Lower Urinary Tract neoplasms Flashcards
Benign Urothelium
The normal urothelial lining varies in thickness from two layers to seven layers of cells, depending upon the degree of distension of the bladder.
Muscularis propria consists of thick bundles of smooth muscle in contrast to wispy fascicles of muscularis mucosae. In invasive urothelial cancers, the involvement of muscularis propria (Stage T2) warrants a definitive therapy such as cystectomy or radiation
Urothelial Papilloma
Urothelial papilloma is a papillary lesion composed of delicate fibrovascular cores lined by cytologically and architecturally normal urothelium less than seven cell layers thick
Urothelial Inverted Papilloma
Inverted papilloma is a benign proliferation
Histologically, inverted papilloma shows an inverted growth pattern, usually composed of anastomosing islands and trabeculae of histologically and cytologically normal urothelial cells invaginating from the surface urothelium into the subjacent lamina propria but not into the muscularis propria
Urothelial Neoplasm Important Points
Grading of urothelial tumors has particular importance in noninvasive disease specifically papillary neoplasm.
Greater than 95% of invasive tumors are high-grade.
Invasive urothelial tumors develop along at least two molecular pathways via either high-grade papillary tumors or carcinoma in situ.
Depth of invasion critical for prognosis and treatment
Discovery of molecular pathways involved in urothelial cancer recurrence and progression has allowed for the identification of potential prognostic and predictive markers.
In the near future risk assessment and treatment of urothelial carcinomas will be based on prognostic and predictive markers
Urothelial Neoplasia Epidemiology
Cancer of the environment and age –>the incidence and prevalence rates increase with age, peaking in the eighth decade of life
Present with painless hematuria
Likelihood of bladder cancer increases with gross hematuria
Urothelial Neoplasia Risk Factors
Cigarette Smoking 3-7x
aromatic amines
genetic factors
Chr. 17 p deletions –> invasive and carcinoma in situ
Urothelial Neoplasia Treatment Options
Smoking cessation (after 15 years –> never-smoker risk)
Majority of patients (non-invasive carcinoma)
- Transurethral resection (TURBT) and surveillance (No carcinoma in situ)
- Intavesicular therapy with chemotherapeutic agents or bacillus Calmette-Guerin (BCG)
Minority of patients (invasive carcinoma)
- Radical cystectomy for muscle invasive cancer
Consider radical cystectomy for incompletely resected noninvasive high-grade tumor, variant histologies (sarcoma, squamous cell carcinoma, adenocarcinoma) and** women with bladder neck or urethra carcinoma in situ**
Clinical Course of Bladder Cancer
After a excision new tumors/recurrence are common and progression to high-grade may occur
De novo carcinoma in situ progress to muscle invasive cancer (28%)
Some require BCG intravesical therapy
long-term surveillance is required following initial therapy
Squamous Cell Carcinoma
5% of bladder tumors in US
75% of bladder tumors in Egypt/Sudan
(Endemic to North Africa schistosomiasis hematobium)
S. Haematobium (SH)is the one associated with bladder cancer.
Histologic feature: Intracellular keratinization and bridges
Rare Variants of Epithelial Bladder Cancers
Adenocarcinoma of the bladder
Arise from you urachal *** remnants (dome of bladder) or in association with
extensive intestinal metaplasia
Small cell carcinoma of the bladder (Poor prognosis)
how can we follow these Urothelial Neoplasia patients?
urine cytology is not a routine screening test;
Inflammatory or stone disease, or
even instrumentation artifact,
can look like low-grade
Urine cytology using molecular tests for specific chromosomal changes unique to bladder cancer
Upregulated oncogenes
Down regulated tumor suppressor genes
Changes in protein expression
High risk groups
Smokers
Aromatic amines
US Preventive Services Task Force (USPSTF) concluded that there is no high-quality evidence that screening adults for bladder cancer improves outcomes compared with no screening
Treatment of Primary Non-muscle Invasive Urothelial Bladder Cancer
Approximately 70% of new bladder cancer cases are non-muscle invasive
Initial treatment includes complete transurethral resection of bladder tumor TURBT
Examination of bladder mucosa under anesthesia
Postoperative instillation of vesicular chemotherapy in some patients
Serial cystoscopies with cytologic evaluation every three to six months for the first two years with intervals based on clinician discretion.
