Difference between revisions of "Urothelial carcinoma"

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Urothelial carcinoma (view source)

Revision as of 16:57, 11 November 2014

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(re-arrange - put variants at bottom)
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See ''[[Urine_cytopathology#Urothelial_cell_carcinoma|urine cytology]]'' for the [[cytopathology]].
See ''[[Urine_cytopathology#Urothelial_cell_carcinoma|urine cytology]]'' for the [[cytopathology]].


==General==
=General=
*These lesions lack papillae and are typical flat.
*These lesions lack papillae and are typical flat.
*Clinically, it may not be possible to differentiate renal pelvis urothelial carcinoma and [[renal cell carcinoma]].
*Clinically, it may not be possible to differentiate renal pelvis urothelial carcinoma and [[renal cell carcinoma]].
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*Others.
*Others.


==Microscopic==
=Microscopic=
Features:
Features:
*Nuclear pleomorphism - '''key feature'''.
*Nuclear pleomorphism - '''key feature'''.
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*[[Prostate carcinoma]].
*[[Prostate carcinoma]].


===Staging===
==Staging==
*T1 - lamina propria.
*T1 - lamina propria.
**Several subdivisions of T1 exist:
**Several subdivisions of T1 exist:
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**In approximately 15% of cases it is pT0 (no primary tumour identified).
**In approximately 15% of cases it is pT0 (no primary tumour identified).


====Muscularis propria invasion====
===Muscularis propria invasion===
The presence or absence of muscularis propria invasion is a '''very important''' determination, as the clinical management changes between T1 and T2:
The presence or absence of muscularis propria invasion is a '''very important''' determination, as the clinical management changes between T1 and T2:
*T1: usually conservative treatment (local excision).
*T1: usually conservative treatment (local excision).
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A thin layer of discontinous muscularis mucuosae (MM) is present and, especially if hypertrophic, may be confused with muscuaris propria (MP).
A thin layer of discontinous muscularis mucuosae (MM) is present and, especially if hypertrophic, may be confused with muscuaris propria (MP).


=====Comparing MM and MP=====
====Comparing MM and MP====
A comparison between muscularis propria and muscularis mucosae - adapted from Paner ''et al.'':<ref name=pmid17721199>{{Cite journal  | last1 = Paner | first1 = GP. | last2 = Ro | first2 = JY. | last3 = Wojcik | first3 = EM. | last4 = Venkataraman | first4 = G. | last5 = Datta | first5 = MW. | last6 = Amin | first6 = MB. | title = Further characterization of the muscle layers and lamina propria of the urinary bladder by systematic histologic mapping: implications for pathologic staging of invasive urothelial carcinoma. | journal = Am J Surg Pathol | volume = 31 | issue = 9 | pages = 1420-9 | month = Sep | year = 2007 | doi = 10.1097/PAS.0b013e3180588283 | PMID = 17721199 }}</ref>  
A comparison between muscularis propria and muscularis mucosae - adapted from Paner ''et al.'':<ref name=pmid17721199>{{Cite journal  | last1 = Paner | first1 = GP. | last2 = Ro | first2 = JY. | last3 = Wojcik | first3 = EM. | last4 = Venkataraman | first4 = G. | last5 = Datta | first5 = MW. | last6 = Amin | first6 = MB. | title = Further characterization of the muscle layers and lamina propria of the urinary bladder by systematic histologic mapping: implications for pathologic staging of invasive urothelial carcinoma. | journal = Am J Surg Pathol | volume = 31 | issue = 9 | pages = 1420-9 | month = Sep | year = 2007 | doi = 10.1097/PAS.0b013e3180588283 | PMID = 17721199 }}</ref>  
{| class="wikitable sortable"  
{| class="wikitable sortable"  
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**The presence of hyperplastic bundles ranges from ~20% in the trigone to ~70% in the dome.
**The presence of hyperplastic bundles ranges from ~20% in the trigone to ~70% in the dome.


=====Rational assessment of muscularis propria invasion=====
====Rational assessment of muscularis propria invasion====
To call muscularis propria invasion:
To call muscularis propria invasion:
#Definite tumour must be between muscle.
#Definite tumour must be between muscle.
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#Should '''not''' be superficial - surface epithelium if present should be distant.
#Should '''not''' be superficial - surface epithelium if present should be distant.


===Subtypes of urothelial carcinoma===
==Images==
There are numerous subtypes:<ref>URL: [http://www.nature.com/modpathol/journal/v22/n2s/full/modpathol200926a.html http://www.nature.com/modpathol/journal/v22/n2s/full/modpathol200926a.html]. Accessed on: 19 August 2011.</ref>
*Squamous differentiation.
*Clear cell.
*Plasmacytoid.
*Micropapillary.
**Small nests (< ~10 cells/nest).
*Sarcomatoid.
**Images: [http://path.upmc.edu/cases/case615.html UCC with sarcomatoid differentiation (upmc.edu)].
*Many others...
 
Benign patterns - mnemonic ''Much GIN'':
*'''M'''icrocystic.
*Small tubular/'''g'''landular.
*'''I'''nverted.
*'''N'''ested.
 
====Plasmacytoid urothelial cell carcinoma====
{{Main|Plasmacytoid urothelial carcinoma}}
 
====Nested urothelial cell carcinoma====
*[[AKA]] ''nested variant urothelial cell carcinoma''.
 
Features:<ref name=pmid2712189>{{Cite journal  | last1 = Talbert | first1 = ML. | last2 = Young | first2 = RH. | title = Carcinomas of the urinary bladder with deceptively benign-appearing foci. A report of three cases. | journal = Am J Surg Pathol | volume = 13 | issue = 5 | pages = 374-81 | month = May | year = 1989 | doi =  | PMID = 2712189 }}</ref>
*High density of well-circumscribed nests.
*Mild-to-moderate nuclear atypia.
*+/-Foci of unequivocal conventional urothelial carcinoma.
**Focally solid or gland fusion.
**Moderate-to-severe nuclear atypia +/- abundant mitoses.
*+/-Extension into the muscularis propria.
 
DDx:
*[[von Brunn nests]].
*[[Low grade papillary urothelial carcinoma]] with lamina propria invasion.
 
===Images===
<gallery>
<gallery>
Image: Urothelial carcinoma positive margin -- intermed mag.jpg | Typical UCC pos. margin - intermed. mag.
Image: Urothelial carcinoma positive margin -- intermed mag.jpg | Typical UCC pos. margin - intermed. mag.
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*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282447/figure/F2/ Several images of NUCC (nih.gov)].<ref name=pmid22355497>{{Cite journal  | last1 = Terada | first1 = T. | title = Nested variant of urothelial carcinoma of the urinary bladder. | journal = Rare Tumors | volume = 3 | issue = 4 | pages = e42 | month = Oct | year = 2011 | doi = 10.4081/rt.2011.e42 | PMID = 22355497 | PMC = 3282447 }}</ref>
*[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282447/figure/F2/ Several images of NUCC (nih.gov)].<ref name=pmid22355497>{{Cite journal  | last1 = Terada | first1 = T. | title = Nested variant of urothelial carcinoma of the urinary bladder. | journal = Rare Tumors | volume = 3 | issue = 4 | pages = e42 | month = Oct | year = 2011 | doi = 10.4081/rt.2011.e42 | PMID = 22355497 | PMC = 3282447 }}</ref>


==[[IHC]]==
=[[IHC]]=
Recommended by [[ISUP]] consensus panel:<ref name=pmid25025364 >{{cite journal |author=Amin MB, Epstein JI, Ulbright TM, ''et al.'' |title=Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the international society of urological pathology consensus conference |journal=Am. J. Surg. Pathol. |volume=38 |issue=8 |pages=1017–22 |year=2014 |month=August |pmid=25025364 |doi=10.1097/PAS.0000000000000254 |url=}}</ref>
Recommended by [[ISUP]] consensus panel:<ref name=pmid25025364 >{{cite journal |author=Amin MB, Epstein JI, Ulbright TM, ''et al.'' |title=Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the international society of urological pathology consensus conference |journal=Am. J. Surg. Pathol. |volume=38 |issue=8 |pages=1017–22 |year=2014 |month=August |pmid=25025364 |doi=10.1097/PAS.0000000000000254 |url=}}</ref>
*GATA3 +ve, CK20 +ve, p63 +ve, CK5/6, HMWCK (e.g. CK34betaE12) +ve.  
*GATA3 +ve, CK20 +ve, p63 +ve, CK5/6, HMWCK (e.g. CK34betaE12) +ve.  
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*CK20 negative in over 50% of cases with metastases.<ref name=pmid11419977>{{Cite journal  | last1 = Jiang | first1 = J. | last2 = Ulbright | first2 = TM. | last3 = Younger | first3 = C. | last4 = Sanchez | first4 = K. | last5 = Bostwick | first5 = DG. | last6 = Koch | first6 = MO. | last7 = Eble | first7 = JN. | last8 = Cheng | first8 = L. | title = Cytokeratin 7 and cytokeratin 20 in primary urinary bladder carcinoma and matched lymph node metastasis. | journal = Arch Pathol Lab Med | volume = 125 | issue = 7 | pages = 921-3 | month = Jul | year = 2001 | doi = 10.1043/0003-9985(2001)1250921:CACIPU2.0.CO;2 | PMID = 11419977 }}</ref>
*CK20 negative in over 50% of cases with metastases.<ref name=pmid11419977>{{Cite journal  | last1 = Jiang | first1 = J. | last2 = Ulbright | first2 = TM. | last3 = Younger | first3 = C. | last4 = Sanchez | first4 = K. | last5 = Bostwick | first5 = DG. | last6 = Koch | first6 = MO. | last7 = Eble | first7 = JN. | last8 = Cheng | first8 = L. | title = Cytokeratin 7 and cytokeratin 20 in primary urinary bladder carcinoma and matched lymph node metastasis. | journal = Arch Pathol Lab Med | volume = 125 | issue = 7 | pages = 921-3 | month = Jul | year = 2001 | doi = 10.1043/0003-9985(2001)1250921:CACIPU2.0.CO;2 | PMID = 11419977 }}</ref>


===Reactive changes versus UCIS===
==Reactive changes versus UCIS==
:''See [[urothelial carcinoma in situ]]''.
:''See [[urothelial carcinoma in situ]]''.


===UCC versus other===
==UCC versus other==
UCC vs. [[Prostate cancer|prostate]]:
UCC vs. [[Prostate cancer|prostate]]:
*UCC: GATA3 +ve, PSA -ve, p63 +ve, CK20 +ve.
*UCC: GATA3 +ve, PSA -ve, p63 +ve, CK20 +ve.
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**In half the cases the staining is weak and in the other half it is strong.<ref name=pmid19192675/>
**In half the cases the staining is weak and in the other half it is strong.<ref name=pmid19192675/>


===Staging===
==Staging==
Staging - muscularis propria invasion versus muscularis mucosae invasion ''smoothelin'' stain:<ref>{{Cite journal  | last1 = Paner | first1 = GP. | last2 = Shen | first2 = SS. | last3 = Lapetino | first3 = S. | last4 = Venkataraman | first4 = G. | last5 = Barkan | first5 = GA. | last6 = Quek | first6 = ML. | last7 = Ro | first7 = JY. | last8 = Amin | first8 = MB. | title = Diagnostic utility of antibody to smoothelin in the distinction of muscularis propria from muscularis mucosae of the urinary bladder: a potential ancillary tool in the pathologic staging of invasive urothelial carcinoma. | journal = Am J Surg Pathol | volume = 33 | issue = 1 | pages = 91-8 | month = Jan | year = 2009 | doi = 10.1097/PAS.0b013e3181804727 | PMID = 18936687 }}</ref>
Staging - muscularis propria invasion versus muscularis mucosae invasion ''smoothelin'' stain:<ref>{{Cite journal  | last1 = Paner | first1 = GP. | last2 = Shen | first2 = SS. | last3 = Lapetino | first3 = S. | last4 = Venkataraman | first4 = G. | last5 = Barkan | first5 = GA. | last6 = Quek | first6 = ML. | last7 = Ro | first7 = JY. | last8 = Amin | first8 = MB. | title = Diagnostic utility of antibody to smoothelin in the distinction of muscularis propria from muscularis mucosae of the urinary bladder: a potential ancillary tool in the pathologic staging of invasive urothelial carcinoma. | journal = Am J Surg Pathol | volume = 33 | issue = 1 | pages = 91-8 | month = Jan | year = 2009 | doi = 10.1097/PAS.0b013e3181804727 | PMID = 18936687 }}</ref>
*Muscularis propria - usu. strong. †
*Muscularis propria - usu. strong. †
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*† Overlap between the patterns is described,<ref>{{Cite journal  | last1 = Miyamoto | first1 = H. | last2 = Sharma | first2 = RB. | last3 = Illei | first3 = PB. | last4 = Epstein | first4 = JI. | title = Pitfalls in the use of smoothelin to identify muscularis propria invasion by urothelial carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 3 | pages = 418-22 | month = Mar | year = 2010 | doi = 10.1097/PAS.0b013e3181ce5066 | PMID = 20154589 }}</ref> this limits the utility of the stain.
*† Overlap between the patterns is described,<ref>{{Cite journal  | last1 = Miyamoto | first1 = H. | last2 = Sharma | first2 = RB. | last3 = Illei | first3 = PB. | last4 = Epstein | first4 = JI. | title = Pitfalls in the use of smoothelin to identify muscularis propria invasion by urothelial carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 3 | pages = 418-22 | month = Mar | year = 2010 | doi = 10.1097/PAS.0b013e3181ce5066 | PMID = 20154589 }}</ref> this limits the utility of the stain.


==Molecular==
=Molecular=
Not used for diagnosis.
Not used for diagnosis.


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*17p deletion -- site of PT53 (AKA p53).
*17p deletion -- site of PT53 (AKA p53).


==Sign out==
=Sign out=
===High grade UC===
==High grade UC==
<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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</pre>
</pre>


===Nested variant===
==Nested variant==
<pre>
<pre>
  URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION OF BLADDER TUMOUR (TURBT):
  URINARY BLADDER LESION ("TUMOUR"), TRANSURETHRAL RESECTION OF BLADDER TUMOUR (TURBT):
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</pre>
</pre>


===UCC with some suspicion for muscularis propria invasion===
==UCC with some suspicion for muscularis propria invasion==
<pre>
<pre>
URINARY BLADDER LESION ("TUMOUR"), DEEP, RE-RESECTION (TURBT):
URINARY BLADDER LESION ("TUMOUR"), DEEP, RE-RESECTION (TURBT):
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</pre>
</pre>


====Alternate comment====
===Alternate comment===
<pre>
<pre>
The sections shows thickened muscle bundles with frayed edges between the  
The sections shows thickened muscle bundles with frayed edges between the  
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</pre>
</pre>


==See also==
=Subtypes of urothelial carcinoma=
There are numerous subtypes:<ref>URL: [http://www.nature.com/modpathol/journal/v22/n2s/full/modpathol200926a.html http://www.nature.com/modpathol/journal/v22/n2s/full/modpathol200926a.html]. Accessed on: 19 August 2011.</ref>
*Squamous differentiation.
*Clear cell.
*Plasmacytoid.
*Micropapillary.
**Small nests (< ~10 cells/nest).
*Sarcomatoid.
**Images: [http://path.upmc.edu/cases/case615.html UCC with sarcomatoid differentiation (upmc.edu)].
*Many others...
 
Benign patterns - mnemonic ''Much GIN'':
*'''M'''icrocystic.
*Small tubular/'''g'''landular.
*'''I'''nverted.
*'''N'''ested.
 
==Plasmacytoid urothelial cell carcinoma==
{{Main|Plasmacytoid urothelial carcinoma}}
 
==Nested urothelial cell carcinoma==
*[[AKA]] ''nested variant urothelial cell carcinoma''.
 
Features:<ref name=pmid2712189>{{Cite journal  | last1 = Talbert | first1 = ML. | last2 = Young | first2 = RH. | title = Carcinomas of the urinary bladder with deceptively benign-appearing foci. A report of three cases. | journal = Am J Surg Pathol | volume = 13 | issue = 5 | pages = 374-81 | month = May | year = 1989 | doi =  | PMID = 2712189 }}</ref>
*High density of well-circumscribed nests.
*Mild-to-moderate nuclear atypia.
*+/-Foci of unequivocal conventional urothelial carcinoma.
**Focally solid or gland fusion.
**Moderate-to-severe nuclear atypia +/- abundant mitoses.
*+/-Extension into the muscularis propria.
 
DDx:
*[[von Brunn nests]].
*[[Low grade papillary urothelial carcinoma]] with lamina propria invasion.
 
=See also=
*[[Urothelium]].
*[[Urothelium]].
*[[Urothelial dysplasia]].
*[[Urothelial dysplasia]].
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*[[Prostatic urothelial carcinoma]].
*[[Prostatic urothelial carcinoma]].


==References==
=References=
{{Reflist|2}}
{{Reflist|2}}


[[Category:Urothelium]]
[[Category:Urothelium]]
[[Category:Diagnosis]]
[[Category:Diagnosis]]
Michael
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