic cystitis?
- Infections
- Radiation and chemotherapies
What are the different types of cystitis?
1) Interstitial cystitis
2) Malakoplakia
What is interstitial cystitis?
- Chronic pelvic pain (suprapubic pain that increases with bladder filling and is relieved by the emptying of the bladder)
- Grossly: Hemorrhage followed by localized ulceration (Hunner ulcer)
- Microscopic: Mast cell infiltration in the lamina propria
What is malakoplakia?
- Chronic bacterial cystitis (due to E.coli or proteus)
- Grossly, it appears as a soft, yellow mucosal plaque
- Microscopically, we can see histocytes with eosinophilic cytoplasm (von Hansemann histiocytes) in the lamina propria, with intracytoplasmic calcifications (Michaelis-Gutmann bodies)
What is the hallmark of interstitial cystitis?
Suprapubic pain that increases with bladder filling and gets relieved by bladder emptying
What is the microscopic photo of interstitial cystitis?
Mast cell infiltrate in the lamina propria
What is the microscopic photo of malakoplakia?
1) Von Hansemann histiocytes (Bacteria engulfed by the macrophages but we are not able to kill it)
2) Michaelis gutmann bodies (in the von Hansemann histiocytes, where we will find the bacteria will calcium deposit on it)
What are the benign lesions of the urinary bladder urothelium?
1) Brunn nests
2) Cystitis cystica
3) Cystitis glandularis
4) Squamous metaplasia
5) Nephrogenic metaplasia (there will be shedding of the tubular cells, where they implant and proliferate at sites of injured urothelium)
What is brunn nests?
- Nests of normal urothelium epithelium that proliferates to the inside of the urinary (into the lamina propria) wall instead of the lumen
What is cystitis cystica?
When the brunn nects develop cysts
What is cystitis glandularis?
When the lining in the cysts in cystitis cystica changes from urothelium to a mucus-secreting urothelium
What are the risk factors for developing bladder neoplasms?
1) Smoking
2) Industrial exposure to arylamines
3) Schistosoma hematobium infecion
4) Drugs (analgesics and cyclophosphamide)
5) Radiation
When do we perform a cystectomy?
- If the cancer reaches the propria, we have a cystectomy, and if not, we just remove the tumor
- When someone has squamous cell carcinoma, whether it reaches or not, we remove the bladder & same goes for adenocarcinoma.
How does bladder cancer start?
1) Papillary urothelial lesion
2) Flat lesion
How do papillary urothelial lesions develop into an invasive carcinoma?
1) Papilloma (Beginning)
- Benign tumor of the epithelium making a papillae, it has a central fibrovascular core that is covered by normal urothelial cells formed of 6-7 cells
2) Papillary urothelial neoplasms of low malignant potential (PUNLMP)
- Increase in the number of cells compared to a papilloma, (from benign to low malignant)
3) Non-invasive low-grade papillary urothelial carcinomas
- Papillary tumor tissue that is lined with many layers of urothelial cells with low atypia (mid-cellular grade and nuclear pleomorphism, and a mild disturbed polarity)
4) Non-invasive High-grade papillary urothelial carcinoma
- Papillary tumor tissue that is lined with many layers of urothelial cells with high atypia (marked grade and nuclear pleomorphism, and a mild disturbed polarity)
5) Invasive carcinoma (and once it reaches the muscle, vwala cystectomy)
How does a flat urothelial lesion develop into an invasive carcinoma?
1) Urothelial dysplasia (low-grade intra-urothelial neoplasia)
- Grossly, there is nothing or simple erythema
- Microscopically, there is a loss in the polarity of the cells + nuclear crowding + cytologic atypia
2) Urothelial carcinoma in situ (high-grade intra-urothelial neoplasia)
- Grossly, again nothing or simple erythema
- Microscopically, there isa loss of cell polarity with nuclear crowding and cytological atypia
- If untreated, 75% of carcinoma in situ progresses to a muscle-invasive cancer
3) Invasive carcinoma
What is the genetic mutation in superficial papillary tumors?
FGFR3 & RAS
What is the genetic mutation in carcinoma in situ?
Mutations in P3 and RB
What is the genetic mutation in the invasive tumors of the UB?
Mutations in p53
What is the clinical presentation of invasive urothelial carcinoma?
Painless hematuria
What are the gross findings of invasive urothelial carcinoma?
Fungating tumor that arises from the bladder and the wall, filling the lumen
What are the microscopic findings of the invasive urothelial carcinoma?
- Invasion by urothelial nests or single cells
- he muscularis propria is invaded
How are UB lesions managed?
- Benign:
- Cystoscopic rescection
- Intravesical therapy with BCG
- Invasive:
- Cystectomy
