Difference between revisions of "Urothelium"

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Urothelium (view source)

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=====Urethra in males=====
=====Urethra in males=====
{{Main|Urethra}}
*Pre-prostatic urethra - transitional epithelium.
*Pre-prostatic urethra - transitional epithelium.
*[[Prostate gland|Prostatic]] urethra - transitional epithelium.
*[[Prostate gland|Prostatic]] urethra - transitional epithelium.
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*Should '''not''' have a papillary architecture -- if it does it is likely [[cancer]]!
*Should '''not''' have a papillary architecture -- if it does it is likely [[cancer]]!
**If it is 'papillary' -- it must have fibrovascular cores.
**If it is 'papillary' -- it must have fibrovascular cores.
===IHC===
*Rare superficial [[CK20]] staining.
====Image====
<gallery>
Image: Benign urothelium - CK20 -- high mag.jpg | Benign urothelium - CK20 - high mag. (WC)
</gallery>


===Sign out===
===Sign out===
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| -
| -
|-
|-
| '''Urothelial dysplasia'''
| '''[[Urothelial dysplasia]]'''
| moderate (3x)
| moderate (3x)
| small, some multiple
| small, some multiple
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| -
| -
|-
|-
| '''UCC in situ'''
| '''[[Urothelial carcinoma in situ]]'''
| '''signif. (4-5x)'''
| '''signif. (4-5x)'''
| +/-large
| +/-large
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| -
| -
|-
|-
| '''Invasive UCC'''
| '''[[Urothelial carcinoma|Invasive UCC]]'''
| signif. (4-5X)
| signif. (4-5X)
| +/-large
| +/-large
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*May be confused with [[urothelial carcinoma in situ]].<ref name=Ref_Amin2-57>{{Ref Amin|2-57}}</ref>
*May be confused with [[urothelial carcinoma in situ]].<ref name=Ref_Amin2-57>{{Ref Amin|2-57}}</ref>
*Uncommon.
*Uncommon.
*Considered to be [[normal urothelium]].


===Microscopic===
===Microscopic===
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*Ki-67 low.
*Ki-67 low.
*p53 -ve.
*p53 -ve.
===Sign out===
<pre>
URINARY BLADDER, TRANSURETHRAL BIOPSY:
- UROTHELIAL MUCOSA WITH MILD CHRONIC INFLAMMATION.
- NO EVIDENCE OF MALIGNANCY.
COMMENT:
Levels were cut and show large benign umbrella cells.
</pre>
====Micro====
The sections show small fragments of urothelial mucosa with enlarged benign superficial epithelial cells.  The lamina propria has a mild lymphocytic infiltrate.  No papillary structures are identified.  There is no significant nuclear atypia.  Superficial small blood vessels appear congested.


==Urothelial dysplasia==
==Urothelial dysplasia==
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==Urothelial papilloma==
==Urothelial papilloma==
===General===
{{Main|Urothelial papilloma}}
*Very rare diagnosed.
**If the person has a history of a low grade papillary urothelial carcinoma... it is a low grade papillary urothelial carcinoma.
**These cases are a consensus diagnosis, i.e. you show it to a colleague... if they agree you can call it.
 
===Microscopic===
Features:<ref name=Ref_WMSP310>{{Ref WMSP|310}}</ref>
*Papillary fronds.
*Minimal branching or fusion.
*Cytological features of normal urothelium.
**Normal urothelium approx. 2x the size of stromal lymphocytes.<ref name=Ref_GUP161>{{Ref GUP|161}}</ref>
*No mitoses.
*Thickness < 7 cells.{{fact}}
 
DDx:
*[[Low grade papillary urothelial carcinoma]].
*[[PUNLMP]].


==Inverted urothelial papilloma==
==Inverted urothelial papilloma==
*[[AKA]] ''[[inverted papilloma]]''.
*[[AKA]] ''[[inverted papilloma]]''.
 
{{Main|Inverted urothelial papilloma}}
===General===
*May be confused with papillary urothelial carcinoma with an inverted growth pattern.
 
===Microscopic===
Features:
*Like papillomas... but grow downward.<ref name=Ref_WMSP310>{{Ref WMSP|310}}</ref>
*According to THvdK,<ref>THvdK. 21 June 2010.</ref> ''inverted papillomas'' '''never''' have an exophytic component; if an exophytic component is present it is urothelial carcinoma.  This is disputed by one paper from Mexico that examines two cases.<ref name=pmid19433293>{{cite journal |author=Albores-Saavedra J, Chable-Montero F, Hernández-Rodríguez OX, Montante-Montes de Oca D, Angeles-Angeles A |title=Inverted urothelial papilloma of the urinary bladder with focal papillary pattern: a previously undescribed feature |journal=Ann Diagn Pathol |volume=13 |issue=3 |pages=158–61 |year=2009 |month=June |pmid=19433293 |doi=10.1016/j.anndiagpath.2009.02.009 |url=}}</ref>
*Nests have peripheral palisading of nuclei - '''important'''.
 
DDx:
*[[Low grade papillary urothelial carcinoma]] with an inverted growth pattern.
 
====Images====
<gallery>
Image:Inverted_papilloma_high_mag.jpg | Inverted papilloma - high mag. (WC/Nephron)
Image:Inverted_papilloma_intermed_mag.jpg | Inverted papilloma - intermed. mag. (WC/Nephron)
</gallery>
 
===IHC===
May be useful versus inverted growth pattern UCC:<ref name=pmid18043040>{{Cite journal  | last1 = Jones | first1 = TD. | last2 = Zhang | first2 = S. | last3 = Lopez-Beltran | first3 = A. | last4 = Eble | first4 = JN. | last5 = Sung | first5 = MT. | last6 = MacLennan | first6 = GT. | last7 = Montironi | first7 = R. | last8 = Tan | first8 = PH. | last9 = Zheng | first9 = S. | title = Urothelial carcinoma with an inverted growth pattern can be distinguished from inverted papilloma by fluorescence in situ hybridization, immunohistochemistry, and morphologic analysis. | journal = Am J Surg Pathol | volume = 31 | issue = 12 | pages = 1861-7 | month = Dec | year = 2007 | doi = 10.1097/PAS.0b013e318060cb9d | PMID = 18043040 }}</ref>
*Ki-67 -ve.
*CK20 -ve.
*p53 -ve (rarely +ve).


==Papillary urothelial neoplasm of low malignant potential==
==Papillary urothelial neoplasm of low malignant potential==
*Abbreviated ''PUNLMP''.
*Abbreviated ''PUNLMP''.
**This is pronounced ''pun-lump''.
**This is pronounced ''pun-lump''.
 
{{Main|Papillary urothelial neoplasm of low malignant potential}}
===General===
*Uncommon: prevalence ~ 0-3.5%.<ref name=pmid19346063>{{cite journal |author=May M, Brookman-Amissah S, Roigas J, ''et al.'' |title=Prognostic Accuracy of Individual Uropathologists in Noninvasive Urinary Bladder Carcinoma: A Multicentre Study Comparing the 1973 and 2004 World Health Organisation Classifications |journal=Eur. Urol. |volume= 57|issue= 5|pages= 850|year=2009 |month=March |pmid=19346063 |doi=10.1016/j.eururo.2009.03.052 |url=}}</ref>
*PUNLMP vs. [[low grade papillary urothelial carcinoma]] has a poor inter-rater reliability.<ref name=pmid17095142>{{cite journal |author=MacLennan GT, Kirkali Z, Cheng L |title=Histologic grading of noninvasive papillary urothelial neoplasms |journal=Eur. Urol. |volume=51 |issue=4 |pages=889–97; discussion 897–8 |year=2007 |month=April |pmid=17095142 |doi=10.1016/j.eururo.2006.10.037 |url=}}</ref>
 
Treatment:
*Excision and on-going follow-up - like non-invasive [[low grade papillary urothelial carcinoma]] (LGPUC).<ref name=pmid16697785>{{cite journal |author=Jones TD, Cheng L |title=Papillary urothelial neoplasm of low malignant potential: evolving terminology and concepts |journal=J. Urol. |volume=175 |issue=6 |pages=1995–2003 |year=2006 |month=June |pmid=16697785 |doi=10.1016/S0022-5347(06)00267-9 |url=}}</ref>
**Cheng ''et al.'' have advocated abandoning the term as they are treated like [[LGPUC]]s.<ref name=pmid22542126>{{Cite journal  | last1 = Cheng | first1 = L. | last2 = Maclennan | first2 = GT. | last3 = Lopez-Beltran | first3 = A. | title = Histologic grading of urothelial carcinoma: a reappraisal. | journal = Hum Pathol | volume = 43 | issue = 12 | pages = 2097-108 | month = Dec | year = 2012 | doi = 10.1016/j.humpath.2012.01.008 | PMID = 22542126 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_WMSP310>{{Ref WMSP|310}}</ref>
*Rare fused papillae.
*Infrequent mitoses.
*Nuclei larger than papilloma - but monotonous.<ref name=Ref_GUP170>{{Ref GUP|170}}</ref>
 
DDx:
*[[Low grade papillary urothelial carcinoma]].
*[[Urothelial papilloma|Papilloma]].
 
====Images====
<gallery>
Image:Punlmp1.jpg | PUNLMP - low mag. (WC/Nephron)
Image:Punlmp2.jpg | PUNLMP - high mag. (WC/Nephron)
</gallery>


==Low-grade papillary urothelial carcinoma==
==Low-grade papillary urothelial carcinoma==
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*[[AKA]] ''high-grade papillary urothelial cell carcinoma'', abbreviated ''HGPUCC''.
*[[AKA]] ''high-grade papillary urothelial cell carcinoma'', abbreviated ''HGPUCC''.
{{Main|High-grade papillary urothelial carcinoma}}
{{Main|High-grade papillary urothelial carcinoma}}
==Papillary urothelial hyperplasia==
*[[AKA]] ''papillary hyperplasia''.
*[[AKA]] ''reactive papillary hyperplasia''.
{{Main|Papillary urothelial hyperplasia}}


=Benign urothelial lesions=
=Benign urothelial lesions=
The big table of cystitis:
===Cystitis===
*Inflammation of the [[urinary bladder]]. 
*Comes in many forms (see below).
*Typically a [[clinical diagnosis]] under the more general term [[urinary tract infection]].
 
Note:
*So called "[[giant cell cystitis]]" is dealt with separately; it is a benign non-pathologic change that may or may not be associated with inflammation.<ref name=Ref_Amin2_6>{{Ref Amin|2:6}}</ref>
 
===The big table of cystitis===
{| class="wikitable sortable"  
{| class="wikitable sortable"  
! Type
! Type
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==Interstitial cystitis==
==Interstitial cystitis==
*[[AKA]] ''painful bladder syndrome''.<ref name=pmid21609485>{{Cite journal  | last1 = Tanaka | first1 = T. | last2 = Nitta | first2 = Y. | last3 = Morimoto | first3 = K. | last4 = Nishikawa | first4 = N. | last5 = Nishihara | first5 = C. | last6 = Tamada | first6 = S. | last7 = Kawashima | first7 = H. | last8 = Nakatani | first8 = T. | title = Hyperbaric oxygen therapy for painful bladder syndrome/interstitial cystitis resistant to conventional treatments: long-term results of a case series in Japan. | journal = BMC Urol | volume = 11 | issue =  | pages = 11 | month =  | year = 2011 | doi = 10.1186/1471-2490-11-11 | PMID = 21609485 }}</ref><ref name=pmid21568251>{{Cite journal  | last1 = French | first1 = LM. | last2 = Bhambore | first2 = N. | title = Interstitial cystitis/painful bladder syndrome. | journal = Am Fam Physician | volume = 83 | issue = 10 | pages = 1175-81 | month = May | year = 2011 | doi =  | PMID = 21568251 }}</ref>
{{Main|Interstitial cystitis}}
===General===
*Chronic cystitis, culture negative.
*Treatment difficult.<ref name=pmid21609485/>
 
Epidemiology:<ref name=pmid21568251/>
*Women > men.
 
Symptoms:<ref name=pmid21568251/>
*Urgency.
*Frequency.
*Pain.
 
===Microscopic===
Features:<ref name=Ref_GUP124>{{Ref GUP|124}}</ref>
*+/-Ulceration (uncommon).
 
Note:
*[[Diagnosis]] requires clinical correlation.
 
DDx:
*Urothelial CIS.


==Follicular cystitis==
==Follicular cystitis==
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==Cystitis cystica==
==Cystitis cystica==
===General===
{{Main|Cystitis cystica}}
*Benign.
*Can be thought of as [[von Brunn nests]] with cystic change.<ref name=Ref_WMSP304>{{Ref WMSP|304}}</ref>
*Called ''[[ureteritis cystica]]'' if it happens in a [[ureter]].
**There is also a ''urethritis cystica'' - seen in the [[urethra]].<ref name=pmid22397870>{{Cite journal  | last1 = Conces | first1 = MR. | last2 = Williamson | first2 = SR. | last3 = Montironi | first3 = R. | last4 = Lopez-Beltran | first4 = A. | last5 = Scarpelli | first5 = M. | last6 = Cheng | first6 = L. | title = Urethral caruncle: clinicopathologic features of 41 cases. | journal = Hum Pathol | volume = 43 | issue = 9 | pages = 1400-4 | month = Sep | year = 2012 | doi = 10.1016/j.humpath.2011.10.015 | PMID = 22397870 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_PBoD1028>{{Ref PBoD|1028}}</ref>
*Nests of urothelium within the lamina propria with cyst formation, i.e. lumens are present.
 
Note:
*Nests should '''not''' extend into the muscularis propria.
 
DDx:
*[[Nested urothelial carcinoma]].<ref name=pmid19800100>{{Cite journal  | last1 = Wasco | first1 = MJ. | last2 = Daignault | first2 = S. | last3 = Bradley | first3 = D. | last4 = Shah | first4 = RB. | title = Nested variant of urothelial carcinoma: a clinicopathologic and immunohistochemical study of 30 pure and mixed cases. | journal = Hum Pathol | volume = 41 | issue = 2 | pages = 163-71 | month = Feb | year = 2010 | doi = 10.1016/j.humpath.2009.07.015 | PMID = 19800100 }}
</ref>
 
Image:
*[http://www.webpathology.com/image.asp?n=1&Case=50 Cystitis cystica (webpathology.com)].
 
===Sign out===
<pre>
URINARY BLADDER, BIOPSY:
- CYSTITIS CYSTICA.
- NEGATIVE FOR MALIGNANCY.
</pre>


==Cystitis glandularis==
==Cystitis glandularis==
{{ Infobox external links
{{Main|Cystitis glandularis}}
| Name          = Cystitis cystica et glandularis
| EHVSC          = 10173
| pathprotocols  =
| wikipedia      =
| pathoutlines  =
}}
:''Cystitis cystica et glandularis'' redirects to here.
===General===
*Benign.
*Can be thought of as [[cystitis cystica]] with mucin-secreting cells lining the cystic spaces.<ref name=Ref_WMSP304>{{Ref WMSP|304}}</ref>
*When seen in conjunction with ''cystitis cystica'' it is called ''cystitis cystica et glandularis''.
 
Note:
*There are case reports of ''urethritis glandularis'' - the same lesion in the [[urethra]].<ref name=pmid11104631>{{Cite journal  | last1 = Chan | first1 = YM. | last2 = Ka-Leung Cheng | first2 = D. | last3 = Nga-Yin Cheung | first3 = A. | last4 = Yuen-Sheung Ngan | first4 = H. | last5 = Wong | first5 = LC. | title = Female urethral adenocarcinoma arising from urethritis glandularis. | journal = Gynecol Oncol | volume = 79 | issue = 3 | pages = 511-4 | month = Dec | year = 2000 | doi = 10.1006/gyno.2000.5968 | PMID = 11104631 }}</ref><ref name=pmid17825180>{{Cite journal  | last1 = Yin | first1 = G. | last2 = Liu | first2 = YQ. | last3 = Gao | first3 = P. | last4 = Wang | first4 = XH. | title = Male urethritis glandularis: case report. | journal = Chin Med J (Engl) | volume = 120 | issue = 16 | pages = 1460-1 | month = Aug | year = 2007 | doi =  | PMID = 17825180 }}</ref>
 
===Microscopic===
Features:<ref name=Ref_PBoD1028>{{Ref PBoD|1028}}</ref>
*Nests of urothelium within the lamina propria with cyst formation, i.e. lumens are present.
*Cyst lining cells are cuboidal and/or columnar epithelium.
**Produce mucin.
*+/-Goblet cells, i.e. intestinal metaplasia.<ref name=Ref_WMSP304>{{Ref WMSP|304}}</ref>
 
Note:
*Nests should '''not''' extend into the muscularis propria.
 
Image:
*[http://www.webpathology.com/image.asp?n=2&Case=50 Cystitis glandularis (webpathology.com)].
 
===Sign out===
<pre>
URINARY BLADDER NECK, BIOPSY:
- CYSTITIS CYSTICA ET GLANDULARIS.
- NEGATIVE FOR MALIGNANCY.
</pre>
 
====Micro====
The sections show urothelial mucosa with bland nests within the lamina propria with cyst formation. The stroma is edematous and has a mixed inflammatory infiltrate consisting of plasma cells, eosinophils, lymphocytes and neutrophils.


==Malakoplakia==
==Malakoplakia==
Michael
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