A 73-year-old man comes to the office due to blood in his urine. He has noted bright red blood at the end of micturition on several occasions but has had no urinary frequency or pain with urination. The patient has a history of hypertension and chronic bronchitis. He has smoked a pack of cigarettes daily for 30 years. Temperature is 37 C (98.6 F). Abdominal, external genital, and rectal examinations are unremarkable. Urinalysis shows hematuria. Urine cytology is positive for malignant cells. Cystoscopy is planned for visualization and biopsy of suspected urinary tract cancer. Which of the following features would be most suggestive of a poor prognosis?

Question

A 73-year-old man comes to the office due to blood in his urine.  He has noted bright red blood at the end of micturition on several occasions but has had no urinary frequency or pain with urination.  The patient has a history of hypertension and chronic bronchitis.  He has smoked a pack of cigarettes daily for 30 years.  Temperature is 37 C (98.6 F).  Abdominal, external genital, and rectal examinations are unremarkable.  Urinalysis shows hematuria.  Urine cytology is positive for malignant cells.  Cystoscopy is planned for visualization and biopsy of suspected urinary tract cancer.  Which of the following features would be most suggestive of a poor prognosis?

Quizplus · Accepted Answer

This patient with a significant smoking history has developed painless gross hematuria, which raises suspicion for bladder cancer. Urothelial (transitional cell) carcinomas arising from the transitional epithelium lining the bladder (ie, urothelium) are the most common type of bladder cancer; squamous cell and adenocarcinomas may occur but are significantly less common. Urothelial cancer typically grows as an erythematous papillary, nodular, or sessile mass and is easily diagnosed on cystoscopy. Microscopy may show cells resembling normal bladder epithelium but with irregular architecture, pleomorphism, hyperchromatic nuclei, and atypical mitoses. Tumor stage is the most important factor for determining prognosis in urothelial carcinoma and is based on the depth of invasion into the bladder wall and the degree of spread to other tissues. Tumor penetration through the lamina propria into the muscularis propria layer (indicating stage T2 or higher in the Tumor, Node, Metastasis [TNM] system) carries an unfavorable prognosis. (Choice A) Tumor grade, or the degree of cellular abnormality, also influences prognosis but to a lesser extent than staging. High-grade intraepithelial lesions (eg, urothelial carcinoma in situ), despite their high degree of cellular abnormality, have a relatively favorable prognosis as they have not yet invaded the basement membrane. (Choice C) Urothelial tumors at the bladder neck may have an elevated risk of recurrence, but, in general, tumor location within the bladder has only a minor effect on prognosis. (Choice D) Tumors with papillary morphology are more likely to extend into the bladder lumen rather than penetrate into the bladder wall. However, these tumors can become invasive, and papillary morphology itself does not directly influence prognosis. (Choice E) Larger tumors are associated with worse prognosis; however, depth of tumor invasion is a much more important prognostic factor than tumor size. Educational objective: Urothelial (transitional cell) carcinoma is the most common type of bladder cancer. Tumor stage is the most important factor for determining prognosis and is based on the depth of invasion into the bladder wall and the degree of regional (eg, lymph nodes) and metastatic spread. Tumor invasion into the muscularis propria layer of the bladder wall carries an unfavorable prognosis.

A 73-Year-Old Man Comes to the Office Due to Blood