Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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Urinary Tract Notes
  • A fine GU pathology website: by Dr. D. M. Ramnani.
  • Pelvico-ureteral & bladder:
    • Medical:
      1. hematuria detected: if dipstick positive for "blood", best to repeat with actual micro exam for presence or absence of RBCs. Note an example approach, HERE. If strongly positive and few or no RBCs, think of hemoglobinuria. Workups for occult blood, otherwise, rarely find anything if RBCs note in sediment.
      2. interstitial cystitis [IC] (bladder pain syndrome [BPS]): superficial mucosal bladder biopsy at a focus of cystoscopic-induced, hyperdystention-caused petechial bleed (glomerulation) is primarily done to rule out other specific bladder cystodynia pathology than the bland findings of the significant disorder of "interstitial cystitis" (IC). The only real tip-off might be increased lamina propria mast cells (and maybe plasma cells)...but there is doubt about the specificity of mast cells for IC. If a deep biopsy is deliberately done to include detrusor muscle, then increased mast cells within the muscle is fairly firmly concordant with clinical and cystoscopic IC. Pathology Outlines notes HERE. Biopsy is primarily to (1) rule out occult neoplasia or (2) some other more histologically obvious alternative pathology.
      3. overactive bladder syndrome (OAB): these patients have a quite compelling degree of urgency to urinate. Biopsy is primarily to rule out occult neoplasia or some other more histologically obvious pathology.
    • infections or inflammatory:
      • post-BCG granulomatous disease: when you see evidence of granulomatous inflammation deeper than lamina propria, you may well have found a complication of BCG therapy! Potentially forming inflammatory thickenings, these lesions run a risk of causing false positive PET scans or other imaging as post-treatment neoplastic follow-up goes on. Happens, as with vaccination, in less than 5% of treated patients3.
        1. early...<12 months (usually systemic) disease: hepatitis or pneumonitis
        2. late...>12 months (75% are localized) disease:
          • 42% GU locations: urothelial tract [L12-12472], prostate, testis
          • 58% other locations: the vascular tree (infected aneurysms), vertebral bones, retroperitoneal soft tissues, and the chest wall.
      • other:
    • congenital:
    • endometriosis & related mullerian-type changes:
    • proliferations:
      1. urothelial metaplasias:
        1. post-TURP change: pseudopapillary squamous metaplasia [L13-2967]
      2. benign:
        1. tubulovillous adenoma [L-07-490].
      3. uncertain biological potential & malignant:
        • carcinoma:
          1. transitional cell (urothelial) ca.:
            • grade: always have it clear as to whether reporting in a binary, 3 or 4 grades system [systems] [Johns Hopkins web tutorial] and try to use quantitative terminology if mixed grade (90% low grade & 10% high grade).
            • stage: paradoxically "mature" buds of cells indicate invasion & one should try to quantitate in report (3 submillimeter buds of lamina propria invasion in about 22 grams of TURBT tissue...LMC-06-5756). A huge breakpoint is presence or absence of detrusor muscle invasion.
            • markers: in attempting to decide about adjuvant radiation, hi grade behaves worse, as do smokers, tumor expression other than blood type O, aneuploid tumors, and proliferative tumors (elevated Ki67 or S-phase fraction).
            • treatment implications:
              1. Ta-T1: [depending also on size, evidence of multifocality, and grade] TURBT only, 80% recurrence rate; TURBT plus BCG, 50% recurrence rate; least recurrence rate with adjuvant chemo 1.
              2. Tis & Ta: okay for BCG after TURBT...if pathologists fails to find any subepithelial stromal (lamina propria) invasion.
              3. if T1: see above.
              4. if deeper than T1: XRT needed.
          2. DANGEROUS variant: "invasive micrfopapillary carcinoma", pure or mixed, behaves very badly; and its presence is grounds for cystectomy even at an early stage (see Kamat AM, et. al., J. Urol, March 2006 p. 1967) [S07-5657].
          3. adenocarcinoma:
          4. small cell ca. & related neuroendocrine tumors: [L12-11996 a TCC with major small-cell NEC component].
          5. squamous cell carcinoma:
            1. TCC can have focal squamous features, & SCC Dx is reserved for those cases apparently purely SCC [LMC-05-6805].
            2. basaloid SCC:
            3. verrucous SCC:
            4. warty SCC:
          6. lymphepithelioma-like carcinoma:
          7. sarcomatoid carcinoma & related tumors:
        • sarcoma & melanoma:
        • lymphoma:
    • other:
      1. amyloidosis:
      2. lithiasis (kidney stones):
    • Kidney:
      1. medical:
      2. neoplastic:
    • Prostate:
      1. medical:
      2. neoplastic:
    • Minor adnexae & urethral:
      1. medical:
      2. neoplastic:
    • Associated structures:
      1. testicular:

References:

  1. LMC Oncology Conference specialists
  2. Rosai & Ackerman's 9th Ed
  3. Gonzales OY, et. al., "Spectrum of Bacille Calmette-Guérin (BCG) Infection after Intravesical BCG Immunotherapy", Clinical Infectious Diseases, 36(2):140-148, January 15, 2003, HERE.

(posted 16 April 2003; latest addition 5 October 2013)

 
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