Glandular lesions of the urinary bladder:clinical significance and differential diagnosis

[Mimickers and diagnostic pitfalls of urinary bladder cancer]

Urothelial carcinoma (UC) is by far the most common malignant neoplasm of the urinary bladder; however, there are both benign and malignant changes of the urothelium which morphologically resemble urothelial carcinomas or other carcinomas of the urinary bladder. Thus, these mimickers can cause problems in the histomorphological diagnosis. This article provides an overview of possible mimickers and pitfalls of bladder cancer as well as practical notes on the diagnostic procedure, partly using case studies.

[A 49-year-old woman with long-standing urinary symptoms. Histological and immunohistochemical study of a case of bladder mullerianosis]

Bladder müllerianosis is defined by the presence of Müllerian epithelium (endometrial, endocervical or endosalpinx) in the bladder. It is a rare benign disease that affects women and presents a non-specific clinical presentation that poses a broad differential diagnosis. We present the case of a 49-year-old woman who presented with recurrent urinary tract infections, urinary discomfort and abdominal pain. The approach is carried out by ultrasound and urethrocystoscopy that reveal the presence of a 5mm polypoid lesion that is removed. The histological study revealed bladder müllerianosis together with the complementary finding of glandular cystitis and cystic cystitis.

Primary Adenocarcinoma of the Urinary Bladder: A Case Report on a Rare Malignancy

Of all primary bladder cancers, primary adenocarcinoma is an uncommon tumor. When considering all tumor origin areas, secondary bladder involvement from carcinoma, whether by direct extension or metastasis, is actually more prevalent than primary adenocarcinoma, despite its rarity. The most common source of subsequent bladder tumors is endometrial, lung, colon, prostate, breast, or other organ adenocarcinomas. Primary bladder adenocarcinoma is thought to result from urothelial metaplasia, which is frequently linked to persistent irritation or inflammation. Bladder exstrophy, recurrent urinary tract infections, long-term irritation from calculi or foreign bodies, and history of schistosomiasis are risk factors. A portion of these malignancies are associated with urachal remnants, where the tumor originates at the dome of bladder. Here we present a case of primary adenocarcinoma in a 44-year-old female patient that originated from the dome of urinary bladder.

Pitfalls in Urinary Tract Cytopathology

BACKGROUND

Urine cytopathology is a cost-effective method to diagnose and follow patients with high-grade urothelial carcinoma (UC). However, some benign, reactive, and metaplastic changes may mimic UC and pose a diagnostic challenge for cytopathologists.

SUMMARY

Our comprehensive review focuses on summarizing common pitfalls encountered in urine cytopathology, based on the 2nd edition of The Paris System (TPS) for reporting urinary tract cytopathology and other recent published literature. These pitfalls include urothelial tissue fragments, degenerative changes, treatment effects, viral cytopathic changes, iatrogenic and metaplastic changes. Our aim was to provide a clear understanding of these mimics in order to avoid diagnostic errors.

KEY MESSAGE

It is crucial for cytopathologists to recognize benign, reactive, or metaplastic lesions that sometimes resemble UC. An awareness of these cytological changes is essential to make an accurate diagnosis.

The proteomic landscape shows oncologic relevance in cystitis glandularis

BACKGROUND

The relationship between cystitis glandularis (CG) and bladder malignancy remains unclear.

METHODS

We identified the oncologic significance of CG at the molecular level using liquid chromatography-tandem mass spectrometry-based proteomic analysis of 10 CG, 12 urothelial carcinoma (UC), and nine normal urothelium (NU) specimens. Differentially expressed proteins (DEPs) were identified based on an analysis of variance false discovery rate < 0.05, and their functional enrichment was analyzed using a network model, Gene Set Enrichment Analysis, and Gene Ontology annotation.

RESULTS

We identified 9,890 proteins across all samples and 1,139 DEPs among the three entities. A substantial number of DEPs overlapped in CG/NU, distinct from UC. Interestingly, we found that a subset of DEP clusters (n = 53, 5%) was differentially expressed in NU but similarly between CG and UC. This "UC-like signature" was enriched for reactive oxygen species (ROS) and energy metabolism, growth and DNA repair, transport, motility, epithelial-mesenchymal transition, and cell survival. Using the top 10 shortlisted DEPs, including SOD2, PRKCD, CYCS, and HCLS1, we identified functional elements related to ROS metabolism, development, and transport using network analysis. The abundance of these four molecules in UC/CG than in NU was consistent with the oncologic functions in CG.

CONCLUSIONS

Using a proteomic approach, we identified a predominantly non-neoplastic landscape of CG, which was closer to NU than to UC. We also confirmed a small subset of common DEPs in UC and CG, suggesting that altered ROS metabolism might imply potential cancerous risks in CG.

Single-cell RNA sequencing reveals the immune microenvironment and signaling networks in cystitis glandularis

Introduction

Cystitis glandularis (CG) is a rare chronic bladder hyperplastic disease that mainly manifests by recurrent frequent urination, dysuria and gross hematuria. The current lack of unified diagnosis and treatment criteria makes it essential to comprehensively describe the inflammatory immune environment in CG research.

Methods

Here, we performed scRNA-sequencing in CG patients for the first time, in which four inflamed tissues as well as three surrounding normal bladder mucosa tissues were included. Specifically, we isolated 18,869 cells to conduct bioinformatic analysis and performed immunofluorescence experiments.

Results

Our genetic results demonstrate that CG does not have the classic chromosomal variation observed in bladder tumors, reveal the specific effects of TNF in KRT15 epithelial cells, and identify a new population of PIGR epithelial cells with high immunogenicity. In addition, we confirmed the activation difference of various kinds of T cells during chronic bladder inflammation and discovered a new group of CD27-Switch memory B cells expressing a variety of immunoglobulins.

Discussion

CG was regarded as a rare disease and its basic study is still weak.Our study reveals, for the first time, the different kinds of cell subgroups in CG and provides the necessary basis for the clinical treatment of cystitis glandularis. Besides, our study significantly advances the research on cystitis glandularis at the cellular level and provides a theoretical basis for the future treatment of cystitis glandularis.

A genome-wide association study with tissue transcriptomics identifies genetic drivers for classic bladder exstrophy

Classic bladder exstrophy represents the most severe end of all human congenital anomalies of the kidney and urinary tract and is associated with bladder cancer susceptibility. Previous genetic studies identified one locus to be involved in classic bladder exstrophy, but were limited to a restrict number of cohort. Here we show the largest classic bladder exstrophy genome-wide association analysis to date where we identify eight genome-wide significant loci, seven of which are novel. In these regions reside ten coding and four non-coding genes. Among the coding genes is EFNA1, strongly expressed in mouse embryonic genital tubercle, urethra, and primitive bladder. Re-sequence of EFNA1 in the investigated classic bladder exstrophy cohort of our study displays an enrichment of rare protein altering variants. We show that all coding genes are expressed and/or significantly regulated in both mouse and human embryonic developmental bladder stages. Furthermore, nine of the coding genes residing in the regions of genome-wide significance are differentially expressed in bladder cancers. Our data suggest genetic drivers for classic bladder exstrophy, as well as a possible role for these drivers to relevant bladder cancer susceptibility.

A genome-wide association study on classic bladder exstrophy reveals eight genome-wide significant loci, most of which contained genes expressed in embryonic developmental bladder stages.

Survival of Patients With UrAC and Primary BAC and Urothelial Carcinoma With Glandular Differentiation

Purpose

To investigate the significance of demographic and pathological characteristics on the survival outcomes of urachal adenocarcinoma (UrAC), primary bladder adenocarcinoma (BAC) and urothelial carcinoma with glandular differentiation (UCGD) in China.

Materials and Methods

We retrospectively analyzed cases with non-distant metastases (≤ T4M0). Of 106 patients, 30 (28.3%), 40 (37.7%), and 36 (34.0%) met the criteria for UrAC, primary BAC, and UCGD, respectively. Data on patient demographics, tumor pathology, and survival outcomes were collected. The median follow-up was 36 months. Survival was analyzed using multivariate Cox regression.

Results

Patients with UrAC were younger (51.87 ± 15.25 years) than those with primary BAC (60.50 ± 12.56 years) and UCGD (63.83 ± 11.60 years) (P<0.001). Patients with UrAC were the most likely to be stage T3–4 (70.0% vs. 40.0% vs. 44.4%; P<0.001), while the primary BAC group had a higher rate of poor differentiation than the UrAC and UCGD groups (57.4% vs. 18.5% vs. 24.1%; P<0.001). The Kaplan–Meier curves showed that the overall survival (OS), progression-free survival (PFS), and disease-specific survival (DSS) of the primary BAC group were poorer than those of both the UrAC and UCGD groups (P=0.0046,P<0.0001,P=0.0077 respectively). Regarding BAC, patients with mucinous adenocarcinoma tended to have better OS and PFS than those with other histological types (P<0.005,P=0.0245). Multivariate Cox regression analysis revealed that tumor type (P=0.002), T stage (P=0.034), and the age-adjusted Charlson Comorbidity Index (aCCI) scores (P=0.005) predicted the postoperative OS and DSS of the patients. For PFS, the tumor type (P=0.011), grade (P=0.000), and aCCI (P=0.002) scores were predictive.

Conclusion

Among UrAC, primary BAC, and UCGD patients, the prognosis was poorest for those with primary BAC. Attempts should be made to diagnose these aggressive tumors early, since patients in whom tumors are detected early appear to survive longer.

Genetic Counseling for Bladder Exstrophy-Epispadias Complex

Bladder exstrophy-epispadias complex (BEEC) represents the severe end of the uro-rectal malformation spectrum and has profound impact on continence, sexual, and renal function. Treatment of BEEC is primarily surgical, and the main goals are safe closure of the abdominal wall, urinary continence while preserving renal function, and adequate cosmetic and functional genital reconstruction. Psychosocial and psychosexual outcomes and adequate health-related quality of life depend on long-term multidisciplinary care. The overall outcome is now considered very positive and affected individuals usually lead self-determined and independent lives with the desire to start their own families later in life. Certainty about the risk of recurrence and the provision of information about the current state of knowledge about the identified genetic causes with high penetrance will have an impact on family planning for healthy parents with an affected child and for affected individuals themselves. This review addresses this information and presents the current state of knowledge.

Telomerase reverse transcriptase (TERT) promoter mutations in primary adenocarcinoma of bladder and urothelial carcinoma with glandular differentiation: pathogenesis and diagnostic implications

Telomerase reverse transcriptase (TERT) promoter mutations have been implicated in urothelial carcinogenesis and are present in 60-80% of conventional and variants of urothelial carcinomas. We investigated the prevalence of TERT promoter mutations in 46 cases of bladder nonurachal adenocarcinoma, 30 cases of urothelial carcinoma with glandular differentiation, 24 cases of nephrogenic adenoma, eight cases of villous adenoma, 31 cases of florid cystitis glandularis, and 20 cases of intestinal metaplasia of the bladder. TERT promoter mutations were detected in 33% of adenocarcinomas of urinary bladder and in 67% of urothelial carcinomas with glandular differentiation. All 30 cases of urothelial carcinoma with glandular differentiation harbored identical TERT promoter mutation in both glandular and urothelial carcinoma components from the same tumor, suggesting a common clonal origin. TERT promoter mutations were absent in nephrogenic adenoma, villous adenoma, florid cystitis glandularis, and intestinal metaplasia of the bladder. TERT promoter mutation analysis may be a useful ancillary study in the differential diagnosis.

Molecular pathology of urothelial carcinoma

The current personalized oncology era has witnessed significant efforts to integrate clinical, pathological, and molecular classifications. The growing need for molecular biomarkers to feed personalized oncology, together with the unprecedented wealth of knowledge on the molecular basis of bladder cancer, has led to a novel approach to this disease, incorporating molecularly generated data in clinical practice for locally advanced or metastatic disease. Translational research allows a better understanding of the early events in the development of urothelial carcinoma in the urinary bladder. Thus, mutations in the KMT2D and KDM6A chromatin-modifying genes confer competitive advantages that drive cells to colonize larger regions of the urothelium. Additional mutations in TP53, PIK3CA, FGFR3, or RB1 genes then trigger the process of malignant transformation in the urothelium. In the current review, we provide an overview of what could be the expected transition from the morphology-based classification to a combined, molecularly enriched reporting of clinically meaningful parameters aiming to promote personalized oncology of urothelial carcinoma.

Molecular Genetic Features of Primary Nonurachal Enteric-type Adenocarcinoma, Urachal Adenocarcinoma, Mucinous Adenocarcinoma, and Intestinal Metaplasia/Adenoma: Review of the Literature and Next-generation Sequencing Study

The diagnosis of primary adenocarcinoma of the urinary bladder may be challenging in routine practice. These tumors may morphologically and immunohistochemically overlap with urachal adenocarcinoma and colorectal adenocarcinoma. Further, their genetic background is poorly understood. We systematically searched the PubMed database for results of complex genetic evaluation of primary bladder adenocarcinoma subtypes. Subsequently, we designed our own series of bladder lesions. We evaluated 36 cases: 16 primary enteric-type adenocarcinomas, 7 urachal enteric adenocarcinomas, 3 primary mucinous/colloid adenocarcinomas, and 10 intestinal-type metaplasia/villous adenoma. Detailed clinical data were collected, and all cases were examined using targeted next-generation sequencing. On the basis of the literature, the first mutated gene in these tumors was reported to be KRAS in 11.3% of cases, followed by TERT promoter mutations in 28.5%. In addition to KRAS and TERT, other genes were also found to be frequently mutated in primary bladder adenocarcinoma, including TP53, PIK3CA, CTNNB1, APC, FBXW7, IDH2, and RB1. In our series, the most frequent gene mutations in primary enteric-type adenocarcinomas were as follows: TP53 (56%); BRCA2, KMT2B (both 33%); NOTCH2, KDR, ARID1B, POLE, PTEN, KRAS (all 28%); in urachal enteric adenocarcinoma they were as follows: TP53 (86%); PTEN, NOTCH (both 43%); in primary mucinous/colloid adenocarcinomas they were as follows: KRAS, GRIN2A, AURKB (all 67%); and, in intestinal-type metaplasia/villous adenoma, they were as follows: APC, PRKDC (both 60%); ROS1, ATM, KMT2D (all 50%). No specific mutational pattern was identified using cluster analysis for any of the groups. Herein, we describe the pathologic features and immunohistochemical staining patterns traditionally used in the differential diagnoses of glandular lesions of the bladder in routine surgical pathology. We outline the mutational landscape of these lesions as an aggregate of published data with additional data from our cohort. Although diagnostically not discriminatory, we document that the most common genetic alterations shared between these glandular neoplasms include TP53, APC (in the Wnt pathway), and KRAS (in the MAPK pathway) mutations.

Facing treatment of non-urothelial bladder cancers in the immunotherapy era

Non-urothelial Bladder Cancer (BC) and variants of urothelial carcinoma account for up to 25 % of all BCs. Given their heterogeneity, these entities are not well represented in clinical trials and treatment remains challenging. Checkpoint inhibitor therapy has shown a role in the treatment of urothelial BC. By contrast, robust evidence regarding its use in other histological types is lacking. We aimed to provide a comprehensive update of non-urothelial and variant urothelial BC, exploring the evidence for immune checkpoint inhibitor therapy. A detailed analysis of the literature was conducted regarding epidemiology, aetiology, diagnosis, prognosis, treatment and outcomes of these patients in the immunotherapy era. A growing body of evidence suggests that immune checkpoint inhibition might have a role to play in non-urothelial BC, similarly to what happened with urothelial carcinomas.

Development and validation of a predictive nomogram for the risk of recurrence in patients with cystitis glandularis

Background

Most patients with cystitis glandularis (CG) suffer from recurrence after primary treatment. Therefore, we performed this multicenter study to clarify the recurrent risk factors and constructed a predictive nomogram for the risk of recurrence. Also, we try to investigate the correlation between CG and bladder cancer.

Methods

Consecutive patients with pathologically confirmed CG were divided into training and validation sets. Clinicopathological characters were collected from electronic medical records. Uni- and multivariate logistic regression analyses were used to identify independent risk factors of CG recurrence in the training set. The predictive nomogram was developed by incorporating these independent factors and histological subtype. The performance of the nomogram was assessed and validated with respects to its calibration, discrimination, and clinical usefulness. The risk of developing subsequent bladder cancer was analyzed from the follow-up data.

Results

Ultimately, 278 eligible patients were included and were allocated to a training set (n=190) and a validation set (n=88). Of them, 165 (59.35%) patients experienced CG recurrence, and none showed evidence of subsequent bladder carcinoma during a median (IQR) follow-up time of 27 months (14–57 months). Results of multivariate analysis showed that urinary infections, long-term indwelling catheter usage, urinary calculus, squamous metaplasia, and atypical hyperplasia were independent risk factors of CG recurrence. The C-index (95% CI) of the nomogram was 0.76 (0.69–0.83) in the training set and 0.72 (0.61–0.83) in the validation set. A decision curve analysis (DCA) demonstrated that this predictive nomogram was clinically useful.

Conclusions

We developed and validated a nomogram to predict the individualized risk of CG recurrence. Also, we demonstrated that neither intestinal nor typical CG increased the consequent risk of bladder cancer during the follow-up period.

Non-urothelial carcinomas of the bladder

Non-urothelial carcinomas involving the bladder are uncommon and often diagnostically challenging. These carcinomas may show squamous, adenocarcinomatous or neuroendocrine features, with immunohistochemical stains aiding the diagnosis in only a subset of cases. The clinical history in non-urothelial bladder carcinomas is important, given that the differential diagnosis often includes secondary involvement of the bladder by direct extension or metastasis from carcinomas at other sites. This paper will review non-urothelial carcinomas in each of these three morphological categories, emphasising recent changes in diagnostic grouping and challenges in the histopathological diagnosis. Review of bladder cancers with squamous morphology will include discussion of conventional squamous cell carcinoma and verrucous carcinoma and their distinction from urothelial carcinoma with extensive squamous differentiation. Bladder carcinomas with adenocarcinomatous change will include primary bladder adenocarcinoma, urachal adenocarcinoma and tumours of Müllerian type. Finally, neuroendocrine neoplasms of the bladder, including well-differentiated neuroendocrine tumour and neuroendocrine carcinomas, will be discussed. Associated surface findings, risk factors and prognostic features will be described.

[Comparative morphological characteristics and immunophenotype of urothelial carcinomas of the renal pelvis and bladder]

Urothelial carcinoma is one of the most frequently diagnosed malignant tumors of the bladder and upper urinary tract, which ranks seventh in the pattern of cancer. Urothelial carcinoma of the renal pelvis is less common; but has a more aggressive clinical course and a worse prognosis than that of the bladder. This is due to the clinical and morphological features of this form of cancer, which, unlike bladder cancer, have not been studied enough.

OBJECTIVE

To comparatively analyze the morphological and immunophenotypic parameters of urothelial carcinomas of the renal pelvis and bladder.

SUBJECT AND METHODS

Surgical specimens from 196 patients diagnosed with urothelial carcinoma of the renal pelvis and bladder were investigated. Paraffin sections were immunohistochemically examined using the standard protocol. Antibodies against CK5/6, CD138, CDX2 ('Dako'), CK7, CK14, CK20, CEA, CD10, CD117, EMA, E-Cadherin, HMWCK, p63, Uroplakin III, Vimentin ('Novocastra'), CD44, GATA-3, MUC1, MUC2, and MUC-5AC ('Cell Marque') were used.

RESULTS

Most tumors (n=147 (75%)) were invasive. Of them, 65 (33%) cases had a histological structure of conventional urothelial cancer; and 3 (1.5%) had paradoxical differentiation. Divergent tumor zones were verified in 66 (34%) neoplasms; 4 (2%) cases showed an inverted growth pattern. Pseudosarcomatous stroma reaction in the invasion zones was verified in 9 (5%) cases. The tumor stage corresponded to pT2-pT4 in 128 (65%) tumors.

CONCLUSION

Urothelial carcinomas of the renal pelvis and bladder show a broad spectrum of histological variants. The findings support that, unlike urothelial carcinomas of the bladder, the majority of primary urothelial carcinomas of the renal pelvis are high-grade and highly invasive.

[TYPICAL TYPE CYSTITIS GLANDULARIS PRESENTING URINARY RETENTION IN A YOUNG MAN: ADJUVANT THERAPY USING ORAL CYCLOOXYGENASE-2 INHIBITOR: A CASE REPORT]

A 31-year-old man was referred to our hospital with urinary retention. Cystoscopy revealed multiple edematous papillary tumors on the bladder trigone and neck, which were removed by transurethral resection. The pathological diagnosis was typical type cystitis glandularis. This relapsed six months after surgery and transurethral resection was repeated. Because immunohistochemical findings revealed positive epithelial cyclooxygenase-2 (COX-2) signals, we prescribed an oral COX-2 inhibitor. The tumor revealed shrinkage for six months after medication.

Morphological and Immunohistochemical Biomarkers in Distinguishing Prostate Carcinoma and Urothelial Carcinoma: A Comprehensive Review

The differential diagnosis between high-grade prostate carcinoma and infiltrating urothelial carcinoma (UC) in transurethral resection prostate specimens as well as cystoprostatectomy specimens may often be challenging due to morphologic and clinical overlap of the 2 entities. Such distinction has critical therapeutic and staging consequences, yet it is hampered by both issues in morphology and by the low accuracy rates of single immunohistochemical markers, as reported in literature. This review aims to provide a comprehensive analysis of the available morphological and immunohistochemical parameters, which may allow to discriminate between prostate carcinoma and urothelial carcinoma in the proper clinical context and to discuss their diagnostic applications in daily practice.

Vasitis nodosa and related lesions: a modern immunohistochemical staining profile with special emphasis on novel diagnostic dilemmas

Vasitis nodosa is a benign proliferation of vas deferens epithelium, thought to be a response to trauma or obstruction, usually vasectomy. Although histologic features mimic malignancy, diagnosis is usually straightforward due to the clinical context. We analyzed 21 specimens with vasitis or epididymitis nodosa with antibodies to PAX8, CD10, p63, α-methyl-acyl-coA-racemase (AMACR), GATA3, prostein, NKX3.1, and prostate-specific antigen (PSA). Two diagnostically problematic cases included (1) florid bladder muscle involvement after prostatectomy and (2) involvement of the ampulla and ejaculatory duct in a radical prostatectomy specimen. Vasitis nodosa was excluded in 3 additional histologic mimics (2 post-treatment prostate cancers and 1 bladder cancer). PAX8 yielded consistent positive (100%) nuclear staining in the proliferative glands of vasitis nodosa, often stronger and more uniform than native vas deferens. CD10 labeling was common but also labeled secretions and other structures. Labeling for p63 was often basally located in glands with a multilayered appearance, but often markedly attenuated or lacking in the proliferative glands compared to native epithelium. AMACR positivity was variable but often present (19/21). PSA, prostein, and NKX3.1 were consistently negative. Rare problematic cases of vasitis nodosa include "invasion" of the ejaculatory duct at the prostate and involvement of bladder muscle after prostatectomy. The proliferative vasitis nodosa glands often have a prostate cancer-like staining pattern with variable AMACR positivity and negative or patchy p63. However, reliable positivity for PAX8, patchy GATA3, and negative staining for PSA, NKX3.1, and prostein aid in distinguishing from prostate cancer and tubular variants of bladder cancer.

Role of SATB2 in distinguishing the site of origin in glandular lesions of the bladder/urinary tract

The differential diagnosis of glandular lesions of the bladder/urinary tract can be challenging because of significant morphologic and immunohistochemical overlap between primary lesions and metastasis/direct extension from adjacent organs. Special AT-rich sequence-binding protein 2 (SATB2), encoded on chromosome 2q32-33, is a recently described DNA-binding protein involved in osteoblast lineage commitment and expressed in colorectal and appendiceal neoplasms. In this study, we hypothesized that immunohistochemistry for SATB2 may be of value in distinguishing primary adenocarcinoma of the bladder/urinary tract and urothelial carcinoma with glandular differentiation from gastrointestinal and endocervical primaries. Intensity and distribution of SATB2 nuclear labeling were semiquantitatively scored and compared with those of CDX2. The study included 43 primary adenocarcinomas of the bladder/urinary tract, 20 urothelial carcinomas with glandular differentiation, 26 adenocarcinomas of the uterine cervix, and 22 colorectal adenocarcinomas involving the bladder. Positive SATB2 immunostaining was observed in 21 of 43 (49%) primary bladder/urinary tract adenocarcinomas, in 17 of 22 (77%) colorectal adenocarcinomas, and in the glandular component of 4 of 18 (22%) urothelial carcinomas with glandular differentiation. SATB2 was negative in 25 of 26 endocervical adenocarcinomas and showed focal weak immunostaining (1+) in 1 of 26 (4%). The results were not significantly different from those seen with CDX2. We conclude that SATB2 immunohistochemistry is not useful in supporting urothelial versus gastrointestinal or endocervical origin in the differential diagnosis of glandular lesions of the bladder/urinary tract.

Intestinal metaplasia of the bladder in 89 patients: a study with emphasis on long-term outcome

Background

Intestinal metaplasia of the bladder is an uncommon glandular proliferation. We examined a large series of intestinal metaplasia for the clinicopathological features and discuss the significance of this lesion.

Methods

All cases of intestinal metaplasia diagnosed in our institution between 1990 and 2014 were retrospectively reviewed. Patients with a history of urothelial carcinoma or concurrent adenocarcinoma were excluded. Patient characteristics, pathological features, and follow-up outcomes were obtained.

Results

We identified 89 patients with intestinal metaplasia during this period. Sixty seven were men and 22 were women. Mean age at diagnosis was 57 years (range 23–81). Common presenting complaints included haematuria (73 cases), mucosuria (13 cases), and irritative voiding symptoms (seven cases). The majority of intestinal metaplasias located on or near the trigone (67 cases). Eighty-two patients underwent transurethral resection of their lesions. Partial cystectomy was performed in the remaining seven patients. The mean follow-up of 78 patients was 105 months (range 6–255). One case of bladder adenocarcinoma was indentified 6 months later. The initial histologic findings had revealed intestinal metaplasia with severe dysplasia. Four patients presented recurrence during the follow-up, and this occurred 9, 13, 17 and 24 months after the surgery.

Conclusions

Although intestinal metaplasia can be treated effectively by transurethral resection in most cases, its potential malignancy need to be taken into consideration after the evidence of recurrences and its association with bladder adenocarcinoma. Therefore, it is necessary to perform close surveillance following the surgery, particularly in patients with dysplastic changes.

Novel strategy for cystitis glandularis: Oral treatment with cyclooxygenase-2 inhibitor

Cystitis glandularis, a proliferative disease of the bladder, is resistant to antibiotics, non-steroidal anti-inflammatory drugs, anti-allergy drugs and transurethral resection. Cystectomy or partial cystectomy is occasionally required for refractory cystitis glandularis. It has not been defined if cystitis glandularis is a premalignant lesion. We experienced a case of remission from cystitis glandularis after combination of oral treatment with selective cyclooxygenase-2 inhibitor, celecoxib and transurethral resection. Immunohistochemistry showed positive signals of cyclooxygenase-2 in the epithelium of pretreatment specimens, suggesting the pathophysiological role of cyclooxygenase-2 in cystitis glandularis. Here, we show the effectiveness of celecoxib against cystitis glandularis for the first time. Celecoxib could be one of the therapeutic strategies for cystitis glandularis.

Cytopathological features of villous adenoma of the urinary bladder in urine: A rare case report

Villous adenoma of the urinary bladder is a rare tumor that histologically mimics its enteric counterpart. Patients with an isolated villous adenoma have an excellent prognosis, but associated adenocarcinomas can frequently be identified in them as well. There is no literature that discusses the cytopathologic features of villous adenoma. Here we report a case which was diagnosed as villous adenoma histologically, which has been followed up with urine cytology. In urine cytology, many mucin producing cells are recognized. Few cell clusters show glandular formation or arrangement along the basement membrane. When glandular cells with columnar mucin-filled goblet cells are seen in urine cytology, the presence of a primary glandular lesion of the urinary bladder, such as villous adenoma, should be considered possible. Diagn. Cytopathol. 2016;44:632-635. © 2016 Wiley Periodicals, Inc.

Updates in Benign Lesions of the Genitourinary Tract

The genitourinary tract is a common site for new cancer diagnosis, particularly for men. Therefore, cancer-containing specimens are very common in surgical pathology practice. However, many benign neoplasms and nonneoplastic, reactive, and inflammatory processes in the genitourinary tract may mimic or cause differential diagnostic challenges with malignancies. Emerging clinicopathologic, immunohistochemical, and molecular characteristics have shed light on the pathogenesis and differential diagnosis of these lesions. This review addresses differential diagnostic challenges related to benign genitourinary tract lesions in the kidney, urinary bladder, prostate, and testis, with emphasis on recent advances in knowledge and areas most common in diagnostic practice.

Telomerase reverse transcriptase promoter mutations in glandular lesions of the urinary bladder

Glandular lesions of the urinary bladder include a broad spectrum of entities ranging from completely benign to primary and secondary malignancies. The accurate diagnosis of these lesions is both important and challenging. Recently, studies suggest that telomerase reverse transcriptase (TERT) promoter mutations could be a biomarker for urothelial carcinoma (UC). We hypothesized that these mutations can distinguish UC with glandular differentiation from nephrogenic adenoma, primary adenocarcinoma of the urinary bladder (PAUB), or secondary malignancies. Twenty-five cases of benign glandular lesions (including nephrogenic adenoma); 29 cases of UC with glandular differentiation; 10 cases of PAUB; and 10 cases each of metastatic colon cancer, prostatic carcinoma, and carcinoma from Mullerian origin were collected. Slides were reviewed and selected to make sure the lesion was at least 10% to 20% of all tissue. Macrodissection was performed in some of cases, and genomic DNA was extracted from the tissue. Telomerase reverse transcriptase promoter mutations were determined by standard polymerase chain reaction sequencing. Twenty-one cases (72%) of UC with glandular differentiation were positive for TERT promoter mutations. However, none of the remaining cases (total 65 cases of benign lesions, PAUB, and metastatic carcinomas) was positive for TERT promoter mutation. Telomerase reverse transcriptase promoter mutations were highly associated with UC including UC with glandular differentiation but not other glandular lesions of bladder. Therefore, in conjunction with morphologic features, Immunohistochemistry stain profile, and clinical information, TERT promoter mutations could distinguish UC with glandular differentiation from other bladder glandular lesions. In addition, lack of TERT promoter mutations in primary adenocarcinoma of bladder suggests that this entity may have different origin or carcinogenesis from those of UC.

Deceptive muscle invasive bladder cancer recurrence with benign biopsy foci after bladder sparing treatment

Most of recurrent bladder carcinoma after partial cystectomy did not cause diagnostic difficulties for urologists, because of the appearance of typical papillary in ultrasonography or cystoscopy, and could be easily confirmed by tumor biopsy. Three patients, ages from 35 to 62 years, had undergone bladder sparing treatment for muscle invasive bladder cancer, all of them had biopsy revealed benign bladder lesion at surveillance cystoscopy. However, transurethral resection of bladder tumor showed high-grade muscle invasive urothelial bladder carcinoma for these patients. Two patients were thus delayed for timely cystectomy and consequently resulted in local or distal metastasis.As a result, we recommended that timely pelvic enhanced computed tomography and transurethral resection of bladder tumor were necessary when bladder lesion occurred after partial cystectomy, avoiding the possibility of missing muscle invasive urothelial bladder carcinoma recurrence and delaying timely cystectomy.

Intestinal metaplasia of the bladder with dysplasia: a risk factor for carcinoma?

AIMS

Intestinal metaplasia (IM) of the bladder is a benign glandular proliferation, where the urothelium becomes lined by intestinal-type epithelium. There is no association between IM and an increased risk for the development of adenocarcinoma. However, in rare cases IM shows dysplasia, similar to that of the gastrointestinal tract. We evaluated the significance of urothelial IM with dysplasia.

METHODS AND RESULTS

Consultation cases were searched for IM of the bladder with dysplasia. We identified 20 cases, including 17 males and females, aged 31-85 years (mean 60 years). Twelve (60%) patients had low-grade dysplasia and eight (40%) patients had high-grade dysplasia. Focal dysplasia was found in eight (40%) patients and non-focal dysplasia in 12 (60%) patients. IM with dysplasia was found with concurrent adenocarcinoma in eight (40%) cases. Five of these patients (63%) had disease recurrence and three (38%) patients died from their disease. IM with dysplasia was found with concurrent urothelial carcinoma in one case. Eleven patients had IM with dysplasia without evidence of malignancy. Of these, one went on to develop non-invasive, high-grade papillary urothelial carcinoma.

CONCLUSIONS

Clinical follow-up is recommended in cases of IM with dysplasia, as a significant number of these cases are associated with concurrent carcinoma.

Intestinal metaplasia of the renal pelvis: A case report and literature review

Metaplastic changes in the renal pelvis are infrequent and may be malignant transformations to adenocarcinoma. The current study reports a case of intestinal metaplasia in the right renal pelvis, which was associated with staghorn calculi, in a 56-year-old female. The patient underwent a percutaneous nephrolithotomy. Immunohistochemical assessment of the mucosa of the renal pelvis revealed the positive expression of carcinoembryonic antigen, cytokeratin (CK)-7 and CK20, but negative expression for CK5/6 and vimentin. Furthermore, Ki67 expression was diffusely positive, while p53 was negative. Unlike other previously reported cases, the patient opted for active surveillance as opposed to radical nephrectomy, following the removal of the calculi. No evidence of progression was observed after three years of follow-up. Therefore, etiological treatment and close follow-up may be a suitable treatment option for localized intestinal metaplasia.

EGFR alterations and EML4-ALK rearrangement in primary adenocarcinoma of the urinary bladder

The identification of mutations in epidermal growth factor receptor (EGFR) and translocations involving anaplastic lymphoma kinase (ALK) in lung adenocarcinoma has drastically changed understanding of the disease and led to the development of targeted therapies. Adenocarcinoma of the urinary bladder is rare and poorly understood at the molecular level. We undertook this study to determine whether EGFR mutations, increases in EGFR copy number, or ALK translocations are present in these tumors. Twenty-eight cases of primary bladder adenocarcinoma were analyzed. For EGFR mutational analysis, PCR-amplified products were analyzed on the Q24 Pyrosequencer with Qiagen EGFR Pyro Kits. All cases were analyzed via fluorescence in situ hybridization (FISH) using Vysis ALK Break Apart FISH Probes for detection of ALK chromosomal translocation and Vysis Dual Color Probes to assess for increased gene copy number of EGFR. None of the 28 cases examined showed mutational events in EGFR or ALK rearrangements. EGFR polysomy was seen in 10 out of 28 (36%) cases. No correlation with EGFR polysomy was seen in the tumors with respect to age, histologic subtypes, pathologic stage, or lymph node metastasis. In summary, EGFR mutations and ALK rearrangements do not appear to be involved in the development of primary adenocarcinoma of the urinary bladder. A subgroup of cases (36%), however, demonstrated increased gene copy number of EGFR by FISH.

Clinical character of cystitis glandularis accompanied with upper urinary tract obstruction

OBJECTIVE

We explore the clinical character of cystitis glandularis accompanied with upper urinary tract obstruction.

METHODS

We compared 70 cases of cystitis glandularis accompanied with upper urinary tract obstruction with 60 cases of cystitis glandularis without upper urinary tract obstruction. The difference of clinical manifestation and surgical efficacy was observed between the 2 groups.

RESULTS

The incidence of cystitis glandularis in women was higher than in men and the age of patients with cystitis glandularis and upper urinary tract obstruction was younger than the age of patients without upper urinary tract obstruction. The main symptom of cystitis glandularis accompanied with upper urinary tract obstruction were renal colic and abdominal pain; a few patients with a shorter course of the disease also had nausea, vomiting, frequency, urgency, dysuria, hematuria and fever. The distribution and morphological characteristics of lesions on the bladder and in the urine culture were not different between the 2 groups. There was no second operation on patients with upper urinary tract obstruction, but at least a second operation was performed on 9.3% patients without upper urinary tract obstruction.

CONCLUSIONS

In patients with upper urinary tract obstruction, we found that it was the main clinical symptom of their cystitis glandularis. Identifying and removing the causes of upper urinary tract obstruction is the most important management method. For the cystitis glandularis, active treatment or close follow-up should be made.

[Non-invasive and invasive urothelial tumours: special challenges in uropathological diagnostics]

The current 2004 WHO classification of bladder tumors categorizes non-invasive and invasive urothelial neoplasms into prognostically relevant groups according to the histopathological cell morphology and underlying genetic changes. Although many parts of the classification have not been changed dramatically, even small changes have caused uncertainty and scepticism among urologists and pathologists in recent years. The following review article is structured into various challenges for urologists and pathologists and provides an overview of rare but clinically relevant subgroups and diagnostics, interpretation of diagnoses and pathological findings with respect to consequences for the daily clinical routine (extended diagnosis, therapy and prognosis).

Distinguishing primary adenocarcinoma of the urinary bladder from secondary involvement by colorectal adenocarcinoma: extended immunohistochemical profiles emphasizing novel markers

Glandular neoplasms involving the urinary bladder carry a challenging differential diagnosis including primary and secondary processes. We investigated the potential diagnostic utility of cadherin-17 and GATA3 in 25 primary adenocarcinomas of the urinary bladder, as compared with other commonly used markers including β-catenin and p63. Urothelial carcinoma with glandular differentiation (11), colorectal adenocarcinoma secondarily involving the bladder (25), and primary colorectal adenocarcinoma (22) were also analyzed and the results were compared using a Fisher exact test. Cadherin-17 was expressed in 23/25 primary bladder adenocarcinomas (92%), 23/25 colorectal adenocarcinomas involving the bladder (92%), 21/22 primary colorectal adenocarcinomas (95%) and entirely negative (0/11) in both components of urothelial carcinoma with glandular differentiation (P<0.001). In urothelial carcinoma with glandular differentiation, positive nuclear staining for GATA3 was evident in the urothelial component for 18% (2/11) and the glandular component for 9% (1/11) with additional tumors showing only cytoplasmic staining. Nuclear reactivity for GATA3 was not present in primary bladder adenocarcinoma and primary/secondary colorectal adenocarcinoma (P<0.05). Positive nuclear and cytoplasmic immunostaining for β-catenin was evident in 21/22 primary colorectal adenocarcinomas (95%) and 23/25 cases of secondary involvement by colorectal adenocarcinoma (92%). In contrast, positive membranous and cytoplasmic staining for β-catenin was observed in 23/25 primary bladder adenocarcinomas (92%) and 11/11 urothelial carcinomas with glandular differentiation (100%, P<0.001). p63 was expressed only in the urothelial component of urothelial carcinoma with glandular differentiation and not in the glandular component (P<0.001). In summary, cadherin-17 is a relatively specific and sensitive marker for primary adenocarcinoma of the urinary bladder, distinguishing it from urothelial carcinoma with glandular differentiation. However, it does not distinguish primary bladder adenocarcinoma from secondary involvement by colorectal adenocarcinoma. The pattern of reactivity for β-catenin remains the most useful marker for distinguishing these two tumors.

Primary adenocarcinoma of the urinary bladder: differential diagnosis and clinical relevance

CONTEXT

Glandular lesions of the urinary bladder include a broad spectrum of entities ranging from completely benign glandular lesions to primary and secondary malignancies. Common benign bladder lesions that exhibit glandular differentiation include cystitis cystica, cystitis glandularis, von Brunn nests, nephrogenic adenoma, intestinal metaplasia, urachal remnant, endometriosis, and prostatic-type polyp. The World Health Organization defines primary adenocarcinoma of the bladder as an epithelial malignancy with pure glandular differentiation without evidence of typical urothelial carcinoma. Malignant lesions that should be included in the differential diagnosis of a primary adenocarcinoma of the bladder include noninvasive and invasive urothelial carcinoma with glandular differentiation and secondary malignancies involving the bladder by direct extension or metastasis. The recognition and distinction of these different entities may be a challenge for pathologists, but they are of great clinical importance.

OBJECTIVE

To review features of primary bladder adenocarcinoma as well as those entities that need to be differentiated from primary bladder adenocarcinoma, with emphasis on clinical findings, pathologic characteristics, and immunoprofiles.

DATA SOURCES

Selected original articles published in the PubMed service of the US National Library of Medicine.

CONCLUSIONS

The accurate diagnosis of adenocarcinoma of the urinary bladder is important and challenging. It has to prompt an extensive clinical workup to rule out other glandular lesions in the urinary bladder, especially the possibility of secondary involvement of the bladder by an adenocarcinoma from a different site.