Bladder, ureter & renal pelvis
General
Features to report, grossing & frozen section
Author: Monika Roychowdhury, M.D.
Last author update: 1 May 2011
Last staff update: 28 December 2020
Copyright: 2002-2023, PathologyOutlines.com, Inc.
PubMed Search: Bladder tumor features to report
Table of Contents
Features to report: Definition / general | Features to report: cystectomy, cystoprostatectomy, pelvic exenteration | Features to report: bladder biopsy / TURBT | Grossing | Frozen sectionCite this page: Roychowdhury M Features to report, grossing & frozen section. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderreport.html. Accessed September 28th, 2023.
Features to report: Definition / general
- Editor's note
- Mandatory / optional are for accreditation purposes by the American College of Surgeons Committee on Cancer
- Recommended to include clinically relevant historical information (Virchows Arch 2004;445:103)
- Features to report by organization:
Features to report: cystectomy, cystoprostatectomy, pelvic exenteration
Mandatory:
Optional but recommended:
- Specimen type / procedure
- Tumor size
- Tumor histologic type
- Tumor histologic grade
- Adequacy of specimen to determine muscularis propria invasion (muscularis propria found / not found / indeterminate)
- Lymphovascular invasion (present / absent / indeterminate)
- Pathologic stage (includes depth of invasion) (pTNM)
- Regional lymph nodes: either no nodes submitted or found, number examined / cannot be determined (explain), number involved (any size) / cannot be determined (explain); optional - extranodal extension of tumor
- Surgical margins: specify margins involved by invasive carcinoma or in situ carcinoma; if uninvolved by invasive carcinoma, specify distance from invasive carcinoma to margin
- Presence of tumor at margins of urethra, ureter, paravesicular soft tissue or pelvic soft tissue
- Involvement of adjacent structures: perivesical fat, ureter (specify laterality), urethra, vagina, uterus and adnexae, pelvic sidewall (specify laterality), prostate, seminal vesicle (specify laterality), rectum, other
- Additional epithelial lesions: papilloma, inverted papilloma, papillary neoplasm of low malignant potential
Optional but recommended:
- Site of tumor
- Tumor configuration (papillary, solid / nodule, flat, ulcerated, indeterminate)
- Additional findings: multifocality, carcinoma in situ, dysplasia, hyperplasia, inflammation, therapy related changes, keratinizing squamous metaplasia, intestinal metaplasia, inflammation / regenerative changes, cystitis cystica glandularis, urothelial carcinoma involving urethra / prostatic ducts and acini (use protocol for carcinoma of urethra)
- References: Mod Pathol 2009;22:S70, Arch Pathol Lab Med 2003;127:1263
Features to report: bladder biopsy / TURBT
-
Mandatory:
- None
- Site of tumor / procedure
- Tumor size
- Tumor histologic type
- Tumor histologic grade
- Macroscopic pattern of growth (papillary, flat, invasive)
- Type of invasion: broad spread or tentacular (like tentacles)
- Depth of invasion
- Layers of wall represented (muscularis propria identified or not)
- Denuded / ulcerated
- Involvement of prostate
- Additional findings: carcinoma in situ, dysplasia, hyperplasia, inflammation, normal, other
- Histologic type - urothelial carcinoma with / without squamous differentiation, squamous cell carcinoma (classical or variant), adenocarcinoma (classical or variant), small cell carcinoma, undifferentiated, mixed cell type, undetermined
- Histologic grade - based on tumor type
- Tumor configuration - papillary, flat, nodule, invasive, ulcerated, undetermined
- Invasion assessment - detrusor muscle (muscularis propria) present, absent or indeterminate
- Lymphovascular invasion - present, not identified, indeterminate, should be assessed away from the main tumor (only if unequivocal, often is overdiagnosed, Mod Pathol 1990;3:83)
- Microscopic extent of tumor - noninvasive flat carcinoma in situ, involves lamina propria, involves muscularis propria
- Extension in prostatic chips sampled by TURBT - involvement of prostatic urethra, prostatic and acini ducts (by carcinoma in situ) or prostatic stroma (by invasive carcinoma)
- Associated epithelial lesions - urothelial papilloma (classic or inverted type), papillary urothelial neoplasm of low malignant potential, other
- Additional findings - carcinoma in situ, dysplasia, metaplasia, hyperplasia, inflammation, regenerative changes, treatment related changes, other
- References: Mod Pathol 2009;22:S70
Optional / recommended:
Tumor:
Grossing
- TURBT (transurethral resection of bladder tumor): weigh fragments together and measure largest fragment in one dimension; submit all specimen fragments if possible
- Cystectomy: ink entire external surface; either open with Y shaped incision through anterior wall, pin and fix overnight or fill with formalin, fix overnight, and divide into anterior and posterior halves
Gross inspection of cystectomy specimen:
- Document and measure all organs received
- Document number and location of lesions
- Examine ureters carefully
- Document gross tumor extension into surrounding soft tissues (for substaging of pT3 disease)
- Evaluate surgical margins
Distal urethral margins:
- Women: usually taken en face
- Men: prostatic urethra at apex may be taken en face or as apical cone (perpendicular)
- Apical margin in men may be involved by incidental prostate cancer
Soft tissue:
- Careful gross examination will identify deepest point of invasion that should be sampled
- Sections usually taken perpendicular to inked outer surface
Lymph node identification in both cystectomy and separately submitted specimen:
- At least 10 to 14 nodes should be retrieved, although node numbers vary widely according to individual patient circumstances (J Urol 2004;171:1823)
- Clearly report anatomic node groups sampled, if possible (e.g. paraaortic)
- Submit 1 section from each grossly positive lymph node
- Submit all possible nodal tissue if it can be done in 5 or fewer cassettes
- All other lymph nodes should be entirely submitted, as presence of nodal disease may be used as an indication for adjuvant therapy
- Lymph nodes may be grossly or microscopically detected in the perivesical fat (See CAP Cancer Protocols and Checklists, 2011)
- Submit grossly normal fat for small (< 1 cm) lymph nodes
Ureters and urethra:
- Examination is usually for carcinoma in situ
- Invasion may rarely be seen in surrounding soft tissue
Sections to submit:
- Tumor, representative, 1 per cm of tumor diameter (up to 10 cassettes); if initial sampling shows only noninvasive or non-muscle invasive tumor, submit additional sections as necessary to rule out invasion or muscle invasion
- Tumor, deepest penetration into wall (multiple sections)
- Tumor and adjacent normal bladder wall
- Bladder neck
- Bladder trigone (two sections)
- Anterior and posterior wall (two sections each)
- Left lateral and right lateral wall
- Dome (two sections)
- Ureteral orifices, including intramural portion
- Ureteral margin, possibly additional sections if long segment is present
- Urethral margin
- Prostatic urethral margin (if present)
- Margins of resection
- Other grossly abnormal areas in bladder, ureters, urethra or other tissue
- Prostate (peripheral zone, central zone, seminal vesicles, grossly suspicious areas)
- Lymph nodes
- Pelvic wall
Frozen section
Indications
Procedure
Microscopic (histologic) description
- Frozen sections usually performed for ureteral margin evaluation for carcinoma in situ or invasive carcinoma
- Only 3% positive ureteral margins in one study, which suggests it should not be done routinely (Can Urol Assoc J 2010;4:28)
- More useful if carcinoma in situ present in bladder (J Urol 2006;176:2409)
- Frozen sectioning may be useful for evaluating lymph nodes (Urology 2007;69:83)
Procedure
- Recommended to obtain cross section of distal ureter, not shaved margin
- Frozen section is highly sensitive for malignant ureteral margins, but reresection often does not convert positive margins to negative margins (World J Urol 2011;29:451)
Microscopic (histologic) description
- Technical artifact from freezing may induce atypical features in urothelium
- Use stromal lymphocytes as a reference of nuclear size
- Variant invasive patterns, such as plasmacytoid, may mimic inflammatory cells
