29 October 2014 - Case #331
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Thanks to Dr. Bhavesh Papadi, University of Miami (USA), for contributing this case.
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Case #331
Clinical history:
A 72 year old man with hematuria underwent cystoscopy. An erythematous area was biopsied.
Microscopic 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, 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).
All cases are archived on our website. To view them sorted by case number, diagnosis or category, visit our main Case of the Month page. To subscribe or unsubscribe to Case of the Month or our other email lists, click here.
Thanks to Dr. Bhavesh Papadi, University of Miami (USA), for contributing this case.
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For more information, visit our Books page.
Website news:
(1) We have posted the ten most popular books sold through Amazon.com from January to September 2014 on our Top Books page.
(2) You can use the Google search box on our Home Page to find any text, including books by particular authors posted on our Books pages. Just type the main author's last name to see all places where that name appears (we are in the process of adding all of the authors but currently, some books just have the first author's name). Similarly, you can look for all reviews by a particular pathologist or all references to a disease such as ITP or a biomarker such as caldesmon.
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Visit and follow our Blog to see recent updates to the website.
(1) We have posted the ten most popular books sold through Amazon.com from January to September 2014 on our Top Books page.
(2) You can use the Google search box on our Home Page to find any text, including books by particular authors posted on our Books pages. Just type the main author's last name to see all places where that name appears (we are in the process of adding all of the authors but currently, some books just have the first author's name). Similarly, you can look for all reviews by a particular pathologist or all references to a disease such as ITP or a biomarker such as caldesmon.
(3) Check out our most recently posted article on New Business Model for Medical Billing Companies, by Mick Raich, President, Vachette Pathology. For more articles on Management of Pathology Practices, visit our Management page.
(4) We recently exhibited at the ASCP conference in Tampa, FL. We always enjoy meeting with the pathology community to hear what you like about the website and receive feedback on what we can improve.
Visit and follow our Blog to see recent updates to the website.
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).
