Analysis Of Pathological Grading And Prognosis Of Inverted Urinary Bladder Neoplasm In Large Sample

[Objective]We analyzed the correlations between architectural variation,cytologic variation,proliferative activity of inverted bladder urothelial neoplasm(UN)and the invasive and survival rate.And then we proposed pathologic grading diagnostic criteria for inverted non-invasive UN with verification.The significance and value of immunohistochemical staining and FISH of chromosomes 3,7,17,as well as 9p21 loci,was evaluated for staging,pathologic grading,and prognosis of inverted UN.The difference and significance of growth patterns in UN staging,pathologic grading and biological behavior judgment were also discussed.The purpose of the current study was to provide a practicing rule which can be followed by pathologists and clinicians in routine diagnosis and treatment.In this way,patients can access to correct pathologic diagnosis and appropriate,timely treatment.[Materials and Methods]All patients of non-specific variants of bladder UN were searched during 2010.01-2016.12 from the PACS system of the General Hospital of PLA.According to the experimental design,sample size estimation,random sampling and reviewing all the slides were performed,and then the remaining cases were included in this study after those undesirable ones were removed.The correlation between infiltrative,survival rate,and 7 morphologic characteristics were analyzed,including the exogenous papillary,the structure of endogenous trabeculaes,central umbrella cells,tumor cell polarity,nuclear atypia,mitotic figures and pathological mitosis.Having evaluated the above results by the combination of parallel and series principle,we raised the pathologic grading standard of inverted UN.And then by comparing the survival rates,and analyzing the correlation between morphologic characteristics and pathologic grades,we verified the feasibility of the grading standard.The correlation between the infiltrative rate,pathologic grading,survival rate and the staining results of 8 immunohistochemical markers,including CK20,Ki-67,p53,P16,CK5,CD44,CyclinDl,and GATA-3,as well as the FISH findings of chromosomes 3,7,and 17,9p21 loci,were explored.The differences between the two growth patterns(papillary and inverted)of UN in gender,age,tumor pathologic type,and survival rates were also explored.[Results]Part one:In the 7 years,a total of 3610 cases of bladder UN were diagnosed and treated,including 3240 cases of exogenous tumors,327 inverted ones,and 43 flat ones.In inverted UNs,the ratio of male and female was 6.4:1,the average age was 54.60 years old.Of the 156 inverted cases selected in the study,126 cases were non-invasive tumors.In the 30 invasive cases,19 cases underwent radical surgery.Between invasive and non-invasive tumors,there were statistical significance in the structure of endogenous trabeculaes,tumor cell polarity,nuclear atypia,mitotic figures and pathological mitosis(P<0.01),but there was no significant difference in exogenous papillary and central umbrella cells(P>0.05).Follow-up results of 133 patients were obtained.Up to date of follow-up,20.30%of the cases had recurrences and/or metastases.The tumor-free survival time was 1-30 months.And 7.52%died of bladder tumor.The overall survival time was 7-134 months.The structure of endogenous trabeculaes,central umbrella cells,tumor cell polarity,nuclear atypia,mitotic figures and pathological mitosis were statistically correlated with tumor-free and overall survival(P<0.01),but gender,age,exogenous papillary structure had no correlation with tumor-free and overall survival(P>0.05).According to the results above we raised the grading standard of non-invasive inverted UN.Of the 156 cases,33 cases were diagnosed with IP,50 I-PUNLMP,36 I-NIPUC,LG,and 7 cases were diagnosed to I-NIPUC,HG.The results of reverse analysis showed there were significant differences in tumor-free and overall survival(P<0.01)among the inverted UNs with different pathologic grading.All the 7 pathologic characteristics were correlated with pathologic grading(P<0.01),but gender and age were not significantly correlated(P>0.05).Part two:Immunohistochemical expression of ki-67,CK20,p53,and p16 were higher in invasive than non-invasive UN,and CK5,CD44,and CyclinDl were lower.The chi-square test showed that the difference was significant(P<0.01).There were no significant differences of GATA-3 expression between invasive and non-invasive UN(P>0.05).CK20,p53,ki-67,P16,and CD44 were statistically correlated with tumor pathologic grades,of which CK20,ki-67,p53,and p16 with positive correlation,while CD44 with negative one.CK20,CK5,CD44,ki-67,and CyclinDl expressions were statistically correlated with tumor-free and overall survival rates.The cases with positive expression of CK20,negative expression of CK5,CD44,and CyclinDl,and high ki-67 proliferation index(>20%)were more likely to recur and/or metastasize and die of the tumor(P<0.01).The diffuse expression of p53 was positively correlated with the tumor-free survival rates,had no significant correlation with overall survival rate.The diffuse expression of p16 was positively correlated with the overall survival rates,had no significant correlation with tumor-free survival rate.There was no significant correlation between the expression of GATA-3 and the survival rate(P>0.05).Part threeChromosomes 3,7,and 17 and the 9p21 loci were examined by FISH in 115 inverted UNs.The chi-square test showed that the positive rate of FISH in invasive carcinomas(68%)was higher than non-infiltrating ones(12.22%).In 90 cases of non-invasive inverted UN,11 were positive,and the I-NIPUC,HG group had the highest positive rate(57.14%),while the IP and I-PUNLMP groups only had a positive rate of 5.26%.Spearman rank correlation analysis showed that the higher the tumor grade was,the higher the positive rate was.Compared with IP,the sensitivity of I-NIPUC,LG and I-NIPUC,HG was 15.38%and 57.14%,respectively,and the diagnostic index were 110.11%and 151.87%,respectively.With IPUNLMP as the control group,the sensitivity and the diagnostic index of I-NIPUC,HG was 57.14%and 144.44%,respectively.Single factor survival analysis showed that the results of FISH examination were closely related to tumor-free and overall survival,and the risk of relapse and/or metastasis and death were greater in the cases with positive results.Part fourThe distribution of pathologic grading,gender and age were significantly different between exogenous and inverted UNs.In exogenous UN cases,NIPUC.LG and IPUC were more common,while UP was the least one(0.56%).But in inverted UNs,IP,I-PUNLMP and I-NIPUC,LG accounted for relatively equal and large proportions(30.28%,32.11%,and 29.66%,respectively)and the proportions of I-NIPUC,HG and I-IUC was very low.More commonly UNs with inverted and exogenous growth pattern were all found in males,and the ratio of males-to-females was 6.4:1 and 3.4:1,respectively.The gender distribution was quite different among the exogenous UNs with different pathologic grade.The component ratio of UP was lower,but one of IPUC was the highest.The average age of patients with inverted UN(54.60 years)was lower than with exogenous ones(60.70 years).The overall age distribution of patients exogenous UN was significantly different.The patients with NIPUC,HG and IPUC were older,with the mean age of 65.89 and 64.99 years,respectively.There was no significant difference in the overall and tumor-free survival rate between the two different growth patterns,no matter between all the cases and the cases with each parallel pathologic grade.[Conclusions]Inverted UN is a rare type of bladder tumor,accounting for 9.06%of bladder tumors.Between the exogenous and inverted UN,the distributions of gender,age,and pathologic type were significantly different.Compared with exogenous ones,the constituent ratios of male and female of inverted UNs were higher,but the age was younger.In exogenous tumors,NIPUC,LG and IPUC were more common,while UP was very rare.But in the inverted ones,IP,I-PUNLMP and I-NIPUC LG were the major grade and similar in constituent ratios.In routine pathologic diagnostic work,the structure of endogenous trabeculaes,tumor cell polarity,nuclear atypia,mitotic figures and pathological mitosis can be used as a non-invasive tumor pathologic grading reference index.The consistency of exogenous papillary could be considered as a removed index for IP.Central umbrella cells cannot be used as a pathologic grading reference.Combined application of CK20,Ki-67,p53,p16 and CD44 immunohistochemical staining can assist the pathological classification of non-invasive tumors.The results of chromosome 3,7,and 17 and 9p21 loci examination in paraffin-embedded tissues had slightly lower sensitivity,thus cannot be a molecular genetics reference in the pathological classification of non-invasive inverted UNs independently.There was no significant difference in prognosis between the bladder UNs with different growth patterns,but the composition ratio of infiltrative tumor in inverted UNs is significantly lower than that of exogenous ones.The grades of non-infiltrative inverted UNs,the expression of CK20,Ki-67,CK5,CD44 and CyclinD1 were the influence factors of tumor infiltration and prognosis.And the combined application can assess the infiltration and prognosis risk of these tumors.The cases with p53-positive expression were more prone to infiltration and recurrence and/or metastasis.Diffuse p16-positive expression was positively correlated with infiltration and overall survival rate,but had no significant correlation with the tumor-free survival rate.In the cases with positive results of chromosome 3,7 and 17 and 9p21 loci examination in paraffin-embedded tissues often correspond to high grade morphology and prone to infiltration,recurrence/metastasis and death from tumor.