Handling and Pathology Reporting of Specimens with Carcinoma of the Urinary Bladder, Ureter, and Renal Pelvis $

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1 European Urology European Urology 45 (2004) Review Handling and Pathology Reporting of Specimens with Carcinoma of the Urinary Bladder, Ureter, and Renal Pelvis $ Antonio Lopez-Beltran a,*, PierFrancesco Bassi b, Michele Pavone-Macaluso c, Rodolfo Montironi d a Department of Pathology, Unit of Anatomic Pathology, Faculty of medicine, Cordoba University Medical School, Avda. Menendez-Pidal S/N, Cordoba, Spain b Department of Urology, University of Padova Medical School, Padova, Italy c Clinica Urologica, Universitá di Palermo, Palermo, Italy d Institute of Pathological Anatomy, Polytechnic University of the Marche Region (Ancona), Ancona, Italy Accepted 23 September 2003 Published online 22 October 2003 Abstract Objective: Pathologists play a pivotal role in the diagnosis and in the report of the pathological features related to prognosis. Methods: To meet these endpoints, the following issues must be accomplished: adequate information about the patient history, proper handling of the specimens, identification of the reliable histopathological techniques necessary to reach the more detailed diagnostic information and evaluate the prognostic variables, and a standardized pathological report. Results: Recent efforts to standardize the histopathological evaluation have generated significant confusion among the urological and pathological communities as well. No consensus has been achieved about the optimal pathological grading of urothelial tumors, to date. Conclusion: A proposal for standardization of sampling and reporting of the urothelial tissues achieved within Uropathology follows. The urologists have a great role in assisting pathologists in the proper examination by providing them with clinical information. # 2003 Elsevier B.V. All rights reserved. Keywords: Bladder; Ureter; Pelvis; Neoplasms; Transitional cell; Squamous carcinoma; Adenocarcinoma; Pathology report; Sampling; Standardization 1. Introduction The urothelium covers the urinary tract, from kidney calyces, renal pelvis, ureter, the urinary bladder, and a variable portion of the urethra. Most carcinomas of these organs are histologically similar [1]. Surgical procedures of these organs provide an important number of specimens in clinical practice $ This publication is made under the auspices of the European Society of Uropathology (a full section office member of the European Association of Urology, EAU) and the Uropathology Working Group (European Society of Pathology, ESP). * Corresponding author. Tel. þ ; Fax: þ address: em1lobea@uco.es (A. Lopez-Beltran). [2]. An appropriate assessment of the specimens and reporting of pathological findings may assist urologists in the appropriate management of these patients [2]. The most common bladder specimens are obtained from endoscopic biopsies and transurethral resections of the bladder (TURB), both of which sample subepithelial tissue of varying depth [3]. Other specimens can be obtained from a cystectomy (partial/total), cystoprostatectomy, pelvic exanteration ( en block resection), and resection of diverticula [3]. Surgical excision of a urachal carcinoma usually includes the bladder dome, urachus, and umbilicus [3]. A bladder biopsy provides information to assess risk factors /$ see front matter # 2003 Elsevier B.V. All rights reserved. doi: /j.eururo

2 258 A. Lopez-Beltran et al. / European Urology 45 (2004) Table 1 Current prognostic factors in bladder cancer specimens Number of tumors Cancer size > 5 cm in diameter Tumor extent (stage) Histological grade Coexistent dysplasia or CIS Tumor growth pattern Vascular/lymphatic invasion Lymph node involvement Recurrence at 3 month follow-up cystoscopy Molecular markers (p53, RB, cadherins) Others: DNA ploidy, Ki67 for recurrence, progression, and response to treatment [4 9] (Table 1). Small noninvasive papillary neoplasms are often excised by biopsy using cold cup forceps, diathermy forceps, or a small diathermy loop. To avoid tissue distortion, these specimens should be transferred to fixative with minimal handling [2,3]. Larger neoplasms are often sampled by TURB using a diathermy loop that produces strips of tissue 6 mm in diameter and of variable length [10]. Additional resection of the bladder base after a previous TURB provides additional information on tumor extension. All hyperemic or velvety areas of urothelium are sampled to exclude carcinoma in situ (CIS); random biopsies are commonly taken from macroscopically normal urothelium distant from the tumor site to determine the extent of involvement [11,12]. Ideally, random samples should be obtained from predetermined sites in four vesical quadrants [11]. Some urologists also submit biopsy specimens of the urethra to assess other areas of the urothelium, particularly in patients with high-grade papillary urothelial carcinoma or CIS [13]. Nephroureterectomy or ureterectomy specimens are the result of cancer in these organs. This article reviews the handling and pathology reporting of bladder, ureter and renal pelvis specimens with tumor. 2. Role of the urologist (1) To provide the pathologist with adequate tissue samples for pathological evaluation. The diffuse neoplastic involvement of the urothelium may take a number of forms and may signal a prognostically different diathesis depending on the molecular changes that have occurred and how these changes have been expressed pathologically and clinically [9]. This concept has not as yet been practical to factor into standard staging systems. These distinctions, however, have suggested the importance of analyzing the mucosa by biopsy of multiple areas of the bladder that may or may not appear abnormal endoscopically [11]. The precision of resection may also play a role in the ability of the pathologist to assess accurately the stage of disease. It has become common practice to resect a tumor superficially and then to resect more deeply, sending specimens separately for pathologic analysis. This approach is based on the concept that accurate staging is more easily fulfilled when the resection specimen can be provided in different layers for analysis of the depth of tumor involvement [14,15]. It may be equally important to repeat resection when initial pathology does not show a clear margin of normal tissue beneath the deepest layer of resection. Random biopsies of endoscopically normal urothelium and the prostatic urethra are needed to assess a neoplastic diathesis in case of a multifocal tumor [11].For small and single primary tumor, the random biopsies are not routinely recommended if urine cytology is negative. In case of small papillary and multiple tumors the urologist will provide not only the exophytic lesion but also the deeper specimen (including suburothelial connective tissues and superficial detrusor muscle) of at least the greater lesion. To avoid missing crucial information, it is important be sure to submit all of the pieces of tissue for processing and multiple sectioning. (2) To handle the biopsies in a way that will enable the pathologist to give the urologist an overall assessment of the neoplasia. This is linked to the fact that the pathologist must provide the urologist with all the necessary information for a correct management of the pathological specimens in operating room (see assessment of specimens) [14,15]. In selected cases (clinical or experimental research) the specimen(s) may be handled directly by the pathologist. (3) To provide to pathologist with all useful clinical information. A complete history of the patient, in terms of urological and non-urological disease, must be provided to the pathologist. In particular, information about previous treatments (intravesical immuno- or chemotherapy, radiation, systemic chemotherapy, other) is essential. 3. The role of the pathologist 3.1. Part 1: handling of specimens Routine protocol-based tissue sampling ensures consistent and thorough examination by trainees and consultants. The issue has been addressed in the last

3 A. Lopez-Beltran et al. / European Urology 45 (2004) few years by different groups and societies, among which the Association of Directors of Anatomic Pathology and the College of American Pathologists. Lopez-Beltran et al. incorporated the conclusions of each of these contemporary statements to create a standardized approach to examination of tumor specimens obtained from the bladder, ureter and renal pelvis [2]. The recommendations are as follows Bladder biopsy and transurethral resection of bladder tumor (TURBT) specimens Biopsies of the urinary bladder are taken through the cystoscope or resectoscope and hold important information regarding tumor type, tumor grade, and extent of tumor invasion into various layers of the bladder wall [10]. They vary from single and minute to numerous, large and papillary lesions or solid tumors. Orientation of these specimens is generally difficult, even for the larger papillary fragments. It is important for the pathologist to avoid the common mistake of overfilling specimen cassettes with tissue fragments [2]. Transurethral resections should be weighted in aggregate [2]. Separately submitted biopsies, including random biopsies, should receive separate diagnosis. Pathology reports on cold cup biopsies should include the number, size, and classification of epithelial proliferations with emphasis in reporting intraepithelial lesions and conditions [13,16]. When there is no evaluable detrusor muscle in the sample, once all the resected tissue is processed, this should be stated in the final report. The biopsy report should record what tissues are present. In patients with urothelial malignancy, a report of denuded biopsy (most probably related to CIS) is significantly different from one stating that no tumor is seen [16]. Similarly, invasion of the suburothelial connective tissue may have different implications depending on the presence of muscularis mucosae [7,10,17 19]. Caremustbe taken to distinguish the thin and often incomplete muscularis mucosae bundles within the subepithelial connective tissue from the detrusor muscle. Immunohistochemical staining with anti-smooth musclespecific actin can help in this distinction in selected cases [10]. Pathologist should provide the TNM (Tumor Node Metastases) staging system ( clinical stage and grade for endoscopical specimens) [20]. The depth of muscle invasion is often impossible to be assessed in TURBT specimens, and the only reasonable statement is stage T2 at least [2,21]. The presence of fat tissue in biopsy specimens is not an absolute indication of extravesical extension because fat may be present within the suburothelial connective tissue and the muscle layers of the urinary bladder [18]. In TURBT specimens, embedding all the resected tissue chips, is necessary to diagnose or rule out the presence of invasion, and for the appropriate grading of the tumor [22] Total cystectomy, radical cystoprostatectomy, pelvic exanteration specimens The processing of urinary bladders can be accomplished in three steps: Orientation of the specimen and identification of relevant structures (e.g., ureters) Fixation of the specimen Dissection of the specimen Orientation of the specimen. Given the spherical shape of the bladder, orientation is not an easy procedure [3]. The peritoneum covering the surface of the bladder can be used as reliable, though subtle, anatomic landmark [3]. The peritoneum descends further along the posterior wall of the bladder than it does along the anterior wall. If they are present, other pelvic organs can also be used to orient the specimen. Once the specimen is oriented, locate both ureters and, when present, the vasa deferentia. The best place to look for the ureters is in the lateral perivesical fatty connective tissues [2,3]. The ureters are much easier to locate and dissect in the fresh state than they are once the specimen is fixed Fixation of the specimen. Fixation of the bladder must be performed as soon as possible. To avoid unnecessary delay in bladder fixation in specific situations, the urologist himself can open the bladder from the urethra to the bladder dome using scissors, and then, fix it in formalin. Otherwise, the pathologist will do it once the bladder arrives at the Pathology Lab Dissection of the specimen. This includes the following steps (see also Appendix A): Once the specimen is open, the bladder mucosal surface is examined for ulcerations, exophytic/nodular tumors, or more subtle mucosal alterations. Size, gross morphology (flat, papillary, nodular, or ulcerated), and location (e.g., dome, trigone, free walls, and so on) of any lesion in the bladder are noted [2 4,14,15]. Photograph(s) of the opened specimen are taken, if necessary. Fresh tissue may be collected for special studies by the urologist or, preferably by

4 260 A. Lopez-Beltran et al. / European Urology 45 (2004) the pathologist, but this must be stated in the pathological report. Then, resume the dissection by shaving the margins from each of the ureters and the urethra. When the specimen includes the prostate, this distal urethral margin should be taken from the distal end of the prostate. Next, beginning at their trigone orifices open the ureters on both sides using a small pair of scissors. Look for ureteral strictures and dilatations, and examine the mucosa for ulcerations, diverticula or exophytic lesions [2,3]. Document these findings in the gross dictation. Submit transverse sections of the ureters. If a tumor is identified in the bladder, make a fullthickness cut through the tumor and bladder wall [2,3,14,15]. See whether or not the tumor appears to infiltrate the muscularis propria of the bladder and, if so, whether it extends into the perivesical fat or other anatomic structures. Take sections of the tumor to demonstrate its relationship to the adjacent urothelium and, importantly, its maximal depth of invasion. Keep in mind that for large exophytic tumors, sections will be more informative when they are taken from the base of the tumor than when they are taken from its surface. It is important that bladders be extensively sampled for histology, even at sites that appear distant from the tumor [1,7,14,15,23,24]. Carefully inspect and sample the normal appearing bladder mucosa, because many in situ neoplasms of the bladder are flat and are characterized by a subtle red velvety appearance [13,16]. Be sure to search for lymph nodes, which are sometimes present in the perivesical fat (see Appendix B). Prostate examination will be performed according to the standard rules for pathological evaluation and reporting for radical prostatectomy [8,25,26]. Similarly, uterus, rectum and vagina will be evaluated according to standardized criteria. Section these structures, keeping four objectives in mind (see Appendix C): Document the presence of these structures Demonstrate the relationship between the tumor and each of these structures Evaluate the resection margins for each organ Examine the attached pelvic organs for other primary diseases Partial cystectomy specimens Partial cystectomy specimens (including resections of diverticula) should be fixed and dissected according to the guidelines given for complete bladder specimens. The edges of the specimen are important because they represent the surgical margins of the bladder wall. Ink the edges and assess these margins for tumor involvement by taking perpendicular sections from all edges of the specimen at regular intervals. Remember to include mucosa as well as the bladder wall. A peculiar variation of the partial cystectomy is seen in resections of neoplasms arising from the urachal tract [2,3]. These specimens consist of the dome of the bladder in continuity with the urachal tract up to and including the umbilicus. The bladder portion of the specimen should be routinely processed as any ordinary partial cystectomy. In particular: Sections should be taken at right angles to the long axis of the urachal tract [2]. Submit a number of these cross sections from the urachal tract for histology as well as the standard bladder sections. Remember to sample the two additional margins introduced by this resection: the soft tissue margin surrounding the urachus and the skin margin around the umbilicus Nephro-ureterectomy specimens The purpose of evaluating kidneys resected for renal pelvis neoplasms is to determine the type of tumor, its extent, and the completeness of the resection. Begin the dissection at the kidney hilum and identify the ureter, renal artery, and renal vein. Then, direct your attention to the dissection of the kidney itself [3]. The next step is to bivalve the kidney so that the relationship of the tumor of the renal pelvis or the calyces of the upper and lower poles can be easily visualized. In general it will be a sagittal cut that begins at the hilum and exits laterally trough the perinephric fat. Once the tumor is exposed, obtain enough tissue sections to show the tumor and its relationship with renal parenchyma and peri-pelvic soft tissues. Establish size of the tumor and if papillary or solid. At histology, describe type, grade, and stage [20,27,28]. Submit sections that include the tumor, and the adjacent non-neoplastic kidney and distal ureter Ureterectomy specimens When examining the ureter resected for neoplasms the following procedure had to be adopted, the purpose being to determine the type of tumor, its extent, and the completeness of the resection:

5 A. Lopez-Beltran et al. / European Urology 45 (2004) Submit both margins for separate evaluation and then open the entire ureter with a pair of scissors. Carefully inspect the mucosa and wall. Report the gross characteristics of the ureter and of the tumor. Describe the findings, measure the size of the tumor and if it is papillary or solid, invasive or non-invasive, and if the surgical margin or peri-ureteric soft tissues are affected [20,27,28] Part 2: diagnostic reporting of pathological findings The pathology report should include clinically relevant information as well as provide clinically useful information derived from the macroscopic examination and microscopic evaluation Histologic tumor type More than 95% of carcinomas of the urinary bladder, ureter, and renal pelvis are urothelial. Focal squamous and/or glandular differentiation may be present in the tumor (mixed differentiation), aspect that must be clearly reported [2,27]. Pure squamous or adenocarcinomas may also arise in these organs, as well as other unusual histologic variants of urothelial carcinoma [29] (Table 2) Histologic grade There is significant controversy in the classification of these lesions [9,30,31]. Papillary and invasive lesions are graded separately. Due to the different classification systems available and the need for a universally acceptable system, the World Health Organization (WHO) and the International Society of Urological Pathology (ISUP) proposed in 1998 a consensus classification known as the WHO/ISUP classification [21]. This has recently been recognized as the WHO 2004 histological classification of noninvasive papillary urothelial tumors [28,32] (Table 2) (Fig. 1). Until the WHO 2004 system is clinically and prognostically validated, tumor grade according to both the WHO 2004 system and the previous WHO (1973) system should be used, for instance, papillary urothelial neoplasm of low malignant potential (WHO 2004)/transitional cell (urothelial) carcinoma, grade I (WHO, 1973) Tumor growth pattern The most important morphology-based prognostic factors in patients with advanced bladder cancer are tumor stage and lymph node status. With regards to tumor grade, recent studies have failed to demonstrate a significant prognostic impact in muscle-invasive Table 2 Histologic type of tumors of the urinary bladder, ureter, and renal pelvis (WHO, 2004) [27,28] Urothelial Neoplasia Benign Urothelial papilloma Inverted papilloma Papillary Urothelial Neoplasia of Low Malignant Potential Malignant Papillary Papillary carcinoma, low grade Papillary carcinoma, high grade Papillary carcinoma with squamous or glandular differentiation Malignant Non-papillary Flat carcinoma in situ Invasive carcinoma Variants of invasive carcinoma Nested pattern Small tubular patter Microcystic pattern Inverted pattern With squamous differentiation With glandular differentiation Micropapillary Sarcomatoid carcinoma Clear cell urothelial carcinoma Plasmocytoid With syncitiotrophoblasts With unusual stromal reactions Pseudosarcomatous stroma Stromal osseous or cartilaginous metaplasia Osteoclast-type giant cells With prominent lymphoid infiltrate Squamous cell carcinoma Usual type Variant Verrucous Basaloid With sarcomatoid features Adenocarcinoma (from bladder mucosa, urachal, with extrophy) Usual intestinal type Mucinous (including colloid) Signet-ring cell Clear cell Hepatoid Mixture of above patterns Adenocarcinoma NOS Tumors of mixed cell types Undifferentiated carcinomas a Small cell carcinoma Large cell neuroendocrine carcinoma Lymphoepithelioma-like carcinoma Giant cell carcinoma Undifferentiated carcinoma NOS Metastatic carcinoma a Refers to tumors that are undifferentiated by light microscopy.

6 262 A. Lopez-Beltran et al. / European Urology 45 (2004) the bladder is located extraperitoneally. Fig. 1. Diagram showing bladder wall infiltration by tumor and its corresponding staging classification (A). Non-invasive urothelial papillary carcinoma, low grade (B) (H&E, 100). Urothelial carcinoma in situ (C) (H&E, 100). Invasive bladder carcinoma with nodular (D), trabecular (E), and infiltrative patterns (F)(D,E, and F, H&E 100). bladder cancer. In an attempt to identify new parameters allowing to assess prognosis in bladder cancer patients more accurately, Jimenez et al. have recently introduced a new morphologic classification distinguishing three patterns of growth (nodular, trabecular, and infiltrative type) [33]. Tumors with an infiltrative growth pattern are associated with worse prognosis in comparison with tumor displaying a non-infiltrative growth pattern (Fig. 1). Morphologically the three patterns are following: Nodular pattern. Tumor growing as well-demarcated, round nests of cells. The nests vary in diameter, but display tendency toward roundness. Desmoplasia is usually inconspicuous. Necrosis is uncommon. Trabecular pattern. Tumor composed of infiltrating broad trabeculae usually anastomosing with each other. The trabeculae are at least three cell layers thick and are sometimes associated with extensive necrosis and desmoplastic stroma. Infiltrative pattern. Tumor composed of infiltrating narrow cords or single cells. Desmoplasia and necrosis are common. The cells are highly pleomorphic or small and morphologically undifferentiated Tumor extent The definition of the tumor extent requires knowledge of the components of the organ and its relationship with the adjacent structures. For instance, the urinary bladder consists of three layers: pithelium and sub-epithelial connective tissue (or lamina propria), muscularis mucosae (present in 94% of bladders), muscularis propria (or detrusor muscle), the peri-vesical fat (peritoneum covering the superior surface and upper part), A critical role of the pathologist is to diagnose the depth and extent of invasion breaking down a distinction between bladder mucosa (Ta), suburothelial connective tissue (T1), detrusor muscle (T2), or beyond (T3 or T4) (Fig. 1). The TNM Staging System, 2002 revision, for carcinomas of the urinary bladder, ureter, and renal pelvis of the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) is recommended [20] (Table 3). The corresponding pt (pathological tumor stage) category must be applied only to the surgical (cystectomy) specimens. The pathologist must pay attention to diagnose tumor infiltrating the sub-epithelial connective tissue (T1); this diagnosis should be supported in uncertain cases by immunohistochemical studies [10,19,34].T1 substaging based on the relationship of tumor with the muscularis mucosae is not universally accepted even though evidence seems to support its clinical value. Designation of a tumor as merely muscle-invasive is inappropriate: the type of muscle invasion, i.e., muscularis mucosae (T1 tumors) versus detrusor muscle (T2 tumors) invasion, needs to be clearly stated [10]. Descriptive terminology, such as urothelial carcinoma with muscle invasion, indeterminate for type of muscle invasion, may be used when it is not possible to assess the type of muscle invaded by the tumor (muscularis mucosae or detrusor muscle). A comment on thermocoagulation effect may be reported if it makes diagnostic evaluation difficult Tumor size and multicentricity The pathology report has to include the size of the tumor and information on its multicentricity, especially when dealing with bladder specimens. Tumor size affects tumor invasiveness. Thirty-five percent of lesions that are larger than 5 cm will progress to muscularis propria invasion, whereas only 9% of tumors smaller than 5 cm progress similarly. In some studies, the presence of multiple tumors affects recurrence rates but does not affect the likelihood for invasion, whereas other studies have shown an association with progression of disease [7] Margins Tumor involving the resection margin on pathologic examination may be assumed to correspond to residual tumor in the patient and may be classified as macroscopic or microscopic according to the findings at the specimen margin(s). The resection margins status should be carefully specified. In particular:

7 A. Lopez-Beltran et al. / European Urology 45 (2004) Table 3 TNM Staging System (AJCC/UICC, 2002) of the urinary bladder, renal pelvis, and ureter [20] Primary Tumor (T): Urinary bladder TX Primary tumor can not be assessed T0 No evidence of primary tumor Ta Papillary no-invasive carcinoma Tis Carcinoma in situ: flat tumor T1 Tumor invades sub-epithelial connective tissue T2 T2a T2b T3 T3a T3b T4 T4a T4b Tumor invades muscle Tumor invades superficial muscle (outer half) Tumor invades deep muscle (outer half) Tumor invades perivesical tissue Microscopically Macroscopically (extra-vesical mass) Tumor invades any of the following: prostate, uterus, vagina, pelvic wall, and abdominal wall Tumor invades prostate or uterus or vagina Tumor invades pelvic wall or abdominal wall Primary Tumor (T): Renal pelvis and ureter TX Primary tumor cannot be assessed T0 No evidence of primary tumor Ta Papillary noninvasive carcinoma Tis Carcinoma in situ T1 Tumor invades subepithelial connective tissue T2 Tumor invades the muscularis T3 For renal pelvis only: Tumor invades beyond muscularis into peripelvic fat or the renal parenchyma T3 For ureter only: Tumor invades beyond muscularis into periureteric fat T4 Tumor invades adjacent organs, or through the kidney into the perinephric fat The suffix m should be added to the appropriate T category to indicate multiple tumors. The suffix is may be added to any T to indicate the presence of associated carcinoma in situ Regional Lymph Nodes (N) NX Regional Lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single lymph node, 2 cm or less in greatest dimension N2 Metastasis in a single lymph node, more than 2 cm but not more than 5 cm in greatest dimension, or multiple lymph nodes, none more than 5 cm in greatest dimension N3 Metastasis in a lymph node more than 5 cm in greatest dimension Distant Metastasis (M) MX Distant metastasis cannot be assessed M0 No distant metastasis M1 Distant metastasis Statements about deep soft tissue margins should specify whether peritoneal surfaces are involved by tumor. In cases of urachal adenocarcinoma in which partial cystectomy with excision of the urachal tract and umbilicus is performed, the margins of the urachal tract, i.e., the soft tissue surrounding the urachus and the skin around the umbilical margin, should be specified. In renal pelvis, ureter, and nephroureterectomy specimens, the margins may include radial hilar soft tissue margin, bladder cuff, ureteral, renal parenchyma, and Gerota s fascia margins, depending on the type of surgical specimen Venous/lymphatic vascular invasion Urothelial carcinoma may invade blood vessels or lymphatic channels. In suspicious cases, blood vessels can be highlighted by immunohistochemical staining for factor VIII related antigen, CD31 or CD34 [35]. Staining will not resolve the problem of differentiating lymphatic versus artifactual space entrapment by tumor cells. Retraction artifact is also prominent in the micropapillary variant of urothelial carcinoma Urothelial carcinoma in situ (CIS) The evaluation of urothelium in patients who have superficial tumors is important because those patients who have associated CIS are at much higher risk of

8 264 A. Lopez-Beltran et al. / European Urology 45 (2004) Table 4 Practice parameters for handling and reporting bladder, ureter, and renal pelvis specimens (Checklist) I. General information Pertinent clinical information: name, medical record number, data, referring physician, relevant clinical history past and present. II. III. IV. Gross description Fresh or fixed specimen Nature of the specimens: biopsy, chips (TURBT), partial cystectomy, radical cystectomy, cystoprostatectomy, En bloc resection, nephroureterectomy, ureterectomy. Total weight of resected tissue fragments (TURBT); three dimensional measurements of recognizable anatomic structures and tumors or other recognizable lesions Site of involvement, gross fat extension Diagnostic and prognostic information Histologic tumor type: urothelial, squamous, adenocarcinoma, other Tumor grade: use current grading schemes (WHO 2004, WHO 1973, or both) Extent of tumor in bladder (degree of invasion) a No invasion Invasion of the suburothelial connective tissue, muscularis propria, perivesical tissue Presence or absence of lymphatic/vascular invasion Tumor arising in a diverticulum (state whether muscularis propria is present) Intraepithelial abnormalities (dysplasia, CIS) Report focality or multifocality Report presence of pagetoid spread of CIS (this finding is not dysplasia) Extent of tumor in organs attached to the bladder Prostate: direct extension to the prostate, involvement of prostatic urethra, involvement of prostatic ducts with or without stromal involvement Ureter, renal Pelvis, and urethra: Report any dysplastic/neoplastic change of the mucosa, and report any invasion into adjacent suburothelial connective tissue or muscularis propria Seminal vesicles: report spread of carcinoma in these organs either through epithelium or by direct extension of an infiltrative tumor Vagina/uterus: report direct extension or metastases to either organ Surgical margins: report status of ureteral/urethral margins. Report perivesical margin involvement Report important associated conditions such PIN and adenocarcinoma of the prostate Lymph nodes: report presence or absence of metastases. If metastases are present state number and size of the largest one (<2.0 cm, 2.1 to 5 cm, >5 cm) Features considered optional in the final report Invasion of the muscularis mucosa, if present; T1 substaging with micrometer, or just focal/wide suburothelial connective tissue invasion Genetic abnormalities Cytometric examination Morphometric examination p53, ki-67 Growth factors and receptors Other immunohistochemical markers Stage: use TNM/AJCC 2002 revision (T1-T4, N, and M) a Immunohistochemistry may be useful in selected cases using either cytokeratin for suburothelial connective tissue invasion or vascular endothelial markers for vascular invasion. tumor recurrence and disease progression (Fig. 1) [16] Additional information Additional information (epidemiological, morphological, and molecular or genetic abnormalities) can be reported by the pathologist (Table 4). For instance, urothelial carcinoma has been studied extensively on a biological (molecular or genetic) basis. Prognostic factors identified from such studies have been proposed and include blood group antigen expression in tumor cells, measurement of proliferative activity by DNA content analysis and S-phase fraction, and proliferation markers. Immunohistochemical analysis has been used to detect abnormal gene products. Multiple genetic changes are associated with bladder carcinoma and are detected by karyotyping, FISH, restriction-fragment-length polymorphisms, and microsatellite analysis. There is no consensus in the current literature about the definitive role and value of such prognostic factors [34,36,37]. Acknowledgements This paper is one of the seven dedicated to standardization of handling and pathology reporting in Uro-

9 A. Lopez-Beltran et al. / European Urology 45 (2004) pathology. The additional six deal with adrenal gland, kidney, radical prostatectomy specimens, prostate biopsies, testis and penis. It is based on the Uropathology Workshop held in Sesto Fiorentino (Ely Lilly Italia Headquarter), Florence, Italy, June 15, Appendix A. Sections for microscopic evaluation (with special reference to bladder) In TURBT specimens, submit 1 section per centimeter of tumor diameter (up to 10 cassettes). If the tumor is non-invasive by the initial sampling, additional submission of tissue (including possibly submitting all tissue) is necessary to diagnose or rule out the presence of invasion. If tumor is invasive into lamina propria in the initial sampling, additional sections (including possibly submitting the entire specimen) may be necessary to diagnose or rule out the possibility of muscularis propria invasion. In cystectomy specimens, several representative sections of the tumor, including the macroscopically deepest penetration, should be sampled. Submit several sections of the mucosa remote from the carcinoma, especially if abnormal, including the lateral wall(s), dome, and trigone. Submit 1 section of ureteral margin, unless submitted separately as frozen section specimens, and 1 section of urethral margin. If a long segment of the ureter(s) is present, then additional sections from the mid-portion may be necessary, as urothelial cancer often is multifocal. For additional information see: ftp://ftp.cap.org/cancerprotocols/blad03_p.pdf. Appendix B. Lymph nodes and distant spread The regional lymph nodes are the nodes of the pelvis, which essentially are the pelvic nodes below the bifurcation of the common iliac arteries. The significance of the regional lymph node metastasis in staging bladder cancer lies in the number and size, not in whether metastasis is unilateral or bilateral. One of the major prognostic determinants of ultimate cure is whether the tumor is confined to the bladder, and a major adverse prognostic feature is the presence of any lymph node metastasis. Regional lymph nodes include: hypo-gastric, obturator, iliac (internal, external, NOS), peri-vesical, pelvic (NOS), sacral (lateral, sacral promontory), pre-sacral. The common iliac nodes are considered sites of distant metastasis and should be coded as M1. It is recommended that: The number of lymph nodes submitted by the urologist should be reported. All the nodes should be widely sampled and evaluated. In particular, submit 1 section from each grossly positive lymph node. All other lymph nodes should be entirely submitted, as presence of nodal disease may be used as an indication for adjuvant therapy. Lymph nodes may be grossly or microscopically detected in the perivesical fat. In case of positive node(s) the size must be reported in order to fulfill TNM requirements for staging [4,20] (Table 4). Distant spread is most commonly to liver, bone, lung and lymph nodes. Appendix C. Sampling criteria for the definition of T4 In the male, the bladder adjoins the rectum and seminal vesicle posteriorly, the prostate inferiorly, and the pubis and peritoneum anteriorly. In the female, the vagina is located posteriorly and the uterus superiorly. As far as the prostate and prostatic urethra are concerned, prostatic urethral involvement should be carefully investigated in cystectomy specimens [11,25,26] (Table 4). In particular: Sections should include the prostatic urethra, including at the margin and with the surrounding prostatic parenchyma. Representative sections of the peripheral zone, central zone, and seminal vesicles should be included. It must be noted that there is a higher incidence of prostatic adenocarcinoma in cystoprostatectomy specimens of bladder carcinoma. Close gross examination may help target sampling of selective abnormal appearing areas. As far as other tissues are concerned, the following is recommended: Submit 1 or more sections of uterus, as indicated; and 1 or more sections of vagina, seminal vesicles, and other organs, as indicated. If the tumor grossly appears to invade the prostate, uterus, or vagina, sections should be targeted, such that the relationship of the infiltrating tumor in the bladder wall and the adjacent viscera is clearly demonstrable.

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