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Bladder

Cystitis

Radiation cystitis


Reviewers: Turki Al-Hussain, M.D., Johns Hopkins Medical Centers (see Reviewers page)
Revised: 23 September 2012, last major update March 2011
Copyright: (c) 2003-2012, PathologyOutlines.com, Inc.

Definition
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● Acute or chronic histologic changes associated with radiation therapy

Clinical features
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● Histologic and clinical changes are time and dose dependent
● Symptoms include urinary frequency, urgency, voiding pain and gross hematuria
● Early signs may appear 4-6 weeks after initiation of therapy
● Late reactions may appear between 3 months and 10 years (Am J Surg Pathol 1978;2:159)
● Toxicity enhanced if radiation is given with cyclophosphamide
● Similar changes with intravesical chemotherapy, which often affects superficial layer of urothelium and causes denuding cystitis
● Need high threshold for diagnosis of carcinoma after radiation and chemotherapy
● If uncertain of diagnosis, do repeat cystoscopy and biopsy after inflammation subsides

Case reports
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● 71 year old man with radiation therapy for prostate carcinoma (Arch Pathol Lab Med 2005;129:1067)

Treatment
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● Severe hemorrhage is treated with topical application of formalin-soaked pledgets (Asian J Surg 2002;25:232)
● Argon-beam coagulator (BJU Int 2006;98:610)
● Possibly recombinant activated factor VII (Ir J Med Sci 2010;179:431)

Clinical images
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Cystoscopy

Micro description
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● Hemorrhage and hemosiderin, fibrin deposition, acute and chronic inflammation, edema and thickened mucosal folds, vascular ectasia, swollen endothelial cells, microvessel thrombi, atypical fibroblasts
● Degenerative type epithelial changes resembling carcinoma in situ but more bizarre including cytoplasmic ballooning, smudged chromatin, nuclear and cytoplasmic vacuoles, karyorrhectic cellular debris; these changes may persist for longer intervals in von Brunnís nest (Epstein: Bladder Biopsy Interpretation)
● May have pseudoinvasive urothelial nests wrapping around the vessels associated with fibrin deposition and hemorrhage - so called pseudocarcinomatous epithelial hyperplasia (Am J Surg Pathol 2004;28:909)
● Late changes are blood vessels with myointimal proliferation and hyalinization, scattered atypical fibroblasts, intramural fibrosis with replacement of smooth muscle by collagen

Micro images
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Prominent dilated blood vessels


Fig 1: dilated vascular spaces, hemorrhage, acute inflammation, fibrinous exudate and focal fibrosis in the lamina propria
Fig 2/3: rounded and irregular tufts of bland urothelium without mitotic activity, with foci conveying an invasive appearance
Fig 4: Some areas showed urothelium surrounding dilated blood vessels, which contained fibrinous deposits


Differential diagnosis
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Urothelial carcinoma: need high threshold for this diagnosis after history of radiation therapy; has no radiation associated changes of vascular ectasia or atypical fibroblasts (Hum Pathol 2000;31:678)

Additional references
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eMedicine

End of Bladder > Cystitis > Radiation cystitis


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