Bladder, ureter & renal pelvis

General

Features to report, grossing & frozen section



Topic Completed: 1 May 2011

Minor changes: 28 December 2020

Copyright: 2002-2021, PathologyOutlines.com, Inc.

PubMed Search: Bladder tumor features to report


Monika Roychowdhury, M.D.
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Cite this page: Roychowdhury M Features to report, grossing & frozen section. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderreport.html. Accessed December 8th, 2021.
Features to report: Definition / general
Features to report: cystectomy, cystoprostatectomy, pelvic exenteration
Mandatory:
  • 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

    Optional / recommended:
    • 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

    Tumor:
    • 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
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
  • 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
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