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Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6 42
ORIGINAL RESEARCH Goyal VK et al: Spectrum of Lesions in Urinary Bladder Biopsies
Correspondence to: Dr. Dharm Chand Kothari, Room No.- 40, Hostel No.- 4, Vivek Hostel, UG Hostel Medical College Campus, Bikaner PIN- 34001, Rajasthan, India.
Spectrum of Lesions in Urinary Bladder
Biopsies: Histopathological Study Vaibhav Kumar Goyal1, Surendra Prakash Vyas2, Dharm Chand Kothari3
Background: Bladder tumor is the seventh most common tumor worldwide. Urothelial carcinoma is the commonest
type accounting for 90% of all primary tumors of the bladder. As per Indian Cancer Registry data, it is the 9th
most
common cancer accounting for 3.9% of all cancers. Material method: The study was carried out in the department of
Pathology, Sardar Patel medical college Bikaner. Clinicopathological data of all TURBT biopsies collected were
analyzed. Results: One hundred TURBT biopsy were studied, and urothelial carcinoma were classified according to
WHO /ISUP (2004) classification. The most common age group was 61-70 years (33%) with Male to female ratio was
5.25:1. In carcinoma most common type was high-grade papillary urothelial carcinoma (58%) followed by low-grade
papillary urothelial carcinoma (31%) papillary urothelial neoplasm of low malignant potential (4%) moderately
differentiated squamous cell carcinoma (2%)and moderately differentiated adenocarcinoma (1%). In cystitis most
common type is Chronic non-specific cystitis (3%) followed by eosinophilic cystitis (1%). Conclusion: In bladder most
common lesion was of high-grade urothelial carcinomas presented with lamina propria and muscle invasion.
Pathological grade and muscle invasion are the important valuable prognostic factors of survival. Awareness is very
much needed in the public about haematuria because they neglect it causing in an advanced stage of bladder cancer at
the time of presentation.
KEYWORDS: Adenocarcinoma, squamous cell carcinoma, Urothelial carcinoma, Urinary Bladder
AAA
Diseases of the urinary bladder both non-neoplastic and
neoplastic are quite common. The non-neoplastic lesions
include cystitis, malakoplakia, urachal lesions, and
tuberculosis. Urothelial carcinoma is the commonest type
accounting for 90% of all primary tumors of the bladder.1
As per Indian Cancer Registry data, it is the 9th
most
common cancer accounting for 3.9% of all cancers.2
Urothelial bladder tumors are classified in flat and
papillary type most tumors are papillary. Carcinoma in
situ and few invasive tumors have a flat pattern.3-6
The
papillary equivalent of flat in situ carcinoma is the high-
grade noninvasive papillary urothelial carcinoma.3
Progress has been made in the field of non-invasive
imaging and scientists continue to identify and
characterize potential markers or surrogate end points for
bladder tumor physical examination, cystoscopic
evaluation and histopathological analysis of biopsy
material are the mainstays of contemporary bladder
cancer diagnosis and treatment.
The study was carried out in the department of Pathology,
Sardar Patel medical college Bikaner including all the
patients with urinary bladder lesion diagnosed on biopsy,
who attended the hospital. Data were collected in a preset
proforma. Clinical and cystoscopic findings with the
clinical diagnosis of all cases of urinary bladder lesion
sent to the laboratory were noted.
The material for the study was comprised of biopsy from
Transurethral resection of bladder Tissue (TURBT).
Inclusion Criteria
All the TURBT biopsies received in the department of
Pathology, Sardar Patel medical college Bikaner.
Exclusion Criteria
Autolysed specimen
Inadequate biopsies.
Biopsy specimens were processed as per routine
histopathological technique. Paraffin section was cut and
stained by haematoxylin and eosin. Then bladder lesions
were studied according to WHO/ISUP (2004)
classification (Table 1).
Total of 100 TURBT biopsies were analyzed. A spectrum
of different pathological lesions was observed in the
study. In our study most common age group was 61-70
years where 33% patients were found followed by 51-60
years (28%), 41-50 years (18%), >70 years (17%) and
least common age group was < 40 years (4%). Mean and
Median Age of bladder lesion were 60.7911.07 and
61.00 years respectively. Male to female ratio was 5.25:1.
How to cite this article: Goyal VK , Vyas SP, Kothari DC Spectrum of Lesions in Urinary Bladder Biopsies: Histopathological Study. Int J Dent Med Res 2015;1(6):42-46.
INTRODUCTION
1,3- MD, Department of Pathology, Sardar Patel Medical College, Bikaner. 2- Associate Professor, Department of Pathology, Sardar Patel Medical College, Bikaner.
ABSTRACT
MATERIALS & METHODS
RESULTS
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ORIGINAL RESEARCH Goyal VK et al: Spectrum of Lesions in Urinary Bladder Biopsies
Haematuria was the most common clinical symptoms in
91% cases followed by strangury (48%), burning (39%)
and pain in 38% of cases.
According to cystoscopic findings, 72% patients had
papillary mass, 21% patients had solid mass, 3% patients
each diffuse thickening and ulcer while only one patient
had fungating mass.
In the present study, total cases of inflammatory lesions
were (4%) while carcinoma was present in (96%)
patients. The most common microscopic diagnosis was Papilloma Papillary
Neoplasm Of
Low
Malignant
Potential
Low-Grade
Papillary
Carcinoma
High-Grade
Papillary
Carcinoma
Architecture
Papillae Delicate Delicate;
occasionally
fused
Fused, branching,
and delicate
Fused,
branching,
and delicate
Organization
of cells
Identical
to normal
Polarity
identical to
normal; any
thickness;
cohesive
Predominantly
ordered, yet
minimal crowding
and minimal loss
of polarity; any
thickness;
cohesive
Predominantl
y disordered
with frequent
loss of
polarity; any
thickness;
often
discohesive
Cytology
Nuclear size Identical
to normal
May be
uniformly
enlarged
Enlarged with
variation in size
Enlarged with
variation in
size
Nuclear
shape
Identical
to normal
Elongated,
round–oval,
uniform
Round–oval;
slight variation in
shape and contour
Moderate–
marked
pleomorphis
m
Nuclear
chromatin
Fine Fine Mild variation
within and
between cells
Moderate–
marked
variation both
within and
between cells
with
hyperchromas
ia
Nucleoli Absent Absent to
inconspicuous
Usually
inconspicuous
Multiple
prominent
nucleoli may
be present
Mitoses Absent Rare, basal Occasional, at any
level
Usually
frequent, at
any level
Umbrella
cells
Uniformly
present
Present May be absent absent
Microscopic Diagnosis No. %
Inflammatory Lesions
Chronic non-specific cystitis 3 3.0
Eosinophilic cystitis 1 1.0
Carcinoma
High-grade papillary urothelial carcinoma 58 58.0
Low-grade papillary urothelial carcinoma 31 31.0
Moderately differentiated adeno carcinoma 1 1.0
Moderately differentiated squamous cell carcinoma 2 2.0
Papillary urothelial neoplasm of low malignant potential 4 4.0
Total 100 100
high-grade papillary urothelial carcinoma (58%) while
the least common microscopic diagnosis was moderately
differentiated adenocarcinoma and eosinophilic cystitis
(1%) and other microscopic diagnosis were also found
like low-grade papillary urothelial carcinoma (31%)
Papillary urothelial neoplasm of low malignant potential
(4%) chronic non-specific cystitis (3%) moderately
differentiated squamous cell carcinoma (2%) (Figure –1,
2, 3, 4, 5, 9), (Table 2).
According to the invasion, Lamina Propria was present in
73.03% of cases while the muscular invasion was present
in 62.92% of patients (Figure-6), (Table 3).
In the present study, differentiation was present in seven
cases (7.86%) and out of them Glandular was present in
one case(1.12%), nested was present in one case(1.12%)
and squamous was present in five cases (5.61%) while
remaining eighty-two cases(92.13%) patients had no
differentiation (Figure- 7, 8, 10), (Table 4). Invasion Present Absent
No. % No. %
Lamina
Propria
65 73.03 24 26.96
Muscular 56 62.92 33 37.07
Table 1-Histologic features used to classify urothelial papillary lesions according to the scheme proposed by the WHO/ISUP (2004)
Table 2 Distribution of Cases according to Microscopic Diagnosis
Figure -1: Chronic non-specific cystitis with lymphoid aggregates in lamina propria (H&E, 10x).
Figure -2: Chronic non-specific cystitis with lymphoid aggregates in lamina propria (H&E, 10x).
Table 3: Distribution of Cases According to Invasion in uorthelial carcinoma
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ORIGINAL RESEARCH Goyal VK et al: Spectrum of Lesions in Urinary Bladder Biopsies
Figure 3: Papillary urothelial neoplasm of low malignant potential (H&E, 10x).
Figure 4 - Low grade papillary urothelial carcinoma showing papillae with mild pleomorphism of cells with maintained basal polarity (H&E, 10x).
Figure 5 - high grade papillary urothelial carcinoma with fused papillae with marked pleomorphism and loss of basal polarity (H&E, 4x).
Figure 6- High grade urothelial carcinoma showing muscle invasion (H&E 10X)
Figure 7- showing high grade urothelial carcinoma with squamous differentiation and keratin pearls (H&E, 10x)
Figure 8- high grade urothelial carcinoma with glandular differentiation (H&E, 40x).
Figure 9- Moderately differentiated adenocarcinoma bladder (H&E 10X)
Figure 10- Moderately differentiated squamous cell carcinoma (H&E, 40x).
Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6 45
ORIGINAL RESEARCH Goyal VK et al: Spectrum of Lesions in Urinary Bladder Biopsies
Differentiation No. %
Nil 82 92.13
Glandular 1 1.12
Nested 1 1.12
Squamous 5 5.61
Total 89 100
Diseases of the urinary bladder both non-neoplastic and
neoplastic are quite common. Bladder tumor is the
seventh most common tumor worldwide. Urothelial
carcinoma is the commonest type accounting for 90% of
all primary tumors of the bladder.
Hundred cases of urinary bladder lesions were included
in our study. In our study haematuria was the most
common clinical symptoms (91%), while pain was
present in 38% of cases, burning was present in 39% of
cases and strangury was present in 48% of cases which
was correlated with the study of Ray et al7 (2013) who
find that 91% of urinary bladder patients were presented
with painless haematuria.
In our study we found the male to female ratio was 5.25:1
which was correlated with Lim et al8
and Vaidya et al9
and they found male to female ratio in their study was 5:1
and 4.5:1 respectively.The male to female ratio of our
study was slightly higher than the study of Hasan et al10
(2.58:1), Cheng et al11
(3.3:1.0) and lower than Matalka
et a112
(9:1).
In our study the most common age group was 61-70 years
with 33%cases which was correlated with Vaidya et al9 of
33.73% cases of 61-70 years while Mean age of
presentation was 60.79 years ( range 35-85) which was
correlated with Matalka et al12
studied in which mean age
of the patients was 60.6 years (range 19-91) and median
age of presentation was 61.00 years (range 35-85) which
was correlated with Vaidya et al9 in which median age of
the patients was 65 years (range 16-88) .
We found the urothelial carcinoma was 96.87% out of
total bladder carcinomas cases which were nearly
correlated with the study of Eble and Young13
(80%) and
Sharma et al14
(91.9%)(Table 5).
Small no of cases of chronic non-specific cystitis was due
to unawareness of symptoms by patient and biopsy was
sent in most of the cases only for carcinoma by the
clinician(Table 6).
In our study muscle invasion was seen in 62.92% cases of
urothelial carcinoma which was correlated with Shah et
al16
whose result showed muscle invasion in 69% cases
while lamina propria invasion in our study was seen in
73.03% cases of urothelial carcinoma which was
correlated with Sathya et al15
whose results showed
lamina propria invasion in 87% cases(Table 7).
In our study we found pure urothelial carcinoma was
(92.13%) cases, Squamous differentiation (5.61%),
glandular differentiation (1.12%), nested differentiation
(1.12%) which was nearly correlated with study of Billis
et al17
, which showed (92.72%) were conventional
urothelial carcinomas and 7.27% showed squamous and
glandular differentiation. Microscopic Diagnosis Laishram
et al2
Sathya
et al15 Vaidya
et al9 our
study
PUNLMP 7.69% 10.28% 4.1%
Low grade urothelial
carcinoma.
53.85% 25.0% 29.91% 32.29
%
High grade urothelial
carcinoma
34.61% 62.85% 32.7% 60.41
%.
Moderately
differentiated adeno
carcinoma
- 0.93% 1.04%
Moderately
differentiated
squamous cell
carcinoma
- 2.08%
Microscopic Diagnosis Vaidya et al9 Present study
Chronic Non-Specific Cystitis 14.95% 3.0%
Eosinophilic Cystitis 1.88% 1.0%
Study Grade Present Absent
Present
study
High-grade 48 (82.75%) 10 (17.24%)
Low-grade 8 (25.80%) 23 (74.19%)
Vaidya et
al9 High-grade 76.92% 23.08%
Low-grade 16% 84%
In our study most common bladder lesion was urothelial
carcinoma. Out of total carcinoma cases most common
carcinoma was of high-grade urothelial carcinoma
presented with lamina propria and muscle invasion.
Another bladder tumor was squamous cell carcinoma
followed by adenocarcinoma. Pathological grade and
muscle invasion are the most valuable prognostic
predictors of survival. Awareness is very much needed in
the public about haematuria because they neglect it
causing in an advanced stage of bladder cancer at the
time of presentation.
1. Kumar MU, Yelikar BR. Spectrum of Lesions in
Cystoscopic Bladder Biopsies – A Histopathological
Study. Al Ameen J Med Sci 2012; 5(2):132 – 136.
2. Laishram RS, Kipgen P, Laishram S, Khuraijam S, Sharma
DC. Urothelial Tumors of the Urinary Bladder in Manipur:
A Histopathological Perspective. Asia Pacific J Cancer
Prev, 2012; 13:2477-2479.
Table 4: Distribution of cases according to Differentiation
DISCUSSION
Table 5: Correlation of Distribution of carcinoma Cases according to Microscopic Diagnosis
Table 6: Correlation of Distribution of inflammatory Cases according to Microscopic Diagnosis
Table 7: Correlation of Distribution of Cases of urothelial carcinoma According to muscle Invasion
CONCLUSION
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Int J Dent Med Res | MAR- APR 2015 | VOL 1 | ISSUE 6 46
ORIGINAL RESEARCH Goyal VK et al: Spectrum of Lesions in Urinary Bladder Biopsies
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Source of Support: Nil
Conflict of Interest: Nil