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Presented by Dr. Epstein and prepared by Dr. Daniel Miller
A 50 year old woman with a history of leukemia treated with chemotherapy presented with hematuria and was biopsied.
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Question 1 of 1
1. Question
A 50 year old woman with a history of leukemia treated with chemotherapy presented with hematuria and was biopsied.
Choose the correct diagnosis:
Correct
Answer: C. Pseudocarcinomatous urothelial hyperplasia
Discussion: Pseudocarcinomatous urothelial hyperplasia (PCUH) is a late reactive process to bladder ischemia. In most cases, it is seen several years following radiation to pelvic organs with most common a history of prior irradiation for prostate cancer. Less frequently there is a history of systemic chemotherapy, severe systemic ischemic disease, indwelling catheter, or sickle cell disease. Architecturally, it resembles infiltrating urothelial carcinoma with nests of urothelial cells irregularly within lamina propria. The nests do not involve the muscularis propria; if there are nests of urothelium in the muscularis propria then it is invasive urothelial carcinoma and not PCUH. The key to recognizing PCUH is not focusing on the nests of urothelium but recognizing the background stroma with numerous vessels having fibrin thrombi, recent hemorrhage and, extensive hemosiderin deposition, and in most cases prominent acute and chronic inflammation. Infiltrating urothelial carcinoma does not have fibrin, extravasated red blood cells and hemosiderin as a reaction in the adjacent stroma. As PCUH is a reactive process, the urothelium can have mild to moderate nuclear atypia and mitotic figures can be seen in 25% of cases. Overlying ulceration is present in 40% of cases. Vascular changes associated with prior irradiation can often be found. Typically the pathologist does not get a history of prior radiation or other ischemic etiologies and needs to call the urologist for this information which helps to confirm the diagnosis. Although PCUH mimics infiltrating urothelial carcinoma, it is not associated with an increased risk of carcinoma.
-Reference: Kryvenko ON, Epstein JI. J Urol. 2013 Jun;189(6):2083-6. PMID: 23228381
Incorrect
Answer: C. Pseudocarcinomatous urothelial hyperplasia
Discussion: Pseudocarcinomatous urothelial hyperplasia (PCUH) is a late reactive process to bladder ischemia. In most cases, it is seen several years following radiation to pelvic organs with most common a history of prior irradiation for prostate cancer. Less frequently there is a history of systemic chemotherapy, severe systemic ischemic disease, indwelling catheter, or sickle cell disease. Architecturally, it resembles infiltrating urothelial carcinoma with nests of urothelial cells irregularly within lamina propria. The nests do not involve the muscularis propria; if there are nests of urothelium in the muscularis propria then it is invasive urothelial carcinoma and not PCUH. The key to recognizing PCUH is not focusing on the nests of urothelium but recognizing the background stroma with numerous vessels having fibrin thrombi, recent hemorrhage and, extensive hemosiderin deposition, and in most cases prominent acute and chronic inflammation. Infiltrating urothelial carcinoma does not have fibrin, extravasated red blood cells and hemosiderin as a reaction in the adjacent stroma. As PCUH is a reactive process, the urothelium can have mild to moderate nuclear atypia and mitotic figures can be seen in 25% of cases. Overlying ulceration is present in 40% of cases. Vascular changes associated with prior irradiation can often be found. Typically the pathologist does not get a history of prior radiation or other ischemic etiologies and needs to call the urologist for this information which helps to confirm the diagnosis. Although PCUH mimics infiltrating urothelial carcinoma, it is not associated with an increased risk of carcinoma.
-Reference: Kryvenko ON, Epstein JI. J Urol. 2013 Jun;189(6):2083-6. PMID: 23228381
