Know the pathology and classification of bladder epithelial tumors and staging of bladder CA

• classification: urothelial (transitional cell) tumors--inverted papilloma, papilloma (exophytic), urothelial carcinoma, carcinoma in situ; squamous cell carcinoma; mixed carcinoma; adenocarcinoma; small cell carcinoma; sarcoma

• pathology--urothelial tumors represent about 90% of all bladder tumors; range from small benign to low or indeterminate malignant potential to lesions that metastasize frequently; many are multifocal; no reliable grading system (that people agree on); majority of tumors can be separated into 2 categories at time of initial dx: 1) low-grade urothelial tumors--always papillary (red, elevated excrescences; <1cm-5cm),>

• papilloma--rare variant, <1%>

• staging:

depth of invasion AJCC/UICC (2 CA groups)

• noninvasive, papillary Ta
• noninvasive, flat TIS
• lamina propria T1
• superficial muscularis propria T2
• deep muscularis propria T3a
• perivesical fat T3b
• adjacent structures T4
• lymph node metastases N1-3 (N1 = regional lymph node <2cm; n2 =" regional" n3 =" regional">5cm or other lymph nodes)
• distant metastases M1

Know the grading of TCC (transitional cell carcinoma).

• grade I--appearance similar to papilloma; some cytologic and architectural atypia but well differentiated; thin line between papilloma and grade I tumor; seldom become invasive and 95-98% 10 yr. survival

• grade II--most are papillary, may have contiguous flat regions; cells still recognizable as of transitional origin; increased # of layers and increased # of mitosis; increased variation in cell size, shape, and chromaticity; may be assoc. w/invasion at time of dx but have low risk of progression

• grade III--papillary, flat, or both; appear fungating, necrotic, sometimes ulcerative; larger, more extensive; may increase preponderance for invasion of muscularis; many cells show anaplastic changes, disarray of cells w/loosening and fragmentation of superficial layers; occasional giant cells; sometimes cells flatten out and lesions resemble squamous cell carcinomas; or may have foci of glandular differentiation; much higher incidence of invasion into muscular layer, higher risk of progression, significant metastatic potential

Know the factors that are associated w/ increased risk of bladder CA.

• smoking, industrial exposure to arylamines, Schistosoma haematobium infections, long term use of analgesics, heavy long term exposure to cyclophosphamide

Know the possible pathogenesis of bladder CA: injury, chromosome abnormalities, ras, c-myc.

• increased expression of ras, c-myc, and epidermal growth factor Rcs is seen in some bladder CAs; 30-60% show deletions in chromosome 9 (only genetic change in superficial papillary tumors and occasionally in noninvasive flat tumors), as well as deletions of 17p, 13q,11p, and 14q

Know the px of TCC and SCC (squamous cell carcinoma).

• px of TCC depends on grade and stage at time of dx

TCC grade I--98% 10 yr survival

TCC grade III--40% 10 yr survival; tumor is progressive in 65%

no specific #s given for TCC grade II px

• SCC--70% death w/in yr

Know the factors associated w/ good and bad px.

• good px: pts whose tumor express A, B, H Ags; grade I tumor

• bad px: tumors that don't express A, B, H Ags; detection of multiple chromosomes and gene mutations; grade III tumor and SCC

Know the clinical manifestations of bladder CA.

• painless hematuria (dominant and sometimes only clinical manifestation), frequency, urgency, and dysuria sometimes accompany; if ureteral orifice is involved, hydronephritis and pyelonephritis may follow

Know the techniques available for early detection of bladder CA.

• cystoscopy and biopsy; w/subtle changes, can use cytologic examination possibly augmented by flow cytometric analyses of urinary sediment

What is the most common malignant mesenchymal tumor in infancy and childhood?

• embryonal rhabdomyosarcoma or sarcoma botryoides

Know the causes and consequences (effects on the kidneys, ureters, acquired diverticulosis, UTI) of urinary bladder obstruction.

• causes: in males, most important cause is enlargement of prostate; in females, usually due to cystocele; more infrequent causes include congenital narrowings or strictures of urethra, inflammatory strictures of urethra, inflammatory fibrosis and contraction of bladder after varying types of cystitis, bladder tumors (benign or malignant), 2º invasion of bladder neck by growths arising in perivesical structures, mechanical obstruction (foreign bodies and calculi), injury to innervation causing neurogenic or cord bladder

• consequences--dilation of bladder, eventual effect on kidney, acquired diverticuli

Category: Pathology Notes