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Presented by Jonathan Epstein, M.D. and prepared by Mohammed Lilo, M.D.
Case 1: A 77 year old male was noted to have a bladder lesion
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Question 1 of 1
1. Question
Week 594: Case 1
A 77 year old male was noted to have a bladder lesion which was biopsied.images/lilo/JIE/JIE-1-A.jpg
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images/lilo/JIE/JIE-1-E.jpgCorrect
Answer: Denuded papillary urothelial carcinoma
Histology: The lesion consists of delicate papillary fronds that with the exception of one partial frond are entirely denuded of urothelium. The one cluster of urothelium shows thickened relatively bland cells with polarity preserved and lack of mitotic activity.
Discussion: It is not straightforward to recognize this lesion as being a papillary tumor as the surface urothelium is almost entirely denuded. One clue is that the presence of numerous tightly clustered capillaries is typical of what is seen in papillary fronds in papillary urothelial neoplasms. If there were questions as to the nature of the lesion, communication with the urologist would document the presence of a papillary lesion seen at cystoscopy. Flat urothelial carcinoma in situ (CIS) is often characterized by prominent dyscohesion with some cases having only a few clinging CIS cells remaining on biopsy. The finding of extensive denudation on urothelial biopsies is associated with a risk of CIS on either prior or subsequent biopsies. The significance of denudation in papillary urothelial lesions has only been recently formally studied by our group. In 22/28 (79%) patients, prominent denudation was associated with high-grade papillary carcinomas, 4/28 (14%) low-grade papillary carcinomas, and 2/28 (7%) papillary urothelial neoplasms of low-grade malignant potential. We concluded that
(1) the majority of papillary urothelial lesions associated with prominent urothelial denudation are high grade;
(2) a significant percentage of papillary urothelial lesions with denudation occur with either prominent cautery artifact or in anatomically confined areas, suggesting both iatrogenic and mechanical contributing factors, respectively;
(3) a minority of cases with prominent urothelial denudation occur in association with low-grade papillary urothelial lesions and are not associated with progression to higher grade lesions on follow-up studies; and
(4) prominent urothelial denudation in papillary lesions should prompt careful examination of these specimens for rare clinging high-grade carcinoma cells, although in a minority of cases the underlying lesion will be low grade.Reference(s):
– Am J Surg Pathol. 2007 Feb;31(2):298-303Incorrect
Answer: Denuded papillary urothelial carcinoma
Histology: The lesion consists of delicate papillary fronds that with the exception of one partial frond are entirely denuded of urothelium. The one cluster of urothelium shows thickened relatively bland cells with polarity preserved and lack of mitotic activity.
Discussion: It is not straightforward to recognize this lesion as being a papillary tumor as the surface urothelium is almost entirely denuded. One clue is that the presence of numerous tightly clustered capillaries is typical of what is seen in papillary fronds in papillary urothelial neoplasms. If there were questions as to the nature of the lesion, communication with the urologist would document the presence of a papillary lesion seen at cystoscopy. Flat urothelial carcinoma in situ (CIS) is often characterized by prominent dyscohesion with some cases having only a few clinging CIS cells remaining on biopsy. The finding of extensive denudation on urothelial biopsies is associated with a risk of CIS on either prior or subsequent biopsies. The significance of denudation in papillary urothelial lesions has only been recently formally studied by our group. In 22/28 (79%) patients, prominent denudation was associated with high-grade papillary carcinomas, 4/28 (14%) low-grade papillary carcinomas, and 2/28 (7%) papillary urothelial neoplasms of low-grade malignant potential. We concluded that
(1) the majority of papillary urothelial lesions associated with prominent urothelial denudation are high grade;
(2) a significant percentage of papillary urothelial lesions with denudation occur with either prominent cautery artifact or in anatomically confined areas, suggesting both iatrogenic and mechanical contributing factors, respectively;
(3) a minority of cases with prominent urothelial denudation occur in association with low-grade papillary urothelial lesions and are not associated with progression to higher grade lesions on follow-up studies; and
(4) prominent urothelial denudation in papillary lesions should prompt careful examination of these specimens for rare clinging high-grade carcinoma cells, although in a minority of cases the underlying lesion will be low grade.Reference(s):
– Am J Surg Pathol. 2007 Feb;31(2):298-303
