Benign tumors and Mimickers of UB tumors.pptx

Benign tumor of UB

1. Benign lesions and mimickers of UB CANCER Dr Hemanta Pun Mch Resident 1 st year

2. Epithelial Metaplasia Defn : focal area of transformed urothelium , normal nuclear and cellular morphology Features: Site: Trigone of UB Squamous or glandular metaplasia v/s UB ca : Glandular m.: inflammatory areas Squamous m.: H/O UTI, trauma, prior surgery Role of Bx and Rx: none

3. Urothelial Papilloma Incidence: <1 % Age: younger Site : usu. Trigone of UB ( usu solitary) Cause: chronic inflammation or BOO C/F : Painless hematuria/ Irritative voiding symptoms Behaviour : Benign (<1% recurrence ) Genetics: FGFR-3 mutation (lack p53 and RB mutation) Pathology: exophytic papillary lesions with delicate stalks edematous stroma , covered by a normal-in-thickness multilayer coat of benign- appearing transitional cells

4. Inverted Urothelial Papilloma (IUP) Benign lesion Site : usu. Trigone of UB Cause: chronic inflammation or BOO Recurrence: r/t incomplete resection Pathology: Surface: flat and smooth ( occ papillae) Urothelial cells with peripheral palisading No atypia / inflamm /fibrosis No invasion beyond submucosa [v/s UC: large cells with muscular propria invasion with reactive stroma ]

5. Although initially related with human papillomavirus, the last findings using IHC and different FISH probes exclude this causal link

6. Nephrogenic Adenoma Rare tumor Cause : chronic irritation of urothelium Trauma Prior surgery Renal transplantation Intravesical chemo Stones Catheters Infection

7. C/F : dysuria Hematuria Cystoscopy: Papillary neoplasm (? Aggressive UB neoplasm ) Pathology: Wide histological spectrum microcystic , cystic, papillary, solid, and flat architectures, as well as clear cell, oncocytic , and fibro- myxoid changes Genetics: + ve for PAX-8/ Napsin A and – ve for p63/GATA-3 Potential malignant simulator Treatment : Resection

8. Leukoplakia C/F: Incidental diagnosis (asymptomatic) Recurrent infection Frequency and urgency characteristic white, flaky plaques floating in the bladder Cause: UTI Trauma Prior surgery

9. Cystitis Cystica and/or Glandularis (with Int metaplasia); CCGIM Benign lesion Cause: UB inflammation or chronic BOO HPE: cystic nests that are lines by columnar or cuboidal cells and are generally associated with proliferation of Von Brunn nests lacks cytological atypia , necrosis, signet ring cells and brisk or atypical mitotic activity

10. Cystoscopy: broad based mass Cystic transformation Malignant potential: Low Need of regular endoscopic evaluation Treatment: Transurethral resection

11. BCG-Induced Inflammatory Reaction ( BCGitis ) Cause: BCG admin intravesically in previous TURBT patient---- + local host defense mechanism Cystoscopy: florid inflammation Diagnosis: TUR Bx

12. Endocervicosis (EC) / Endometriosis (EM) (Müllerianosis) presence of endocervical and endometrial tissue outside the endocervix and endometrium , respectively . MC site: UB C/F: hypogastric pain, dysuria, and transient hematuria during menstruation USG: UB mass

13. Pathology: Glands (EC/EM type) within UB with an infiltrative pattern Behaviour : Benign with low risk of malignant potential recurrent and resistant to therapy

14. Malakoplakia (MK) chronic granulomatous inflammation Site: Urinary tract (can inv other organs) Risk Factor: Immunocompromised USG: bladder mass Patho : + nce of Michaelis-Gutmann bodies with chronic inflammation mainly composed of abundant histiocytes , the so-called von Hansemann’s macrophages

15. IgG4-related disease (IGG4) Systemic autoimmune dz Pathogenesis: not clear Site: Urinary tract (with different organs). Pathology: diagnostic criterias dense lymphoplasmacytic infiltrate storiform -type fibrosis Obliterative phlebitis IgG4 population (among total IgG plasma cell infiltrate): >40% No arteritis

16. Schistosomiasis aka Bilharziasis /Snail fever Causative agents: Schistosoma sps . Schistosoma haematobium S . japonicum S . mansoni MC site: UB Pathogenesis (in UB ca ) : IL-4 mediated Increased risk of SCC in endemic regions

17. HPE: Chronic inflamm with abundant eosinophils Hyperplastic changes without atypia Varied quantity of parasitic eggs Treatment : Anti- protozoal agents [ Praziquantel , Metronidazole]

18. Post-radiation changes Site: UB C/F: Intermittent Hematuria/ Irritative voiding symptoms HPE: hyperplastic pseudo-carcinomatous changes No atypia or mitoses Stroma : Hyperemic and edematous Occ , multinucleated giant cells

19. Papillary urothelial neoplasm of low malignant potential ( PUNLMP) Site: Trigone of UB Behaviour : contorversial !!! 5 year recurrence rate: 20% Progression to MIBC : <1% Genetics: TERT promoter mutations and FGFR3 mutations (>60%) HRAS mutation (3%) [ vs 33% in non-invasive UCC] – s/o indolent course Patho : papillary growth; usu solitary minimal cytologic atypia that is more than seven cells thick Maintained cell polarity Mildly enlarged nuclei

20. Precursor Malignant Lesions Normal urothelium : multilayered mucosa (4 to 7 cells thick) BBM Intermediate Superficial umbrella nonkeratinizing squamous and pseudostratified columnar epithelium

21. WHO classification U rothelial hyperplasia (flat and papillary) Reactive atypia U rothelial atypia of unknown significance ( AUS) Urothelial dysplasia low-grade intraurothelial neoplasia

22. Reactive atypia Nuclear abnormalities in the background of an inflamed urothelium Causes: chronic inflammation Noxious stimuli C/F: Irritative voiding symptoms Cystoscopy: mucosa edematous and inflammed HPE: Prominent and enlarged nuclei; maintained nuclear polarity Behavior : No Malignant potential Coexists with dysplasia and CISs

23. Atypia of unknown significance(AUS) Diagnosis of limited clinical utility. ?????premalignant or reactive. HPE: Inflammation of the lamina propria Nuclear atypia disproportionate to the degree of atypia IHC staining : + ve for CK20 and CK44

24. Urothelial dysplasia Def : N ormal urothelial thickness and an altered cytologic appearance Indication of urothelial instability and a marker of recurrence or progression in those with a history of urothelial cancer . Progression to UCC: 15-20% Progressioon to CIS : 60% HPE: loss of nuclear polarity nuclear enlargement Hyperchromasia nuclear membrane irregularity.