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 bladder neck and trigone (20%) or anterior wall in 10%. A multifocal growth can be seen in 50%.

Growth pattern:

The initial growth pattern is either flat and/or exophytic. In advanced disease, the tumor infiltrats 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.

Distant metastases:

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

Microscopic Pathology

Over 95% of bladder cancers are urothelial carcinomas (synonym: transitional cell carcinoma), 2% are squamous cell carcinomas and 1% are adenocarcinomas. Urothelial lesions are divided into expophytic papillary lesions or flat lesions (Helpap and Koller, 2000).

Exophytic and papillary urothelial lesions:


Sharply defined and intact superficial umbrella layer, no mitotic activity. Benign lesion.

Papillary urothelial neoplasm of low malignant potential (PUNLMP):

Increasingly nuclear atypia, interupted superficial umbrella layer, increased urothelial cell layers.

Papillary bladder carcinoma:

Palisading predominantly present, less or more nuclear atypia depends on grading, superficial umbrella layer often not present, increased urothelial cell layers. Malignant lesion. Invasive bladder cancer: infiltration beyond the basal membrane into the lamina propria or muscularis.

Flat urothelial lesions:

Flat hyperplasia:

More than 7 cell layers without cellular atypia and intact polarity of the urothelium. Benign.

Reactive atypia:

More than 7 cell layers with slight cellular atypia. Benign.


Flat atypical urothelium with disorders in polarity, partially preserved palisading. Benign.

Carcinoma in situ:

Typical features of carcinoma in situ are prominent nuclear atypia, disorders of polarity, mitotic activity, high proliferation (MIB-1). Malignant with a high risk of progression.

Reproducibility of the pathological staging:

T stage 50-80% conformity, grading 60-75% conformity. Interobserver variation is even higher for flat high grade lesions.

Rare Carcinomas of the Urinary Bladder

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), germ cell tumors.

Nonepithelial tumors of the urinary bladder

Benign, nonepithelial tumors:

Leiomyoma, rhabdomyoma, hemangioma, lipoma, neurofibroma.


Please see section sarcoma of the bladder

Primary malignant lymphoma:

Malignant lymphoma of the bladder may present either as primary lymphoma localized to the bladder, bladder lymphoma in the context of disseminated disease or secondary bladder lymphoma in patients with a history of malignant lymphoma. Primary bladder lymphoma arises from the mucosa associated lymphoid tissue (MALT) and is associated with an excellent prognosis.


Pheochromocytoma of the bladder are tumors from 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 are 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