Urothelial carcinoma

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Urothelial carcinoma
Diagnosis in short

Urothelial carcinoma at a surgical margin. H&E stain.

Synonyms urothelial cell carcinoma
Subtypes microcystic, micropapillary, glandular, inverted (growth pattern), nested, papillary (dealt with separately in high-grade papillary urothelial carcinoma and low-grade papillary urothelial carcinoma), plasmacytoid urothelial carcinoma, others
LM DDx urothelial carcinoma in situ, metastatic carcinoma (prostate carcinoma, colorectal carcinoma), inverted urothelial papilloma (for UCC with inverted growth pattern)
IHC GATA3 +ve, p63 +ve, CK5/6 +ve, CK34betaE12 +ve, PSA -ve
Molecular not used for diagnosis; typically: 9p deletions, 17p deletions
Grossing notes radical cystectomy grossing, cystoprostatectomy grossing, nephroureterectomy grossing
Staging bladder cancer staging
Site urothelium - ureter, urinary bladder, proximal urethra (see urothelial carcinoma of the urethra, renal pelvis

Syndromes Lynch syndrome - esp. ureters

Clinical history typically smokers
Signs hematuria
Prevalence common
Prognosis dependent on grade and stage
Treatment dependent on grade and stage

Urothelial carcinoma, also urothelial cell carcinoma, is a malignancy that arises from the urothelium. Urothelial carcinoma is abbreviated UC and urothelial cell carcinoma is abbreviated UCC.

This article deals with flat invasive urothelial carcinoma. The direct precursor is dealt with in urothelial carcinoma in situ.

Papillary urothelial carcinomas are dealt with in low-grade papillary urothelial carcinoma and high-grade papillary urothelial carcinoma.

See urine cytology for the cytopathology.

General

  • These lesions lack papillae and are typical flat.
  • Clinically, it may not be possible to differentiate renal pelvis urothelial carcinoma and renal cell carcinoma.
  • May be a part of Lynch syndrome.

Prognosis:

  • Women often have worse outcomes as they present with more advanced tumours.[1]
  • Positive soft tissue margin.[2]
    • Definition (radical cystectomy): tumour touching ink.

Risk factors:

  • Smoking.
  • Toxins.
  • Drugs, e.g. cyclophosphamide.
  • Others.

Microscopic

Features:

  • Nuclear pleomorphism - key feature.
    • Compare nuclei to one another.
  • Increased N/C ratio.
  • Lack of maturation to surface (important).
  • Cells become dyscohesive.

Invasion vs. in situ: Useful features - present in invasion:[3]

  • Thin-walled vessels.
  • Stromal reaction (hypercellularity).
  • Retraction artefact around the tumour cell nests.

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:

Staging

  • T1 - lamina propria.
    • Several subdivisions of T1 exist:
      • T1a - superficial or in muscularis mucosae.
      • T1b - beyond muscularis mucosae - into submucosa.
  • T2 - muscularis propria.

Note:

  • Approximately 25% of muscle invasive urothelial carcinoma on biopsy is a lower stage in the cystectomy specimen.[6]
    • In approximately 15% of cases it is pT0 (no primary tumour identified).

Muscularis propria invasion

Images

www:

High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma High grade urothelial carcinoma
High grade urothelial carcinoma in a 43 year old man. A. At low power, necrosis is seen, luminal, with viable invasive tumor elsewhere. B. Tumor partly fills right ureteral orifice. C. Tumor cells sometimes form Indian files (black arrows), appear to have nuclei that mold (red arrows), and have granular chromatin (cyan arrows), raising possibility of neuroendocrine carcinoma. D. Tumor invades lymphatic spaces. E. Urothelial carcinoma in situ is present. F,G,H. Tumor cells are diffusely positive for CK7, focally positive for CDX2, and diffusely positive for P40, with no positivity for chromogranin or synaptophysin.

IHC

Recommended by ISUP consensus panel:[8]

  • GATA3 +ve, CK20 +ve, p63 +ve, CK5/6, HMWCK (e.g. CK34betaE12) +ve.

Others:

  • CK7 +ve.
  • PSA -ve.

Notes:

  • CK20 negative in over 50% of cases with metastases.[9]

Reactive changes versus UCIS

See urothelial carcinoma in situ.

UCC versus other cancers

UCC vs. prostate:

  • UCC: GATA3 +ve, PSA -ve, p63 +ve, CK20 +ve.
  • Prostate: PSA +ve, GATA3 -ve, PSAP +ve, CK7 -ve, CK20 -ve, p63 -ve.

UCC vs. renal cell carcinoma:

Metastatic UCC versus primary lung squamous cell carcinoma:

See Squamous_cell_carcinoma_of_the_lung#Lung_SCC_versus_metastatic_bladder_urothelial_carcinoma.

Note:

  • In a large series, PSA positivity is reported in 1.4% bladder UCC.[11]
    • In half the cases the staining is weak and in the other half it is strong.[11]

IHC for staging

Molecular

Not used for diagnosis.

Changes:

  • 9p deletion -- site of CDKN2A[12] (AKA p16).
  • 17p deletion -- site of PT53 (AKA p53).

Sign out

High grade UC

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

UCC with some suspicion for muscularis propria invasion

URINARY BLADDER LESION ("TUMOUR"), DEEP, RE-RESECTION (TURBT):
- INVASIVE HIGH-GRADE UROTHELIAL CARCINOMA WITH SQUAMOUS DIFFERENTIATION AT
  LEAST INTO THE LAMINA PROPRIA, SEE COMMENT.
- NO DEFINITE LYMPHOVASCULAR INVASION.

COMMENT:
Tumour is seen adjacent to smooth muscle fibres of intermediate thickness. This is
interpreted as thick muscularis mucosae. The tissue orientation is suboptimal. 
Definite muscularis propria is not apparent. Levels were cut. 

Tumour is abundant in the lamina propria.

Alternate comment

The sections shows thickened muscle bundles with frayed edges between the 
tumour cells. The muscle is thought to represent hypertrophic muscularis 
mucosae. The large extent of lamina propria invasion raises the possibility 
of a higher stage lesion that may not have been sampled.

Subtypes of urothelial carcinoma

There are numerous subtypes:[13]

Benign patterns - mnemonic Much GIN:

  • Microcystic.
  • Small tubular/glandular.
  • Inverted.
  • Nested.

Plasmacytoid urothelial cell carcinoma

Microcystic urothelial carcinoma

Micropapillary urothelial carcinoma

Lymphoepithelioma-like carcinoma

Nested urothelial cell carcinoma

  • AKA nested variant of urothelial cell carcinoma.

See also

References

  1. Mitra, AP.; Skinner, EC.; Schuckman, AK.; Quinn, DI.; Dorff, TB.; Daneshmand, S. (Jan 2014). "Effect of gender on outcomes following radical cystectomy for urothelial carcinoma of the bladder: a critical analysis of 1,994 patients.". Urol Oncol 32 (1): 52.e1-9. doi:10.1016/j.urolonc.2013.08.007. PMID 24239476.
  2. Dotan, ZA.; Kavanagh, K.; Yossepowitch, O.; Kaag, M.; Olgac, S.; Donat, M.; Herr, HW. (Dec 2007). "Positive surgical margins in soft tissue following radical cystectomy for bladder cancer and cancer specific survival.". J Urol 178 (6): 2308-12; discussion 2313. doi:10.1016/j.juro.2007.08.023. PMID 17936804.
  3. Sternberg, SE. Histology for Pathologists. P.2047.
  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. 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.
  6. D'Souza, AM.; Pohar, KS.; Arif, T.; Geyer, S.; Zynger, DL. (Oct 2012). "Retrospective analysis of survival in muscle-invasive bladder cancer: impact of pT classification, node status, lymphovascular invasion, and neoadjuvant chemotherapy.". Virchows Arch 461 (4): 467-74. doi:10.1007/s00428-012-1249-4. PMID 22915241.
  7. Terada, T. (Oct 2011). "Nested variant of urothelial carcinoma of the urinary bladder.". Rare Tumors 3 (4): e42. doi:10.4081/rt.2011.e42. PMC 3282447. PMID 22355497. //www.ncbi.nlm.nih.gov/pmc/articles/PMC3282447/.
  8. Amin MB, Epstein JI, Ulbright TM, et al. (August 2014). "Best practices recommendations in the application of immunohistochemistry in urologic pathology: report from the international society of urological pathology consensus conference". Am. J. Surg. Pathol. 38 (8): 1017–22. doi:10.1097/PAS.0000000000000254. PMID 25025364.
  9. Jiang, J.; Ulbright, TM.; Younger, C.; Sanchez, K.; Bostwick, DG.; Koch, MO.; Eble, JN.; Cheng, L. (Jul 2001). "Cytokeratin 7 and cytokeratin 20 in primary urinary bladder carcinoma and matched lymph node metastasis.". Arch Pathol Lab Med 125 (7): 921-3. doi:10.1043/0003-9985(2001)1250921:CACIPU2.0.CO;2. PMID 11419977.
  10. Langner, C.; Ratschek, M.; Tsybrovskyy, O.; Schips, L.; Zigeuner, R. (Aug 2003). "P63 immunoreactivity distinguishes upper urinary tract transitional-cell carcinoma and renal-cell carcinoma even in poorly differentiated tumors.". J Histochem Cytochem 51 (8): 1097-9. PMID 12871991.
  11. 11.0 11.1 Chen, JC.; Ho, CL.; Tsai, HW.; Tzai, TS.; Liu, HS.; Chow, NH.; Yang, WH.; Cheng, HL.. "Immunohistochemical detection of prostate-specific antigen expression in primary urothelial carcinoma of the urinary bladder.". Anticancer Res 28 (6B): 4149-54. PMID 19192675.
  12. Online 'Mendelian Inheritance in Man' (OMIM) 600160
  13. URL: http://www.nature.com/modpathol/journal/v22/n2s/full/modpathol200926a.html. Accessed on: 19 August 2011.