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29 October 2014 - Case of the Week #331

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Thanks to Dr. Bhavesh Papadi, University of Miami (USA), for contributing this case. To contribute a Case of the Week, follow the guidelines on our Case of the Week page.


     

  • WHO Classification of Tumours of Soft Tissue and Bone edited by Christopher D.M. Fletcher (soft tissue), Pancras C.W. Hogendoorn (bone), Fredrik Mertens and Julia Bridge (genetics), is the fifth volume of the 4th Edition of the WHO series on histological and genetic typing of human tumours. This authoritative, concise reference book provides an international standard for oncologists and pathologists and will serve as an indispensable guide for use in the design of studies monitoring response to therapy and clinical outcome. Diagnostic criteria, pathological features, and associated genetic alterations are described in a strictly disease-oriented manner. Sections on all recognized neoplasms and their variants include new ICD-O codes, epidemiology, clinical features, macroscopy, pathology, genetics, and prognosis and predictive factors.

  • WHO Classification of Tumours of the Female Reproductive Organs edited by Robert J. Kurman, Maria-Luisa Carcangiu, C. Simon Herrington, Robert H. Young is the sixth volume in the Fourth Edition of the WHO series on histological and genetic typing of human tumors. This authoritative, concise reference book provides an international standard for oncologists and pathologists and will serve as an indispensable guide for use in the design of studies monitoring response to therapy and clinical outcome. Diagnostic criteria, pathological features, and associated genetic alterations are described in a strictly disease-oriented manner. Sections on all recognized neoplasms and their variants include new ICD-O codes, epidemiology, clinical features, macroscopy, pathology, genetics, and prognosis and predictive factors.

For more information, visit our Books page.

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Case of the Week #331

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

Micro images:

Various images



Additional images



What is your diagnosis?































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 (Cancer.gov), either bcg (Eur Urol 2010;57:410) or mitomycin-C (World J Urol 2009;27:319, Ther Adv Urol 2012;4:13).


Nat Pernick, M.D., President
and Shivani Thakore, Associate Medical Editor
PathologyOutlines.com, Inc.
30100 Telegraph Road, Suite 408
Bingham Farms, Michigan (USA) 48025
Telephone: 248/646-0325
Email: [email protected]
Alternate email: [email protected]