Urinary Bladder: Biopsy and Transurethral Resection of Bladder Tumor (TURBT)

Surgical Pathology Cancer Case Summary (Checklist)

Applies primarily to invasive carcinomas &/or associated epithelial lesions, including carcinoma in situ

^*Procedure

^*____ Biopsy

____ TURBT

^*____ Other (specify): ______________________________

Histologic Type

____ Urothelial (transitional cell) carcinoma

____ Urothelial (transitional cell) carcinoma with squamous differentiation

____ Urothelial (transitional cell) carcinoma with glandular differentiation

____ Urothelial (transitional cell) carcinoma with variant histology (specify): ______________________________

____ Squamous cell carcinoma, typical

____ Squamous cell carcinoma, variant histology (specify): ______________________________

____ Adenocarcinoma, typical

____ Adenocarcinoma, variant histology (specify): ______________________________

____ Small cell carcinoma

____ Undifferentiated carcinoma (specify): ______________________________

____ Mixed cell type (specify): ______________________________

____ Other (specify): ______________________________

____ Carcinoma, type cannot be determined

Associated Epithelial Lesions (select all that apply)

____ None identified

____ Urothelial (transitional cell) papilloma (World Health Organization [WHO] 2004/International Society of Urologic Pathology [ISUP])

____ Urothelial (transitional cell) papilloma, inverted type

____ Papillary urothelial (transitional cell) neoplasm, low malignant potential (WHO 2004/ISUP)

____ Cannot be determined

Histologic Grade

____ Not applicable

____ Cannot be determined

Urothelial carcinoma (WHO 2004/ISUP)

____ Low grade

____ High grade

____ Other (specify): ______________________________

Adenocarcinoma and squamous cell carcinoma

____ GX: Cannot be assessed

____ G1: Well differentiated

____ G2: Moderately differentiated

____ G3: Poorly differentiated

____ Other (specify): ______________________________

^*Tumor Configuration (select all that apply)

^*____ Papillary

^*____ Solid/nodule

^*____ Flat

^*____ Ulcerated

^*____ Indeterminate

^*____ Other (specify): ______________________________

Adequacy of Material for Determining Muscularis Propria Invasion

____ Muscularis propria (detrusor muscle) not identified

____ Muscularis propria (detrusor muscle) present

____ Presence of muscularis propria indeterminate

Lymph-Vascular Invasion

____ Not identified

____ Present

____ Indeterminate

Microscopic Extent of Tumor (select all that apply)

____ Cannot be assessed

____ Noninvasive papillary carcinoma

____ Flat carcinoma in situ

____ Tumor invades subepithelial connective tissue (lamina propria)

____ Tumor invades muscularis propria (detrusor muscle)

____ Urothelial carcinoma involving prostatic urethra in prostatic chips sampled by TURBT

____ Urothelial carcinoma in situ involving prostatic ducts and acini in prostatic chips sampled by TURBT

____ Urothelial carcinoma invasive into prostatic stroma in prostatic chips sampled by TURBT

^*Additional Pathologic Findings (select all that apply)

^*____ Urothelial dysplasia (low-grade intraurothelial neoplasia)

^*____ Inflammation/regenerative changes

^*____ Therapy-related changes

^*____ Cautery artifact

^*____ Cystitis cystica glandularis

^*____ Keratinizing squamous metaplasia

^*____ Intestinal metaplasia

^*____ Other (specify): ______________________________

^* Data elements with asterisks are not required. However, these elements may be clinically important but are not yet validated or regularly used in patient management. Adapted with permission from College of American Pathologists, “Protocol for the Examination of Specimens from Patients with Carcinoma of the Urinary Bladder.” Web posting date October 2009, www.cap.org.