Spectrum of histomorphological diagnosis in cystoscopic bladder biopsies

Correspondence: Dr Rupendra Thapa, MBBS, MD Department of Pathology Medicare National Hospital & Research Centre, Kathmandu, Nepal. Email; rup432@gmail.com Background: Urinary bladder lesions are the main source of significant clinical symptoms which are more disabling than lethal. Bladder tumors constitute one of the most common urological pathology. Urothelial carcinoma accounts for 90% of all primary tumors of the bladder. This study aimed to determine the frequency of different types of lesions of the urinary bladder and to determine the grade and stage of urothelial tumors.

stained with Haematoxylin and Eosin stain (H&E).Special stains were used whenever required.
The World Health Organization (WHO)/International Society of Urological Pathology (ISUP) classification ( 2004) was used to grade the tumors into: urothelial papilloma, papillary urothelial neoplasm of low malignant potential (PUNLMP), low and high grade urothelial (transitional cell) carcinomas (TCC).Pathological staging of the urothelial cancers was done according to the TNM system and data recorded as pTa: tumor limited to mucosa, pT1: invasion of lamina propria and pT2 as invasion of muscle.6 Inclusion criteria: All the transurethral resection of bladder tissue (TURBT) biopsies received in the Department of Pathology.
Exclusion criteria: Autolysed and inadequate biopsies were excluded.
The main purpose of this study was to determine the of bladder pose biologic, clinical, diagnostic and therapeutic challenges to both urologist and pathologist, as these tumors represent a heterogeneous group of tumors with different subtypes and behavioral patterns. 1,5stoscopic bladder biopsy is a gold standard for accurate diagnosis and prognostic assessment of the patient.Hence, this study was undertaken to determine the frequency of different types of lesions of the urinary bladder and to determine the grade and stage of urothelial tumors so as to prevent mortality and morbidity associated with it.

MATERIAL AND METHODS
This is a prospective study carried out in the Department of Pathology, Medicare National Hospital and Research Centre, Kathmandu, Nepal, over a period of two years from September 2014 to August 2016.All the patients who visited Urology Department and subjected to cystoscopic biopsy were included in this study.The cystoscopic bladder biopsies taken were fixed in 10% formalin and then processed.Four microns thick sections were taken and Thapa R et al.The demographic characteristics of the patients in current study were relatively similar to a number of studies which describe a peak incidence of bladder lesions in the age 61 -70 years and predominance in male with male to female ratio of 2.78 : 1.The increase prevalence of bladder cancers in males than in females is probably related to difference in smoking habits and occupational exposure. 1,9adder tumors were the most common type of lesion in the present study and were seen in 58 (66.67%) cases of which 55 (94.83%) cases were urothelial (transitional cell) tumors.Majority were malignant neoplasm comprising of 51 (58.62%) cases of urothelial carcinoma and 2 (2.30%) cases of squamous cell carcinoma which were in concordance with following studies done by Mahesh K et al, Mohammad    4). 7,10,11e histological grading of the urothelial neoplasm in present study showed increased prevalence of low grade papillary urothelial carcinoma (LGPUC) correlated with similar studies as shown in table 5 .7,8,12,13Histological grading and staging are the two important factors for tumor recurrence, progression and for determination of treatment options for patients with bladder carcinoma. 14In present study we observedmajority of the malignant bladder tumors were invasive, accounting for 45 (77.59%) cases out of which 19 (42.22%) cases were in pTa stage, 15 (33.33%) cases were in pT1 and 11(24.45%)cases were in pT2 stage.This findings were comparable with similar studies shown in table 6. 7,8,12 Muscle invasion was seen in 11(24.45%)cases of high grade papillary urothelial carcinoma whereas none of the cases of low grade papillary urothelial carcinoma showed muscle invasion.

CONCLUSION
This study revealed a wide spectrum of non-neoplastic and neoplastic urinary bladder lesions.Majority of the cases were malignant bladder neoplasms of urothelial origin, large number of which was low grade papillary urothelial carcinoma.The importance of including muscle in cystoscopic biopsies needs to be emphasized as muscle invasion is an important predictor of prognosis.

Table 6 Comparison of frequency of histological stages of bladder neoplasms in different studies TNM Stage Laishram et al 12 Dravid et al 7 Vaidya et al 8 Present study
M et al and Dravid et al ( table