Dr. med. Dirk Manski

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Bladder cancer (2/7): Tumor Stages and Pathology

Review Literature: EAU guidelines superficial bladder cancer. EAU guidelines of muscle-invasive and metastatic bladder cancer. German S3 guidelines bladder carcinoma Harnblasenkarzinom.

TNM Tumor Staging of Bladder Cancer

Superficial bladder carcinoma:

T2: Tumor invades muscle (tunica muscularis).

T3: Tumor invades perivesical tissue.

T4: Tumor invades adjacent organs.

N: Lymph node involvement.

M: Distant metastasis.

G: Grading.

Macroscopic Pathology of Bladder Cancer


Bladder cancer most commonly begins at the side walls or posterior wall in 70%. Less common locations are bladder neck and trigone (20%) or anterior wall in 10%. 50% are multifocal tumors.

Growth pattern:

The initial growth pattern is either flat or exophytic. In advanced disease, the tumor infiltrates the detrusor muscle and adjacent organs [Fig. advanced bladder cancer].

Lymph node metastasis:

Lymphogenic metastases may affect the iliac, obturator, presacral, and aortic lymph node groups. The probability of lymph node metastasis is 5% for pT1 tumors, 30% for pT2, and 60% for pT3b tumors. The tumor manifestation at the bladder trigone is associated with a higher risk of lymph node metastases (HR 1.83) and increased mortality (HR 1.68).

Distant metastases:

Bone, liver, lung, peritoneum, and brain. The risk for distant metastasis is 50% for locally advanced tumors (≥ stage pT3b).

Microscopic Pathology (Histology)

Over 95% of bladder cancers are urothelial carcinomas (synonym: transitional cell carcinoma), 2% are squamous cell carcinomas and 1% are adenocarcinomas. Urothelial carcinoma is differentiated in the current WHO classification (2016) into infiltrative tumors and non-invasive tumors (Humphrey et al., 2016). The reproducibility of the pathological staging has been shown to be highly variable in comparative studies: T-stage 50–80% agreement, grading 60–75% agreement (Meijden et al., 2000).

Infiltrative urothelial carcinoma:

Over 95% of infiltrative tumors are high-grade lesions. Up to 33% of the infiltrative tumors show additional growth patterns in addition to the "normal type": nested variant, microcystic, micropapillary, lymphoepithelioma-like, plasmacytoid, seal-ring cell, sacromatoid, giant cell, lipid-rich, clear cell or low differentiated.

Non-invasive urothelial carcinoma:

Non-invasive urothelial carcinoma can be divided into flat and papillary lesions, both types can exhibit a wide spectrum of atypia (from reactive to highly malignant).

Rare Carcinomas of the Urinary Bladder

2% of bladder carcinoma are squamous cell carcinoma and 1% are adenocarcinoma, other types are infrequent.

Squamous cell carcinoma:

Risk factors for squamous cell carcinoma are chronic infections, schistosomiasis, or chronic indwelling bladder catheter. Prognosis is comparable to transitional cell carcinoma.


Either primary adenocarcinoma from the bladder, often from the urachus. Secondary adenocarcinoma from urinary diversion with bowel segments or from bladder metastasis.


Neoplasms of the urachus:

Neoplasms of the urachus are located at the bladder roof or arise from the extravesical part of the urachus. Adenocarcinoma is the most common type of this rare neoplasia, but transitional cell carcinoma or sarcoma is also possible.

Small-cell carcinoma of the bladder:

The bladder is the most common extrapulmonary manifestation of small-cell carcinoma. The prognosis is poor.

Other rare cancers:

Hepatoid adenocarcinoma, lymphoepithelial carcinoma, carcinoid tumors (neuroendocrine tumors), and germ cell tumors.

Nonepithelial tumors of the urinary bladder

Benign, nonepithelial tumors:

Leiomyoma, rhabdomyoma, hemangioma, lipoma, and neurofibroma.


Please see section sarcoma of the bladder

Primary malignant lymphoma:

Primary bladder lymphoma arises from the mucosa-associated lymphoid tissue (MALT) and is associated with an excellent prognosis. Secondary bladder lymphoma is found in patients with a history of malignant lymphoma.


Pheochromocytoma of the bladder are tumors from the paravesical ganglia. Paroxysmal hypertension may be associated with micturition.

Metastasis of the urinary bladder

Infiltrative growth of tumors into the bladder wall from female genital organs, prostate, or colon is more common than distant metastases caused by malignant melanoma, gastric cancer, breast cancer, or lung cancer.

Index: 1–9 A B C D E F G H I J K L M N O P Q R S T U V W X Y Z


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  Deutsche Version: Pathologie und TNM Tumor Staging des Harnblasenkarzinoms