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29 October 2014 - Case #331

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Case #331

Clinical history:
A 72 year old man with hematuria underwent cystoscopy. An erythematous area was biopsied.

Microscopic images:

Various images




What is your diagnosis?

Click here for diagnosis and discussion:


Diagnosis: Urothelial carcinoma in situ (CIS) involving von Brunn nests

Discussion:
Urothelial carcinoma in situ, also known as high grade intraurothelial neoplasia (HG IUN), is a flat lesion composed of cells in the mid to upper epithelium with high cytologic grade. By definition, no invasion into the lamina propria is present. Symptoms are similar to cystitis and hematuria is common.

No mass is present. The lesion is flat, with erythematous, granular or cobblestone mucosa and may involve large areas of the bladder mucosa, ureters and urethra. Common patterns are large cells with pleomorphism, large cells without pleomorphism, small cell, clinging (single layer of atypical cells on denuded urothelium) or pagetoid / cancerization of urothelium. Histologically, except for the small cell pattern, the cells are large with irregular, hyperchromatic nuclei, prominent nuclear pleomorphism and a high N:C ratio. Mitotic figures are found in the mid to upper epithelium. The nuclear size is typically 5x that of lymphocytes, compared to normal urothelium with a nuclear size of 2x lymphocytes (Hum Pathol 2001;32:997).

Carcinoma in situ can involve von Brunn nests, resulting in nests of neoplastic cells within the lamina propria and suggestive of invasion. However, von Brunn nests typically have a rounded contour and lack the stromal changes associated with invasion (Epstein: Biopsy Interpretation of the Bladder, 2010).

If untreated, 20% of bladder CIS cases become invasive. Nonsurgical treatment typically consists of transurethral resection (TUR) of the bladder tumor followed by a single immediate instillation of intravesical chemotherapy, either bCG or mitomycin C (NIH: Bladder Cancer Treatment [Accessed 28 December 2023], Eur Urol 2010;57:410, World J Urol 2009;27:319, Ther Adv Urol 2012;4:13).


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