Introduction
Urinary bladder neoplasm is responsible for significant morbidity and mortality. Urothelial carcinoma is the commonest type accounting for 90% of all primary tumors of the bladder.1
Urinary bladder cancer is a complex and heterogeneous disease with a broad spectrum of histological findings and potentially lethal behavior. Despite advances in surgical techniques as well as intravesical and systemic therapies, patients with muscle invasive carcinoma experience disease progression, recurrence and eventual death.2
External risk factors are smoking, occupational carcinogens, artificial sweeteners, Schistosoma hematobium infection in endemic areas.3
Although progress has been made in non-invasive imaging, bladder cancer diagnosis and treatment are done through physical examination, cystoscopic evaluation and histopathologic analysis.
Materials and Methods
Source of data
A total of 37 cases of urinary bladder neoplasm [histologically proven] of patients admitted in V.S.Hospital were studied over the period from June 2016- Oct 2018 in Department of Pathology. A detailed history was taken. Findings were recorded in the Performa designated for the study. Macroscopically various parameters like size, configuration and consistency were noted. Tissues were fixed adequately followed by standard processing and staining. All cases of urothelial carcinomas were graded histologically according to WHO (2016)/ISUP classification.
Results
In the present study, of total 37 patients - 29 were male and 8 female with M: F ratio of 3.63:1.
Table 1
Incidence of urinary bladder neoplasms with respect to gender
Haematuria was the most common clinical symptoms in 86.48% cases followed by burning micturition (5.4%), abdominal pain (5.4%) and incidental USG finding (2.7%).
Table 2
Age-wise distribution of urinary bladder neoplasms
|
Age group (years) |
Total no. of patients |
Percentage (%) |
|
<30 |
1 |
2.70 |
|
30-39 |
3 |
8.11 |
|
40-49 |
7 |
18.92 |
|
50-59 |
8 |
21.62 |
|
60-69 |
10 |
27.03 |
|
70-79 |
7 |
18.92 |
|
80-89 |
1 |
2.70 |
|
Total |
37 |
100 |
Lateral wall was the most common location of urinary bladder tumor comprising 46%, followed by anterior wall 22%, posterior wall and bladder neck 13% each.
Amongst 37 neoplastic lesions, 33 cases (89%) were of urothelial neoplasm, 2 cases of Squamous cell carcinoma, 1 case each of Embryonal Rhabdomyosarcoma and Leiomyoma.
Of 33 urothelial neoplasm cases, 6 cases were noninvasive urothelial neoplasm and 27 cases were invasive urothelial neoplasm.
Out of 6 cases of noninvasive urothelial neoplasm, low grade noninvasive papillary urothelial carcinoma was noted in 3 case and 3 cases were of papillary urothelial neoplasm with a low malignant potential (PUNLMP).
14 cases of low grade papillary urothelial carcinoma (PUCLG) and 13 cases of high grade papillary urothelial carcinoma (PUCHG) were noted of 27 invasive urothelial carcinoma cases.
Table 3
Presence of muscle invasion in urothelial bladder carcinoma
|
|
Muscle Invasion |
|
|
|
Grade |
Present |
Absent |
Total |
|
Invasive Urothelial Carcinoma, Low Grade |
2(16.67%) |
10(83.33%) |
12 |
|
Invasive Urothelial Carcinoma, High Grade |
8(88.89%) |
1(11.11%) |
9 |
|
Total |
10 |
11 |
21 |
According to the invasion, Lamina Propria invasion was present in 26 cases while the muscular invasion was present in 10 patients.
The detrusor muscle was absent in 6 cystoscopic biopsy. Hence, muscle invasion could be assessed in the remaining 21 cases. 10 cases showed muscle invasion of which 2 cases were of low grade and 8 cases were high grade Invasive Urothelial Carcinoma.
In the present study, differentiation was present in 2 cases and both of them showed squamous differentiation.
Out of the 27 cases of Urothelial Carcinoma, 11 were superficial /or in the early stage (pTa and pT1) and 10 cases were muscle invasive (pT2).
Discussion
In present study emphasis is kept on the histological grading and staging of bladder tumors. Bladder tumor diagnosis and monitoring is done by combination of cystoscopy, histopathology and urine cytology,4 Histopathology remains mainstay for diagnostic and therapeutic purpose. Histopathology also poses limitations due to friable nature of bladder tumors, technical error and also interpretation errors from artifacts that mimic tumor. Excluding muscle fibers in cystoscopic biopsy can lead to incorrect histological grading and staging of the tumor. Most of the times these problems can be avoided by studying serial sections, using special stains and by encouraging inclusion of muscle layer during cystoscopic biopsy.
Present study showed peak age incidence of cases in 6th decade, 10 cases (27.02%) followed by the 5th decade, 8 cases (21.62%). Least number of cases was seen in 1st and 8th decade. This observation is well correlated with other studies.5, 6
Cigarette smoking, industrial exposure to acrylamine in male leads to higher chance of bladder tumor in them.
Nearly 89% tumors were malignant in the present study, Urothelial carcinoma being the most common malignant lesion followed by Squamous cell carcinoma and Embryonal Rhabdomyosarcoma.
Detrusor muscle layer was absent in the 6 cystoscopic biopsies. This can lead to incorrect staging and grading of tumor. Hence, including muscle layer in the cystoscopic biopsy specimens is very important.
Of the remaining 21 cases that included muscle layer, muscle invasion was seen in 14% cases of low grade and 62% cases of high grade urothelial carcinoma. Similar observation was also made by Laishram et al.,7 and by Vaidya et al.5 From this we can say that muscle invasion also correlates to high grade tumor.
Cystectomy specimens showed 5 cases of High Grade Invasive urothelial carcinoma and 2 cases each of Low grade Invasive urothelial carcinoma and Squamous cell carcinoma out of 9 specimens received.
Cystoscopic biopsies of 7 patients who underwent cystectomy were accessed in our department previously.
Of these 7 cases, one case diagnosed as Invasive Urothelial carcinoma with squamous differentiation in cystoscopic biopsy was diagnosed as Squamous cell carcinoma in radical cystectomy specimen.
While another case of Invasive Urothelial carcinoma with squamous differentiation in radical cystectomy specimen was reported as Squamous cell carcinoma in cystoscopic biopsy.
This usually happens when only a small portion of is obtained in a biopsy specimen; problems rarely arise when the entire lesion is available for examination.
One case diagnosed as High grade invasive urothelial carcinoma in TURBT underwent chemotherapy treatment followed by Total cystectomy which showed no evidence of residual tumor.
Perivesical adipose tissue involvement (T3) by tumor was seen in 2 cases.
Two radical Cystectomy Specimen had lymph node metastasis.
Associated pathology included chronic cystitis in 3 cases, 1 case each of associated chronic pyelonephritis, chronic prostatitis and granulomatous inflammation.
Conclusion
In present study, Urothelial carcinoma was the commonest lesions seen in cystoscopic biopsies as well as cystectomy specimen. Males are more commonly affected than females. Majority of patients were in the age group of 50 to 70 years. A large percentage of high grade urothelial carcinomas presented with muscle invasion. Inclusion of muscle layer in the cystoscopic biopsy helps in accurate diagnosis and staging of tumor. This usually happens when only a small portion of a neoplasm is obtained in a biopsy specimen; problems rarely arise when the entire lesion is available for examination.
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