Presentation
This patient presented with hematuria. Rigid cystoscopy was performed, and a biopsy sent to pathology.
Patient Data
The sections show multiple pieces of partly necrotic urothelium with heat artifact, diffusely infiltrated by tumor showing a variably papillary, solid and nested architecture. There is architectural disarray. Neoplastic cells show enlarged, pleomorphic and hyperchromatic nuclei and a moderate amount of cytoplasm. There are abundant mitotic figures and there is prominent apoptotic debris. Widespread invasion of lamina propria is present, and focally, tumor is seen to dissect between smooth muscle bundles, suspicious for muscularis propria involvement. Definitive lymphovascular space invasion is not seen. The specimen contained no flat urothelium for assessment of carcinoma in situ.
Images, in order, show:
20x H&E - This low-power view shows a highly cellular tumor with subtle papillary architecture highlighted by scattered fibrovascular cores.
20x H&E - This fragment displays peripheral diathermy artefact. The markings bracket thickened smooth muscle fibers which are surrounded by infiltrative tumor, highly suspicious for muscularis propria invasion.
100x H&E - Poorly differentiated tumor infiltrating between smooth muscle fiber bundles.
100x H&E - Poorly differentiated tumor with artefactual spaces.
200x H&E - This higher power view shows a central fibrovascular core, surrounded by architecturally haphazard cells showing scattered apoptotic debris and cellular atypia.
Case Discussion
Of note, a second, 'deep' specimen was also received, which showed thick smooth muscle bundles in keeping with muscularis propria. This showed no evidence of malignancy/tumor involvement. Given the patient's advanced age, the surgical team opted for a surveillance approach, aiming for symptom control, rather than pursuing more aggressive surgical options.
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