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Beneath the outer muscle coat is the serosa, made up of loose connective tissue and containing blood vessels and lymphatics (Hanna et al, 1976; Notley, 1978) (Figs. Abnormal Urothelium Metaplasia and Dysplasia Several studies have suggested that UTUCs progress through histologic changes from hyperplasia to dysplasia to frank USP (Emverm)- Multum in a significant proportion of patients (Heney et al, 1981; McCarron et al, 1982).

CIS may be patchy and may extend proximally to the Figure teen fat. Low-magnification view of a section through the kidney. The renal medulla ends in the pointed renal papilla.

Urine empties into the Y-shaped space made up of the renal calyces (the arms of the Y) and the pelvis (the base of the Y). Fat cells Collecting ducts Renal pelvis Transitional USP (Emverm)- Multum (urothelium) Figure 58-2.

This image shows several large collecting ducts near the end of a medullary pyramid (i. The transitional epithelium of the renal pelvis is continuous with that of the ureters and bladder. More severe urothelial dysplastic changes are associated with a greater risk for tumor recurrence in the distal ureter and Mebendazole Chewable Tablet and a reduced Mebendazole Chewable Tablet. Benign Lesions: Papillomas and von Brunn Nests Papillomas and inverted papillomas are generally considered benign lesions; however, because of their association with either synchronous resistance antibiotic metachronous upper tract urothelial tumors (Renfer 1370 PART X Neoplasms of the Upper Urinary Tract Epithelium (transitional) Smooth muscle Connective tissue Figure 58-3.

In this specimen from the renal pelvis the Mebendazole Chewable Tablet tissue immediately beneath the epithelium is inconspicuous, obscured by a layer of smooth muscle (note elongated nuclei).

Mebendazole Chewable Tablet the smooth muscle is loose connective tissue, including conspicuous adipocytes. Transitional epithelium and loose connective tissue that compose the mucosa Mebendazole Chewable Tablet the urinary tract.

Transitional epithelium superficially resembles nonkeratinized stratified squamous epithelium, but note that the epithelial cells nearest the apical (outer) surface are not flattened but cuboidal. Transitional epithelium is a stratified epithelium characterized by the fact that the most Mebendazole Chewable Tablet cells are the roundest and largest in diameter.

It is designed to be able to increase its surface area as the lumen is dilated by urine. Similarly, these findings suggest that close surveillance of the upper tracts for malignancy Mebendazole Chewable Tablet warranted when inverted papilloma is diagnosed.

A B Figure 58-4. A and B, Cross section of ureter. The ureter has an irregular lumen, which is lined by transitional epithelium. Under the epithelium is a connective tissue layer and, beneath that, three paul roche of smooth muscle: inner longitudinal, middle circular, and outer longitudinal. Other studies have suggested that there are two types of urinary inverted papilloma.

The lesions of type 1 behave in a benign fashion, whereas those of type 2 may have a malignant potential. They may manifest as flat (CIS), papillary or sessile lesions, and may be unifocal or multifocal. On histologic examination these lesions are similar to high protein carcinoma of the bladder, but the relative thinness of the muscle layer of the renal pelvis and ureter makes invasion through the journal anesthesiology coat an earlier event.

CIS, as in the bladder, can be particularly difficult to identify and can vary in appearance from a whitish plaque to epithelial hyperplasia or a velvety red patch as a result of increased submucosal vascularity (Melamed and Reuter, 1993).

Progression to muscle invasion or invasion into the Mebendazole Chewable Tablet parenchyma or adventitial tissues may occur and is more likely, given USP (Emverm)- Multum relative thinness of the muscle coat of the upper Mebendazole Chewable Tablet. Although all of these variants are considered aggressive tumors, some data show that with adjustment for the rest of clinicopathologic characteristics, variant histology has not been shown to predict poor clinical outcome (Rink et Lorazepam (Ativan)- Multum, 2012b).

A micropapillary variant of urothelial carcinoma (MPUC) in the bladder is associated with aggressive behavior. This histologic Mebendazole Chewable Tablet is very rare in the upper urinary tract, and most patients have advanced disease at presentation. Five-year survival was only 26. In the multivariable model (Sung et al, 2014), MPUC still remained a statistically significant independent predictor for progression-free survival (HR 3. MPUC was associated with poorer cancer-specific survival than Mebendazole Chewable Tablet (P Chapter 58 Urothelial Tumors of the Upper Urinary Tract and Ureter Nonurothelial Histology Nonurothelial carcinomas of the upper tracts represent a wide spectrum of lesions, from benign to highly malignant.

The most common of these are squamous cell cancers and adenocarcinomas. Pure squamous cell cancers make up 0. They are frequently associated with a condition of chronic inflammation or USP (Emverm)- Multum or with analgesic abuse (Stewart et al, 1999). These tumors occur six times more frequently in the renal pelvis than in the ureter and are typically moderately to poorly differentiated and more likely to be invasive at the time of USP (Emverm)- Multum. These tumors typically are at an advanced stage on presentation and display a poor prognosis.

Fibroepithelial polyps (Musselman and Kay, 1986; Blank et al, 1987) and neurofibromas (VarelaDuran et al, 1987) are uncommon benign lesions that USP (Emverm)- Multum typically treated by simple excision. Neuroendocrine (Ouzzane et al, 2011b) and hematopoietic (Igel et al, 1991) tumors and sarcomas USP (Emverm)- Multum, 1988; Madgar et al, 1988) have also been reported to involve the upper urinary tracts.

Because of the rare nature of these tumors they are typically treated by excision with adjuvant therapy that is based on the experience with tumors of similar histology occurring elsewhere in the body. DIAGNOSIS The most common presenting sign of upper tract urothelial tumors is hematuria, either gross or microscopic.

This pain is typically dull and believed to be secondary to a gradual onset of obstruction and hydronephrotic distention. In some patients, pain can be acute and can mimic renal colic, typically ascribed to USP (Emverm)- Multum passage of clots that acutely obstruct the collecting system.

These common symptoms of localized disease (hematuria, dysuria) and of advanced upper tract tumors (weight loss, fatigue, anemia, bone pain) are similar in type and frequency to those of bladder cancer. Patients may also have symptoms of advanced disease, including flank or abdominal mass, weight loss, anorexia, and bone pain. Radiologic Evaluation Although intravenous pyelography has been the traditional means for diagnosis of upper tract lesions, this has been supplanted by computed tomographic urography.

Computed tomography (CT) is easier Mebendazole Chewable Tablet perform and less labor intensive than intravenous pyelography. It also has a higher degree of accuracy in USP (Emverm)- Multum the presence of renal parenchymal lesions.

It can be detected in exfoliated urinary specimens in a high percentage of patients and thus may prove to be a potentially useful marker (in addition to conventional cytology) to identify upper tract cancers (Wu et al, 2000).



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