Jesse K. McKenney, MD
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1 Jesse K. McKenney, MD
2 Outline Microscopic anatomy of the urinary bladder Diagnosing invasion Subtle patterns (variants) of carcinoma Clinically important variants of carcinoma
3 Microanatomy of Bladder Initial description of muscularis mucosae Urothelium Dixon JD, Gosling JA. J Anat 1983;136: Muscularis Ro JY, Ayala AG, El-Naggar A. Am J Surg mucosae Pathol 1987;11: Muscularis propria
4 Classic Lamina Propria
5 Classic Muscularis Mucosae
6 Classic Muscularis Mucosae
7 Classic Lamina Propria
8 Classic Lamina Propria
9 Muscularis Propria in Biopsy
10 Lamina Propria Muscularis Propria
11 However
12 Recent Studies Detailing the Bladder Wall Musculature Paner GP, Ro JY, Wojcik EM, et al. Am J Surg Pathol 2007;31: Vakar-Lopez F, Shen SS, Zhang S, Tamboli It s not so easy any more! P, Ayala AG, Ro JY. Ann Diag Pathol 2007;
13 Variability in Bladder Musculature 1) Larger bundles of smooth muscle may be in the lamina propria - Small, individual, round compact - Large aggregates 2) Superficial border of the muscularis propria may not be sharp/distinct - Trigone - Dome
14 Separate round compact smooth muscle bundles in LP
15 Separate round compact smooth muscle bundles in LP
16 Dense compact smooth muscle bundles in LP
17 Dense compact smooth muscle bundles in LP
18 Dense compact smooth muscle bundles in LP
19 Dispersed
20 Dispersed
21 Dispersed Muscle Bundles Contiguous with MP
22 What is the lamina propria?
23
24 Dispersed
25
26 Staging
27 Patterns of Lamina Propria Invasion: What is Invasion? Detached clusters and single cells Retraction spaces Irregular nests of cells with surrounding: Edema Fibrosis (collagen) Desmoplasia (fibroblasts) Inflammation Myxoid stroma Irregular nests of cells with no response
28 Invasive Urothelial Carcinoma
29 Invasive Urothelial Carcinoma
30 Invasive Urothelial Carcinoma
31
32
33 Stalk Invasion (pt1)
34 Stalk Invasion (pt1)
35 Stalk Invasion (pt1)
36 Stalk Invasion (pt1)
37 Stalk Invasion (pt1)
38 Stalk Invasion (pt1)
39 Stalk Invasion (pt1)
40 Stalk Invasion (pt1) with Cautery
41 Mimic of Stalk Invasion: Blood Vessels
42 Mimic of Stalk Invasion: Blood Vessels
43 Mimic of Stalk Invasion: Blood Vessels
44
45 Lamina Propria Invasion
46 Lamina Propria Invasion
47 Lamina Propria Invasion
48
49 Invasion of Muscularis Propria
50 Invasive Urothelial Carcinoma Involving MP
51 Invasive Urothelial Carcinoma Involving MP
52 Invasive Urothelial Carcinoma: Problematic Areas in Staging
53
54
55 Muscularis Mucosae Invasion (pt1)
56 Invasion of Hyperplastic Muscularis Mucosae (pt1)
57 Invasion of Hyperplastic Muscularis Mucosae (pt1)
58 Muscularis Mucosae Invasion (pt1)
59 Muscularis Mucosae Invasion (pt1)
60 Invasion of Individual Thick Muscle bundles in Lamina Propria (pt1)
61 Invasion of Individual Thick Muscle bundles in Lamina Propria (pt1)
62 Invasion of Individual Thick Muscle bundles in Lamina Propria (pt1) Actin HMWCK
63 Which Type of Muscle?
64 Where is the Muscularis Propria?
65 Invasion of Individual Thick Muscle bundles in Lamina Propria (pt1)
66 Invasion of Muscularis Propria
67 Invasive Urothelial Carcinoma
68 Muscle Type?
69 Muscle Type..Muscularis Propria (>pt2)
70 Invasive Urothelial Carcinoma Involving MP (>pt2)
71 Invasive Carcinoma, Indeterminate Depth (pt?)
72 Immunohistochemistry: Help or Hindrance?
73 Utility of Immunohistochemistry in Distinguishing MM from MP NOT sufficient specificity for diagnostic utility Recent marker with some promise? Smoothelin
74 Actin Smoothelin M u c o s a e P r o p r i a
75 H&E Smoothelin Smoothelin Titer Significantly Affects Staining Specificity!!!! Confluent invasion in muscle? MP?
76 Pitfalls in Invasion Evaluation: Potential Overdiagnosis
77 Pitfalls in the Diagnosis of Invasion Invasion Urothelial carcinoma in-situ colonizing von Brunn nests Muscle Invasion Pseudosarcomatous Myofibroblastic Proliferation Urothelial Neoplasia Colonizing Prostatic Glands Near the Bladder Neck Tangentially Sectioned Blood Vessels
78 Cystitis Cystica Colonized by Urothelial Carcinoma In Situ CIS in von Brunn nests Lamina Propria Invasion
79 Carcinoma with Associated Myofibroblastic Proliferation
80 CA with Pseudosarcomatous Myofibroblastic Proliferation
81 CA with Pseudosarcomatous Myofibroblastic Proliferation
82 CA with Pseudosarcomatous Myofibroblastic Proliferation
83 CA with Pseudosarcomatous Myofibroblastic Proliferation
84 CA with Pseudosarcomatous Myofibroblastic Proliferation
85 CA with Pseudosarcomatous Myofibroblastic Proliferation
86 CA with Pseudosarcomatous Myofibroblastic Proliferation
87 Carcinoma Colonizing Prostate Glands
88 Urothelial Carcinoma Colonizing Prostate Glands
89 Endophytic Architecture Amin MB, Gomez JA, Young RH. Am J Surg Pathol 1997;21:
90 WHO/ISUP 2004 Endophytic Urothelial Lesions Inverted Papilloma Urothelial Neoplasm of Low Malignant Potential (PUNLMP) Urothelial Carcinoma, Low-Grade Urothelial Carcinoma, High-Grade
91 Inverted Papilloma
92 Endophytic Urothelial Carcinoma, Low Grade
93 Endophytic Urothelial Carcinoma, High Grade
94 Endophytic Urothelial Carcinoma with Invasion (pt1)
95 Tangentially Sectioned Blood Vessels
96 Tangentially Sectioned Blood Vessels
97 Tangentially Sectioned Blood Vessels
98 Tangentially Sectioned Blood Vessels
99 Substaging in TUR pt1 Not standardized Not recommended by consensus groups >pt2 Cannot be diagnosed Adipose tissue is present in both the lamina propria and muscularis mucosa Abraham, Amin, Tamboli, et al. Am J Surg Pathol 2000;24:
100 Adipose Tissue in Lamina Propria and MP
101 One Mimic that Really, Really, Really Looks Like Invasive Cancer
102
103 Pseudocarcinomatous Hyperplasia Pattern of urothelial injury secondary to radiation and/or chemotherapy effect Very close mimic of urothelial carcinoma Now rarely reported in absence of therapy
104 Pseudocarcinomatous Hyperplasia
105 Pseudocarcinomatous Hyperplasia
106 Pseudocarcinomatous Hyperplasia
107 Pseudocarcinomatous Hyperplasia
108 Pseudocarcinomatous Hyperplasia
109 Pseudocarcinomatous Hyperplasia
110 Pseudocarcinomatous Hyperplasia
111 Pseudocarcinomatous Hyperplasia
112 Pseudocarcinomatous Hyperplasia Invasive carcinoma
113 Summary Microanatomy of the urinary bladder Staging Patterns of invasion Applying new microanatomy data Pitfalls
114 Evaluation of the TURBT Jesse K. McKenney, MD
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