Difference between revisions of "High-grade papillary urothelial carcinoma"

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{{ Infobox diagnosis
| Name      = {{PAGENAME}}
| Image      = High-grade papillary urothelial carcinoma -- intermed mag.jpg
| Width      =
| Caption    = High-grade papillary urothelial carcinoma. [[H&E stain]].
| Micro      = papillae with "architectural complexity" (fused papillae, branching of papillae), +/-nuclear pleomorphism, nuclear enlargement - often 4-5x the size of stromal lymphocytes, mitoses (common), +/-invasion into the lamina propria (common)
| Subtypes  = subtype of [[urothelial carcinoma]]
| LMDDx      = [[low-grade papillary urothelial carcinoma]], [[urothelial carcinoma in situ]], [[squamous cell carcinoma]]
| Stains    =
| IHC        = Ki-67 high (>35% of cells), PAX8 -ve
| EM        =
| Molecular  =
| IF        =
| Gross      = exophytic mass, frond-like appearance, friable
| Grossing  =
| Site      = [[urothelium]] - usu. [[urinary bladder]]
| Assdx      =
| Syndromes  = [[Lynch syndrome]]
| Clinicalhx =
| Signs      = hematuria
| Symptoms  =
| Prevalence = common
| Bloodwork  =
| Rads      =
| Endoscopy  =
| Prognosis  = dependent on stage, usu. moderate
| Other      =
| ClinDDx    = [[low-grade papillary urothelial carcinoma]]
}}
'''High-grade papillary urothelial carcinoma''', abbreviated '''HGPUC''', is a common form of [[cancer]] that arises from the [[urothelium]].
'''High-grade papillary urothelial carcinoma''', abbreviated '''HGPUC''', is a common form of [[cancer]] that arises from the [[urothelium]].


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==General==
==General==
*Aggressive.
*Aggressive.
*May be associated with [[Lynch syndrome]].<ref name=pmid12673555>{{Cite journal  | last1 = Hartmann | first1 = A. | last2 = Dietmaier | first2 = W. | last3 = Hofstädter | first3 = F. | last4 = Burgart | first4 = LJ. | last5 = Cheville | first5 = JC. | last6 = Blaszyk | first6 = H. | title = Urothelial carcinoma of the upper urinary tract: inverted growth pattern is predictive of microsatellite instability. | journal = Hum Pathol | volume = 34 | issue = 3 | pages = 222-7 | month = Mar | year = 2003 | doi = 10.1053/hupa.2003.22 | PMID = 12673555 }}</ref>


==Gross==
==Gross==
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*"High grade nuclear features":
*"High grade nuclear features":
**Nuclear pleomorphism - often 4-5x the size of stromal lymphocytes.<ref name=Ref_GUP161>{{Ref GUP|161}}</ref>
**Nuclear pleomorphism - often 4-5x the size of stromal lymphocytes.<ref name=Ref_GUP161>{{Ref GUP|161}}</ref>
*Architectural complexity.
*Papillae with "architectural complexity":
**Fused papillary common.
**Fused papillae - common.
**Papillae branch.
**Branching of papillae common.
*Mitoses common.
*Mitoses - common.
*+/-Invasion into the lamina propria.
*+/-Invasion into the lamina propria - relatively common.


Note:
Note:
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DDx:
DDx:
*[[Low grade papillary urothelial carcinoma]].
*[[Low grade papillary urothelial carcinoma]].
**Stanford criteria has a 5% rule -- if the high-grade component is <5% it is low-grade.<ref>URL: [http://surgpathcriteria.stanford.edu/bladder/tcc-papillary-transitional-urothelial-carcinoma/ http://surgpathcriteria.stanford.edu/bladder/tcc-papillary-transitional-urothelial-carcinoma/]. Accessed on: 27 January 2014.</ref>
***There is some evidence to suggest low-grade with <5% high-grade behaves similar to low-grade.<ref name=pmid26520419>{{Cite journal  | last1 = Reis | first1 = LO. | last2 = Taheri | first2 = D. | last3 = Chaux | first3 = A. | last4 = Guner | first4 = G. | last5 = Mendoza Rodriguez | first5 = MA. | last6 = Bivalacqua | first6 = TJ. | last7 = Schoenberg | first7 = MP. | last8 = Epstein | first8 = JI. | last9 = Netto | first9 = GJ. | title = Significance of a minor high-grade component in a low-grade noninvasive papillary urothelial carcinoma of bladder. | journal = Hum Pathol | volume = 47 | issue = 1 | pages = 20-5 | month = Jan | year = 2016 | doi = 10.1016/j.humpath.2015.09.007 | PMID = 26520419 }}></ref>
*[[Prostate carcinoma]] with pseudopapillae<ref name=pmid24503758>{{cite journal |author=Gordetsky J, Epstein JI |title=Pseudopapillary features in prostatic adenocarcinoma mimicking urothelial carcinoma: a diagnostic pitfall |journal=Am. J. Surg. Pathol. |volume=38 |issue=7 |pages=941–5 |year=2014 |month=July |pmid=24503758 |doi=10.1097/PAS.0000000000000178 |url=}}</ref> - see ''[[urothelial carcinoma-like prostatic carcinoma]]''.
**Should be considered if a [[urethra]]l tumour.
===Images===
<gallery>
Image: High-grade papillary urothelial carcinoma -- low mag.jpg | HGPUC - low mag.
Image: High-grade papillary urothelial carcinoma -- intermed mag.jpg | HGPUC - intermed. mag.
Image: High-grade papillary urothelial carcinoma -- high mag.jpg | HGPUC - high mag.
Image: High-grade papillary urothelial carcinoma - alt -- high mag.jpg | HGPUC - high mag.
Image: High-grade papillary urothelial carcinoma - inv -- low mag.jpg | HGPUC - low mag.
Image: High-grade papillary urothelial carcinoma - inv -- intermed mag.jpg | HGPUC - intermed. mag.
Image: High-grade papillary urothelial carcinoma - inv -- high mag.jpg | HGPUC - high mag.
</gallery>


==IHC==
==IHC==
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**Rajcani ''et al.'':<ref name=pmid23944616>{{Cite journal  | last1 = Rajcani | first1 = J. | last2 = Kajo | first2 = K. | last3 = Adamkov | first3 = M. | last4 = Moravekova | first4 = E. | last5 = Lauko | first5 = L. | last6 = Felcanova | first6 = D. | last7 = Bencat | first7 = M. | title = Immunohistochemical characterization of urothelial carcinoma. | journal = Bratisl Lek Listy | volume = 114 | issue = 8 | pages = 431-8 | month =  | year = 2013 | doi =  | PMID = 23944616 }}</ref> <25% of tumour cells for low-grade versus >50% tumour cell for high-grade.
**Rajcani ''et al.'':<ref name=pmid23944616>{{Cite journal  | last1 = Rajcani | first1 = J. | last2 = Kajo | first2 = K. | last3 = Adamkov | first3 = M. | last4 = Moravekova | first4 = E. | last5 = Lauko | first5 = L. | last6 = Felcanova | first6 = D. | last7 = Bencat | first7 = M. | title = Immunohistochemical characterization of urothelial carcinoma. | journal = Bratisl Lek Listy | volume = 114 | issue = 8 | pages = 431-8 | month =  | year = 2013 | doi =  | PMID = 23944616 }}</ref> <25% of tumour cells for low-grade versus >50% tumour cell for high-grade.
**Pich ''et al.'':<ref name=pmid7910097>{{Cite journal  | last1 = Pich | first1 = A. | last2 = Chiusa | first2 = L. | last3 = Comino | first3 = A. | last4 = Navone | first4 = R. | title = Cell proliferation indices, morphometry and DNA flow cytometry provide objective criteria for distinguishing low and high grade bladder carcinomas. | journal = Virchows Arch | volume = 424 | issue = 2 | pages = 143-8 | month =  | year = 1994 | doi =  | PMID = 7910097 }}</ref> 11%/17% for G1/G2 versus 34% for G3.
**Pich ''et al.'':<ref name=pmid7910097>{{Cite journal  | last1 = Pich | first1 = A. | last2 = Chiusa | first2 = L. | last3 = Comino | first3 = A. | last4 = Navone | first4 = R. | title = Cell proliferation indices, morphometry and DNA flow cytometry provide objective criteria for distinguishing low and high grade bladder carcinomas. | journal = Virchows Arch | volume = 424 | issue = 2 | pages = 143-8 | month =  | year = 1994 | doi =  | PMID = 7910097 }}</ref> 11%/17% for G1/G2 versus 34% for G3.
**Mai ''et al.'' suggest there is overlap:<ref name=pmid23913166>{{Cite journal  | last1 = Mai | first1 = KT. | last2 = Flood | first2 = TA. | last3 = Williams | first3 = P. | last4 = Kos | first4 = Z. | last5 = Belanger | first5 = EC. | title = Mixed low- and high-grade papillary urothelial carcinoma: histopathogenetic and clinical significance. | journal = Virchows Arch | volume = 463 | issue = 4 | pages = 575-81 | month = Oct | year = 2013 | doi = 10.1007/s00428-013-1456-7 | PMID = 23913166 }}</ref> 10-30% for low-grade versus 20-50% for high-grade.
*p53 +ve - more common in pT2 than pT1 and HGPUC than LGPUC... but not useful to definitively separate.<ref name=pmid23924551>{{Cite journal  | last1 = Koyuncuer | first1 = A. | title = Immunohistochemical expression of p63, p53 in urinary bladder carcinoma. | journal = Indian J Pathol Microbiol | volume = 56 | issue = 1 | pages = 10-5 | month =  | year =  | doi = 10.4103/0377-4929.116141 | PMID = 23924551 }}</ref>
*p53 +ve - more common in pT2 than pT1 and HGPUC than LGPUC... but not useful to definitively separate.<ref name=pmid23924551>{{Cite journal  | last1 = Koyuncuer | first1 = A. | title = Immunohistochemical expression of p63, p53 in urinary bladder carcinoma. | journal = Indian J Pathol Microbiol | volume = 56 | issue = 1 | pages = 10-5 | month =  | year =  | doi = 10.4103/0377-4929.116141 | PMID = 23924551 }}</ref>


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==Sign out==
==Sign out==
<pre>
Urinary Bladder Tumour, Transurethral Resection:
- HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA.
-- NEGATIVE for lamina propria invasion.
-- NEGATIVE for lymphovascular invasion.
-- Please see synoptic report.
- Muscularis propria present and NEGATIVE for invasion.
- NEGATIVE for (flat) urothelial carcinoma in situ.
</pre>
====Block letters====
<pre>
<pre>
URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION:
URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION:
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===Invasion into the lamina propria===
===Invasion into the lamina propria===
<pre>
Urinary Bladder Tumour, Transurethral Resection:
- INVASIVE HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA with lamina propria invasion.
-- Muscularis propria present, NEGATIVE for muscularis propria invasion.
-- NEGATIVE for lymphovascular invasion.
-- Please see synoptic report.
</pre>
====Block letters====
<pre>
<pre>
URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION URINARY BLADDER TUMOUR (TURBT):  
URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION URINARY BLADDER TUMOUR (TURBT):  
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====Micro====
====Micro====
The sections show urothelial mucosa with thick papillary structures. Focally, nuclei are large (~3-4x resting lymphocyte), hyperchromatic and have nucleoli. Mitotic activity is present and focally brisk (4 mitoses in 1 HPF, 1 HPF~0.2376 mm*mm). Umbrella cells are seen only focally.
=====Alternate=====
The sections show a small fragment of urothelial mucosa with two papillary structures,
The sections show a small fragment of urothelial mucosa with two papillary structures,
enlarged nuclei (~3-4x resting lymphocyte) and moderate nuclear size variation.  Mitotic activity is seen focally. Umbrella
enlarged nuclei (~3-4x resting lymphocyte) and moderate nuclear size variation.  Mitotic activity is seen focally. Umbrella
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contains a nest with smaller cells, cystic spaces and no appreciable mitoses
contains a nest with smaller cells, cystic spaces and no appreciable mitoses
(cystitis cystica).
(cystitis cystica).
 
==See also==
==See also==
*[[Urothelium]].
*[[Urothelium]].

Latest revision as of 01:43, 22 February 2017

High-grade papillary urothelial carcinoma
Diagnosis in short

High-grade papillary urothelial carcinoma. H&E stain.

LM papillae with "architectural complexity" (fused papillae, branching of papillae), +/-nuclear pleomorphism, nuclear enlargement - often 4-5x the size of stromal lymphocytes, mitoses (common), +/-invasion into the lamina propria (common)
Subtypes subtype of urothelial carcinoma
LM DDx low-grade papillary urothelial carcinoma, urothelial carcinoma in situ, squamous cell carcinoma
IHC Ki-67 high (>35% of cells), PAX8 -ve
Gross exophytic mass, frond-like appearance, friable
Site urothelium - usu. urinary bladder

Syndromes Lynch syndrome

Signs hematuria
Prevalence common
Prognosis dependent on stage, usu. moderate
Clin. DDx low-grade papillary urothelial carcinoma

High-grade papillary urothelial carcinoma, abbreviated HGPUC, is a common form of cancer that arises from the urothelium.

It is also known as high-grade papillary urothelial cell carcinoma, abbreviated HGPUCC.

General

Gross

  • Exophytic mass.
  • Frond-like appearance.
  • Friable.

Microscopic

Features:[2]

  • "High grade nuclear features":
    • Nuclear pleomorphism - often 4-5x the size of stromal lymphocytes.[3]
  • Papillae with "architectural complexity":
    • Fused papillae - common.
    • Branching of papillae common.
  • Mitoses - common.
  • +/-Invasion into the lamina propria - relatively common.

Note:

  • The presence/absence of muscle should be commented on in biopsy specimens.
  • Adipose tissue may be seen in the lamina propria; tumour adjacent to adipose tissue on a biopsy does not imply invasion deep to the muscularis propria.[4]

DDx:

Images

IHC

  • Ki-67:
    • Rajcani et al.:[8] <25% of tumour cells for low-grade versus >50% tumour cell for high-grade.
    • Pich et al.:[9] 11%/17% for G1/G2 versus 34% for G3.
    • Mai et al. suggest there is overlap:[10] 10-30% for low-grade versus 20-50% for high-grade.
  • p53 +ve - more common in pT2 than pT1 and HGPUC than LGPUC... but not useful to definitively separate.[11]

Molecular

Molecular changes:[12]

  • p53.
  • p21.
  • RB.
  • E-cadherin - decreased bad.
  • RhoGD12 - increased bad.
  • VEGF - increased bad.

Sign out

Urinary Bladder Tumour, Transurethral Resection: 
- HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA.
-- NEGATIVE for lamina propria invasion.
-- NEGATIVE for lymphovascular invasion.
-- Please see synoptic report.
- Muscularis propria present and NEGATIVE for invasion.
- NEGATIVE for (flat) urothelial carcinoma in situ.

Block letters

URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION:
- HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA.
- NO LAMINA PROPRIA INVASION APPARENT.
- NEGATIVE FOR LYMPHOVASCULAR INVASION.
- NO MUSCULARIS PROPRIA IDENTIFIED.

Invasion into the lamina propria

Urinary Bladder Tumour, Transurethral Resection: 
- INVASIVE HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA with lamina propria invasion.
-- Muscularis propria present, NEGATIVE for muscularis propria invasion.
-- NEGATIVE for lymphovascular invasion.
-- Please see synoptic report.

Block letters

URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION URINARY BLADDER TUMOUR (TURBT): 
- INVASIVE HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA WITH LAMINA PROPRIA INVASION.
- MUSCULARIS PROPRIA NEGATIVE FOR INVASIVE MALIGNANCY.
- NEGATIVE FOR LYMPHOVASCULAR INVASION.

Invasion into the muscularis propria

URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION URINARY BLADDER TUMOUR (TURBT): 
- INVASIVE HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA AT LEAST INTO MUSCULARIS PROPRIA. 
- LYMPHOVASCULAR INVASION PRESENT.

Low-grade versus high-grade

URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION URINARY BLADDER TUMOUR (TURBT):
- HIGH-GRADE PAPILLARY UROTHELIAL CARCINOMA, SEE COMMENT.
- NEGATIVE FOR LAMINA PROPRIA INVASION.
- NO MUSCULARIS PROPRIA PRESENT.

COMMENT:
The sections show papillary branching, papillary fusion and scattered large cells (~4-5 a
resting lymphocyte). Atypical for a high-grade lesion is that mitotic activity is scarce
and prominent nucleoli are not present.

Micro

The sections show urothelial mucosa with thick papillary structures. Focally, nuclei are large (~3-4x resting lymphocyte), hyperchromatic and have nucleoli. Mitotic activity is present and focally brisk (4 mitoses in 1 HPF, 1 HPF~0.2376 mm*mm). Umbrella cells are seen only focally.

Alternate

The sections show a small fragment of urothelial mucosa with two papillary structures, enlarged nuclei (~3-4x resting lymphocyte) and moderate nuclear size variation. Mitotic activity is seen focally. Umbrella cells are seen only focally.

A mild lymphocyte-predominant inflammatory infiltrate is present. The lamina propria contains a nest with smaller cells, cystic spaces and no appreciable mitoses (cystitis cystica).

See also

References

  1. Hartmann, A.; Dietmaier, W.; Hofstädter, F.; Burgart, LJ.; Cheville, JC.; Blaszyk, H. (Mar 2003). "Urothelial carcinoma of the upper urinary tract: inverted growth pattern is predictive of microsatellite instability.". Hum Pathol 34 (3): 222-7. doi:10.1053/hupa.2003.22. PMID 12673555.
  2. Humphrey, Peter A; Dehner, Louis P; Pfeifer, John D (2008). The Washington Manual of Surgical Pathology (1st ed.). Lippincott Williams & Wilkins. pp. 310. ISBN 978-0781765275.
  3. Zhou, Ming; Magi-Galluzzi, Cristina (2006). Genitourinary Pathology: A Volume in Foundations in Diagnostic Pathology Series (1st ed.). Churchill Livingstone. pp. 161. ISBN 978-0443066771.
  4. Bochner, BH.; Nichols, PW.; Skinner, DG. (Mar 1995). "Overstaging of transitional cell carcinoma: clinical significance of lamina propria fat within the urinary bladder.". Urology 45 (3): 528-31. doi:10.1016/S0090-4295(99)80030-2. PMID 7879346.
  5. URL: http://surgpathcriteria.stanford.edu/bladder/tcc-papillary-transitional-urothelial-carcinoma/. Accessed on: 27 January 2014.
  6. Reis, LO.; Taheri, D.; Chaux, A.; Guner, G.; Mendoza Rodriguez, MA.; Bivalacqua, TJ.; Schoenberg, MP.; Epstein, JI. et al. (Jan 2016). "Significance of a minor high-grade component in a low-grade noninvasive papillary urothelial carcinoma of bladder.". Hum Pathol 47 (1): 20-5. doi:10.1016/j.humpath.2015.09.007. PMID 26520419.>
  7. Gordetsky J, Epstein JI (July 2014). "Pseudopapillary features in prostatic adenocarcinoma mimicking urothelial carcinoma: a diagnostic pitfall". Am. J. Surg. Pathol. 38 (7): 941–5. doi:10.1097/PAS.0000000000000178. PMID 24503758.
  8. Rajcani, J.; Kajo, K.; Adamkov, M.; Moravekova, E.; Lauko, L.; Felcanova, D.; Bencat, M. (2013). "Immunohistochemical characterization of urothelial carcinoma.". Bratisl Lek Listy 114 (8): 431-8. PMID 23944616.
  9. Pich, A.; Chiusa, L.; Comino, A.; Navone, R. (1994). "Cell proliferation indices, morphometry and DNA flow cytometry provide objective criteria for distinguishing low and high grade bladder carcinomas.". Virchows Arch 424 (2): 143-8. PMID 7910097.
  10. Mai, KT.; Flood, TA.; Williams, P.; Kos, Z.; Belanger, EC. (Oct 2013). "Mixed low- and high-grade papillary urothelial carcinoma: histopathogenetic and clinical significance.". Virchows Arch 463 (4): 575-81. doi:10.1007/s00428-013-1456-7. PMID 23913166.
  11. Koyuncuer, A.. "Immunohistochemical expression of p63, p53 in urinary bladder carcinoma.". Indian J Pathol Microbiol 56 (1): 10-5. doi:10.4103/0377-4929.116141. PMID 23924551.
  12. Ehdaie, B.; Theodorescu, D. (Jan 2008). "Molecular markers in transitional cell carcinoma of the bladder: New insights into mechanisms and prognosis.". Indian J Urol 24 (1): 61-7. doi:10.4103/0970-1591.38606. PMC 2684226. PMID 19468362. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2684226/.