Owens Christopher L, Epstein Jonathan I
Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
Am J Surg Pathol. 2007 Feb;31(2):298-303. doi: 10.1097/01.pas.0000213333.02240.d0.
Flat urothelial carcinoma in situ (CIS) is often characterized by prominent dyscohesion with some cases having only a few clinging CIS cells remaining on biopsy. The finding of extensive denudation on urothelial biopsies is associated with a risk of CIS on either prior or subsequent biopsies. The significance of denudation in papillary urothelial lesions has not been formally studied. We identified from our surgical pathology files 31 specimens (from 28 patients) of papillary urothelial lesions with extensive denudation. In cases in which denudation was associated with low-grade urothelial neoplasms, follow-up of subsequent cytologic and histologic specimens was obtained. Of the 28 patients, 25 (89%) were men and 3 (11%) were women with an age range of 40 to 88 years old (mean age 62). Of 31 biopsies, 15 were from anatomically confined areas (ie, renal pelvis, ureter, and urethra). In 22/28 (79%) patients, prominent denudation was associated with high-grade papillary carcinomas, 4/28 (14%) low-grade papillary carcinomas, and 2/28 (7%) papillary urothelial neoplasms of low-grade malignant potential. The average extent of urothelial denudation was 82% with 61% of cases having > or =90% denudation. Prominent cautery artifact was present in 17/31 (55%) cases. In 13/28 patients with high-grade lesions, there was a concurrent biopsy of a second urothelial lesion that was either high-grade papillary urothelial carcinoma or invasive urothelial carcinoma. Five of the 6 patients in which the prominent denudation was associated with a low-grade papillary urothelial lesion have not progressed to a high-grade lesion. One patient with a denuded papillary urothelial neoplasm of low malignant neoplasm was subsequently diagnosed with a noninvasive low-grade papillary urothelial carcinoma in the bladder and a high-grade infiltrating urothelial carcinoma of the ureter. We conclude that (1) the majority of papillary urothelial lesions associated with prominent urothelial denudation are high grade; (2) a significant percentage of papillary urothelial lesions with denudation occur with either prominent cautery artifact or in anatomically confined areas, suggesting both iatrogenic and mechanical contributing factors, respectively; (3) a minority of cases with prominent urothelial denudation occur in association with low-grade papillary urothelial lesions and are not associated with progression to higher grade lesions on follow-up studies; and (4) prominent urothelial denudation in papillary lesions should prompt careful examination of these specimens for rare clinging high-grade carcinoma cells, although in a minority of cases the underlying lesion will be low grade.
扁平尿路上皮原位癌（CIS）通常以显著的细胞间黏附丧失为特征，有些病例在活检时仅残留少数黏附的CIS细胞。尿路上皮活检发现广泛的剥脱与之前或之后活检时发生CIS的风险相关。剥脱在乳头状尿路上皮病变中的意义尚未得到正式研究。我们从手术病理档案中识别出31例（来自28名患者）有广泛剥脱的乳头状尿路上皮病变标本。在剥脱与低级别尿路上皮肿瘤相关的病例中，获取了后续的细胞学和组织学标本进行随访。28名患者中，25名（89%）为男性，3名（11%）为女性，年龄范围为40至88岁（平均年龄62岁）。31例活检标本中，15例来自解剖学上局限的区域（即肾盂、输尿管和尿道）。在22/28（79%）的患者中，显著的剥脱与高级别乳头状癌相关，4/28（14%）与低级别乳头状癌相关，2/28（7%）与低恶性潜能的乳头状尿路上皮肿瘤相关。尿路上皮剥脱的平均范围为82%，61%的病例剥脱程度≥90%。17/31（55%）的病例存在明显的烧灼假象。在13/28例高级别病变患者中，同时对第二个尿路上皮病变进行了活检，该病变为高级别乳头状尿路上皮癌或浸润性尿路上皮癌。6例显著剥脱与低级别乳头状尿路上皮病变相关的患者中，5例未进展为高级别病变。1例有剥脱的低恶性乳头状尿路上皮肿瘤患者随后被诊断为膀胱非浸润性低级别乳头状尿路上皮癌和输尿管高级别浸润性尿路上皮癌。我们得出以下结论：（1）大多数与显著尿路上皮剥脱相关的乳头状尿路上皮病变为高级别；（2）相当比例的有剥脱的乳头状尿路上皮病变伴有明显的烧灼假象或发生在解剖学上局限的区域，分别提示医源性和机械性促成因素；（3）少数有显著尿路上皮剥脱的病例与低级别乳头状尿路上皮病变相关，随访研究中未发现进展为更高级别病变；（4）乳头状病变中显著的尿路上皮剥脱应促使仔细检查这些标本，寻找罕见的黏附性高级别癌细胞，尽管少数情况下潜在病变为低级别。
