膀胱尿路上皮肿瘤的诊断和鉴别诊断(精品课件)
膀胱尿路上皮肿瘤的诊断和鉴别诊断,膀胱尿路上皮肿瘤,非浸润性尿路上皮肿瘤 non-invasive 浸润性尿路上皮癌 invasive,非浸润性尿路上皮病变,膀胱乳头状肿瘤诊断术语的变迁WHO1973和WHO/ISUP对比,乳头状肿瘤的病理形态学,From Epstein et al. Biopsy Interpretation of the Bladder 4th edition,乳头状瘤 papilloma,外生性乳头状瘤(exophytic papilloma),简称乳头状瘤 内翻性乳头状瘤 (inverted papilloma) 混合性乳头状瘤:内生和外生均有,乳头状瘤Papilloma,Defined as papillary fronds lined by normal appearing urothelium 乳头结构,衬以正常的尿路上皮 Most as single lesions 多数单发 Most having non-branching or minimally branching arrangement, slender fibrovascular stalks 多数乳头为非分叉型或者轻度分叉,乳头轴性纤细 Some have more complex anastomosing papillae 有些有复杂的串联性乳头 No mitosis 无分裂相,Papilloma,乳头状瘤 papilloma,外生性乳头状瘤(exophytic papilloma),简称乳头状瘤 内翻性乳头状瘤 (inverted papilloma) 混合性乳头状瘤:内生和外生均有,内翻性乳头状瘤 (inverted papilloma),Cords and trabeculae of cells arising from a smooth surface and invaginating into the lamina propria 小梁状和条索状,发自表面上皮,向下生长 Periphery cells: darker and palisaded 周围细胞 Central cells: more mature, often streaming, luminal spaces 中间细胞 Cells: minimal to absent cytologic atypia but may have focal degenerative atypia,Inverted papilloma,Inverted papilloma,尿路上皮上皮内瘤变,恶性潜能低的乳头状肿瘤 (PUNLMP),“Lesions that do not have cytologic features of malignancy yet have thickened urothelium or have more cells per unit area compared to papilloma” 与乳头状瘤的区别:尿路上皮较厚,但是细胞形态非常一致,核仁不明显,染色质均匀,核分裂像罕见(基底层),PUNLMP,非浸润性低级别乳头状尿路上皮癌(LGTCC),总体上结构比较有序,但是在低倍镜下无论是结构还是细胞学上都可见轻度的异质性,细胞失去一定程度的极性 常常可见临近的乳头融合 细胞核大小有一定的变异 核仁一般不明显,染色质在不同细胞将有一定的异质性 核分裂像:偶见,可见于任何层,LGTCC,LGTCC,非浸润性高级别乳头状尿路上皮癌HGTCC,明显的结构和细胞异型(低倍镜下就能发现) 细胞核多形性:中等到明显 相当于1973WHO的部分2级+所有的3级,HGTCC (G2),HGTCC (G2),HGTCC (G3),HGTCC (G3),非浸润性乳头状肿瘤伴有内翻性生长,Inverted papilloma PUNLMP with inverted growth pattern LGTCC with inverted growth pattern HGTCC with inverted growth pattern,HGTCC with inverted growth,HGTCC with inverted growth,HGTCC with inverted growth,LGTCC with focal HGTCC,LGTCC伴有HGTCC,只要HGTCC达到5%,就诊断为HGTCC,乳头状尿路上皮肿瘤的复发率,Epstein et al. Biopsy Interpretation of the Bladder 4th edition,乳头状尿路上皮肿瘤的进展率,表来自Epstein et al. Biopsy Interpretation of the Bladder 4th edition,乳头状尿路上皮肿瘤的鉴别诊断,Papillary urothelial hyperplasia 乳头状尿路上皮增生 Papillary/polypoid cystitis 乳头状/息肉性膀胱炎 Papillary nephrogenic adenoma乳头状肾源性腺瘤 Pseudocarcinomatous hyperplasia 假癌性上皮增生,Papillary urothelial hyperplasia 乳头状尿路上皮增生,Undulating urothelium arranged into mucosal narrow papillary folds of varying heights Urothelium in papillary hyperplasia and adjacent mucosa is thicker than normal Cytologically cells in papillary hyperplasia similar to those in normal urothelium,Papillary urothelial hyperplasia 乳头状尿路上皮增生,Distinguished from papillary urothelial neoplasm by a lack of complex arborization (lack of detached papillary fronds) Is likely to be a precursor to low grade papillary urothelial neoplasms,Papillary urothelial hyperplasia,Polypoid cystitis,Polypoid cystitis,Papillary nephrogenic adenoma,Pseudocarcinomatous hyperplasia,Pseudocarcinomatous hyperplasia,尿路上皮上皮内瘤变,Urothelial dysplasia,CIS的生长方式,多形性大细胞 large cell pleomorphic 非多形性大细胞 large cell non-pleomorphic 小细胞 small cell 剥脱型 cling 派杰氏样生长 pagetoid:潜伏在正常上皮下面或者正常上皮的癌化 微乳头型 micropapillary,尿路上皮原位癌CIS的生长方式,CIS: large cell pleomorphic,CIS:Large cell nonpleomorphic,CIS: small cell type,CIS: cling cells,CIS with pagetoid growth,CIS: pagetoid growth,CIS的鉴别诊断,反应性异型 Reactive atypia 意义不明的异型 Atypia of unknown significance 放化疗引起的异型 Chemoradiation atypia 感染引起的异型:病毒 (CMV, Herpes, Polyoma virus),Reactive atypia 反应性异型,Reactive atypia反应性异型,Atypia of unknown significance,Radiation Atypia,尿路上皮上皮内瘤变,In situ adenocarcinoma,膀胱尿路上皮肿瘤,非浸润性尿路上皮肿瘤 non-invasive 浸润性尿路上皮癌 invasive urothelial carcinoma - 浸润至粘膜固有层 (pT1) - 浸润至固有肌层(逼尿肌)(pT2),如何判断浸润粘膜固有层?,肿瘤本身的形态改变 间质反应,如何判断浸润粘膜固有层?,浸润性尿路上皮癌形态亚型,巢状亚型(巢状):小巢和大巢 伴有小管和微囊结构 微乳头型尿路上皮癌 伴腺体分化 伴鳞状上皮分化 混合性尿路上皮癌和小细胞癌 淋巴上皮样尿路上皮癌 肉瘤样尿路上皮癌 浆细胞样尿路上皮癌 伴有透明细胞质的尿路上皮癌 伴有横纹肌样细胞的尿路上皮癌 伴有脂质样细胞质的尿路上皮癌(lipid-rich) 伴有滋养细胞分化的尿路上皮癌 含有破骨巨细胞的未分化癌 巨细胞癌/未分化癌,巢状尿路上皮癌,微囊性尿路上皮癌,微乳头型尿路上皮癌,尿路上皮癌伴腺癌分化,混合性尿路上皮癌和小细胞癌,淋巴上皮样癌,肉瘤样尿路上皮癌,肉瘤样尿路上皮癌,浆细胞样尿路上皮癌,尿路上皮癌伴透明细胞质,伴有脂质样细胞质的尿路上皮癌(lipid-rich),含有破骨巨细胞的未分化癌,巨细胞癌/未分化癌,浸润性尿路上皮癌的主要鉴别诊断,普通尿路上皮癌:假癌性增生,副节瘤,PECOMA,前列腺腺癌 肉瘤样癌:炎性肌纤维细胞瘤 原发腺癌:转移性和继发性腺癌,浸润性尿路上皮癌的主要鉴别诊断,普通尿路上皮癌:假癌性增生,副节瘤,PECOMA,前列腺腺癌 肉瘤样癌:炎性肌纤维细胞瘤 原发腺癌:转移性腺癌,假癌性上皮增生,Hum Pathol. 2000;31:678-683.,20个病人:17例有放疗的病史,2例化疗病史,1例不清楚 年龄: 40-85岁(平均69) 所有病人血尿 间隔:平均27个月(0-80个月) 随访:17个病人,0.25-37个月(平均9个月),没有发生浸润性癌,副节瘤,PECOMA,前列腺腺癌累及膀胱的鉴别诊断,前列腺腺癌累及膀胱(腺体分化),前列腺腺癌累及膀胱(腺体分化),PSA,多形性前列腺腺癌累及膀胱,前列腺腺癌伴鳞化累及膀胱,尿路上皮癌,前列腺腺癌,免疫组化鉴别膀胱癌和前列腺癌,病例,男性,35岁 血尿2个月 影像检查:膀胱3厘米肿块 膀胱部分切除术,Mitotic figure,Pan-CK,男性,35岁膀胱,外院诊断:肉瘤样癌 当地医生建议膀胱切除 病人来会诊: 你是否同意外院的诊断?,其它免疫组化标志物,EMA:- Desmin: - 34BE12: - p63: - SMA: 局部+ (20%细胞) ALK:-,SMA,SMA,男性,35岁膀胱,外院诊断:肉瘤样癌 当地医生建议膀胱切除 病人来会诊: 是否外院诊断? 最后诊断: 炎性肌纤维母细胞瘤(IMT),膀胱炎性肌纤维母细胞瘤 IMT,膀胱炎性肌纤维母细胞瘤 IMT,IMT最主要的鉴别诊断:肉瘤样尿路上皮癌,p63,Sarcomatoid carcinoma with inflammation,IHC鉴别IMT和肉瘤样尿路上皮癌,膀胱尿路上皮肿瘤,非浸润性尿路上皮肿瘤 non-invasive 浸润性尿路上皮癌 invasive,谢谢!,