Lower urinary Tract II.pdf

Pathology of Lower urinary Tract II Bladder Tumor - Most common malignancy in urinary system - >95% of bladder tumors are of epithelial origin - Growths can be benign or malignant Bladder Tumor Risk Factors Smoking tobacco increases risk 4X Exposure to certain chemicals o Dye o Rubber o Leather Chro...

Pathology of Lower urinary Tract II Bladder Tumor - Most common malignancy in urinary system - >95% of bladder tumors are of epithelial origin - Growths can be benign or malignant Bladder Tumor Risk Factors Smoking tobacco increases risk 4X Exposure to certain chemicals o Dye o Rubber o Leather Chronic bladder inflammation or infections Older age Gender (Men mostly) Family history of bladder cancer HPV: Human papilloma virus Iatrogenic: radiation, cyclophosphamide, analgesics Bladder Tumor Common Symptoms: Hematuria: Blood in urine Frequent urination Painful urination Pelvic or lower back pain Bladder Tumor Diagnosis and Treatment Urine tests to detect blood or abnormal cells Imaging tests such as ultrasound, CT scan, or MRI to visualize the bladder Cystoscopy: a thin tube with camera is inserted into the bladder to examine it closely Biopsy to collect a sample of tissue for examination under a microscope. Radical cystectomy surgery: remove tumor or entire bladder Chemotherapy o Intravesical (directly into the bladder) o Systemic (given through the bloodstream) Immunotherapy Radiation therapy is often used in combination with other treatments Classification of Bladder Tumors Urothelial cancers – common (95%) o Papillary urothelial neoplasms with low malignant potential (PUNLMP) o Non-invasive papillary urothelial carcinoma (2) o Urothelial carcinoma in situ o Invasive urothelial carcinoma Squamous cell carcinoma Adenocarcinoma Squamous Cell Carcinoma 2-5% of bladder tumors in Western countries 20-30% of bladder tumors in Egypt/Sudan Arises after squamous metaplasia (urinary tract doesn't have squamous cells) o Chronic cystitis (older woman) o Schistosoma hematobium (HY) infection o Long standing nephrolithiasis Commonly lateral walls and trigone Has infiltrating pattern Adenocarcinoma Malignant tumor with gland cells Restricted diagnosis to pure adenocarcinomas More common in men (age 68) o Usually, lateral wall or trigone o Associated with intestinal metaplasia, chronic irritation of the bladder Usually present with hematuria Treatment: o Surgery o Adjuvant therapy Staging is the most important prognostic factor Urothelial Carcinoma (2 types: in Situ and Invasive) 2 pathways: o Flat § Develops as high-grade flat tumor and then invades § Associated with early p53 mutation o Papillary § Develops as low-grade papillary tumor that progresses to a high-grade papillary tumor and then invades § Not associated with early p53 mutation Cytology of high grade Urothelial Carcinoma o Atypical cells with large irregular nuclei in urine o Aneusomy chromosome (3, 7, 17 or deletion of 9p21 locus) o Papillary Urothelial Neoplasms of Low Malignant Potential (PUNLMP) Subtype of bladder tumor o Papillary urothelial growth o Increased urothelium layer o Slow-growing o Less aggressive o Common in men, age 65 Common in lateral posterior walls and ureteric orifices Asymptomatic or hematuria Excellent prognosis if totally excised Long-term follow-up is often recommended due to the potential for recurrence or progression to high grade tumors Histology: o Orderly arrangement of cells within papillae with minimal architectural abnormalities and minimal nuclear atypia o Thicker epithelium and increase in nuclear size/hyperchromasia Non-Invasive Papillary Urothelial Carcinomas (Low Grade) Papillary urothelial neoplasm with slight architectural abnormality and distinct but low-grade cytologic atypia No high-grade features (no marked pleomorphism, no mitoses toward the surface, no nucleoli throughout) More common in men, mean age 70 o Likely multicentric o Hematuria Treatment: Surgery Prognosis: Likely recur Histology: o Slightly disorganized architecture and mild variation in nuclear shape, size, darkness, etc Non-Invasive Papillary Urothelial Carcinomas (High Grade) Papillary urothelial growth with moderate to marked architectural and cytologic atypia o High rate (15-40%) of progression to invasive disease o More common in men, mean age 50+ o Often aneuploidy, p53, HER2, EGFR o Hematuria, urinary symptoms Treatment: Surgery, chemotherapy, radiation Histology: o Moderate to marked architectural and cytological pleomorphism (great variation of nuclear shape, size, darkness, brisk mitosis, etc) o Complex papillary fronds lined by urothelium with marked cytologic atypia, including nuclear pleomorphism (variability in nuclear size and shape), loss of polarity, and apoptosis Urothelial Carcinoma in Situ Flat urothelial lesion composed of cells in mid to upper urothelium with high cytologic grade o Commonly associated with invasive carcinoma o Likely multifocal o Hematuria, urinary symptoms o Tumor cells shed into the urine Cystoscopy findings: Unremarkable, erythema, or edema Treatment: bCG, complete excision is curative Histology: o Flat lesion, no invasion, atypical cells o Marked nuclear pleomorphism and loss of polarity Invasive Urothelial Carcinoma Either low-grade or high-grade Most common bladder tumor More common in >50, cigarette smokers, men, urban Risk factors: o Cigarette smoking o Industrial exposure o Cyclophosphamide o Chronic irritation o HPV Clinical Presentation: o Painless hematuria o Obstruction if near ureteral orifices o Irritative bladder symptoms: Dysuria, urgency, etc o Atypical cells in urine Genetics: o Aneuploidy o Low grade papillary: FGFR3, PIK3CA, STAG2 o High grade: p53, RB1, Her2, PTEN Histology: o Malignant urothelial cells, high or low grade o Papillary, or nodular o May have glandular or squamous metaplasia o Invasion through basement membrane o Positive for uroplakin Treatment: o Surgery o Chemotherapy