Bladder Lesion in an Elderly Male

Specimen Type:



An 82-year-old man who presented with hematuria and underwent bladder biopsy. Received is a single roughly ovoid fragment of light tan tissue that measures 0.2 x 0.2 x 0.2 cm.

Pathologic Features:

Biopsy reveals a proliferation of urothelium with marked cytologic abnormalities, including abnormal nuclear polarization, prominently enlarged nuclei and prominent nucleoli. Mitotic figures are present (Fig 1, 2). Large markedly atypical cells with abundant cytoplasm are also noted along the surface of adjacent benign reactive urothelium (Fig 3, 4, 5).

Differential Diagnosis:

  • Urothelial dysplasia
  • Urothelial carcinoma with pagetoid spread

Urothelial dysplasia: Urothelium displays proliferative changes and moderate cytologic abnormalities that do not involve the full thickness of the urothelium.

Urothelial carcinoma in situ with pagetoid spread: Diagnosis of urothelial carcinoma in situ is based on identification of abnormal nuclear polarity, prominently enlarged nuclei and mitotic figures. In addition, large pale cells with atypical nuclei are seen within the urothelium, and the cells can be isolated or in clusters.


Urothelial Carcinoma in situ with unique surface spread.

Comment: The diagnosis of urothelial carcinoma in situ is obvious. A unique feature associated with CIS in this case is the presence of pagetoid cells spreading along the surface of the urothelium instead of classic pagetoid spreading within the urothelum.


  1. McKenney JK, Gomez JA, Desai S, et al. Morphologic expressions of urothelial carcinoma in situ: a detailed evaluation of its histologic patterns with emphasis on carcinoma in situ with microinvasion. Am J Surg Pathol. 2001 Mar;25 (3):356-62.