Carcinosarcoma of the urinary bladder

Pictorial review of multiparametric MRI in bladder urothelial carcinoma with variant histology: pearls and pitfalls

Bladder cancer (BC), predominantly comprising urothelial carcinomas (UCs), ranks as the tenth most common cancer worldwide. UCs with variant histology (variant UC), including squamous differentiation, glandular differentiation, plasmacytoid variant, micropapillary variant, sarcomatoid variant, and nested variant, accounting for 5-10% of cases, exhibit more aggressive and advanced tumor characteristics compared to pure UC. The Vesical Imaging-Reporting and Data System (VI-RADS), established in 2018, provides guidelines for the preoperative evaluation of muscle-invasive bladder cancer (MIBC) using multiparametric magnetic resonance imaging (mpMRI). This technique integrates T2-weighted imaging (T2WI), dynamic contrast-enhanced (DCE)-MRI, and diffusion-weighted imaging (DWI) to distinguish MIBC from non-muscle-invasive bladder cancer (NMIBC). VI-RADS has demonstrated high diagnostic performance in differentiating these two categories for pure UC. However, its accuracy in detecting muscle invasion in variant UCs is currently under investigation. These variant UCs are associated with a higher likelihood of disease recurrence and require precise preoperative assessment and immediate surgical intervention. This review highlights the potential value of mpMRI for different variant UCs and explores the clinical implications and prospects of VI-RADS in managing these patients, emphasizing the need for careful interpretation of mpMRI examinations including DCE-MRI, particularly given the heterogeneity and aggressive nature of variant UCs. Additionally, the review addresses the fundamental MRI reading procedures, discusses potential causes of diagnostic errors, and considers future directions in the use of artificial intelligence and radiomics to further optimize the bladder MRI protocol.

Sarcomatoid Urothelial Carcinoma of the Bladder: Analysis of 28 Cases With Emphasis on Clinicopathologic Features and Markers of Epithelial-to-Mesenchymal Transition

Context.—Sarcomatoid urothelial carcinoma (UCa) is a rare but aggressive variant of bladder cancer that can show diagnostic challenges even using ancillary techniques.

Objective.—To examine immunohistochemical markers in the context of sarcomatoid UCa, including those associated with epithelial-to-mesenchymal transition.

Design.—Twenty-eight cases of sarcomatoid UCa were rereviewed. Clinical outcomes were obtained through database search. Immunohistochemistry for clinical and epithelial-to-mesenchymal transition markers was performed.

Results.—All patients had biopsy-proven invasive UCa; 61% (17 of 28) had sarcomatoid UCa at initial diagnosis. A recognizable epithelial component(s) was present in 17 lesions. The sarcomatoid component accounted for 65% of the lesion (average), with heterologous elements present in 3 of 28 cases (11%). The morphologic spectrum of the sarcomatoid element included spindled not otherwise specified, myxoid, pseudoangiosarcomatous, and malignant fibrous histiocytoma–like undifferentiated features. The sarcomatoid component was immunoreactive for pancytokeratin (22 of 26; 85%), p63 (20 of 26; 77%), cytokeratin 903 (17 of 26; 65%), cytokeratin 7 (16 of 26; 62%), GATA3 (16 of 26; 62%), and cytokeratin 5/6 (16 of 26; 62%). STAT-6, CD31, CD34, and HMB45 were all nonreactive, whereas smooth muscle actin often showed at least focal immunoreactivity (22 of 26; 85%). Epithelial-to-mesenchymal transition markers were frequently expressed, including vimentin (26 of 26; 100%), FoxC2 (26 of 26; 100%), SNAIL (23 of 26; 88.5%), and ZEB1 (18 of 26; 69.2%). Follow-up was available for 24 patients (median, 7 months). Sixteen of 28 patients (57%) died of disease (overall mean survival, 9.1 months). The presence of myxoid or chordoid features was associated with reduced survival (P < .05).

Conclusions.—Sarcomatoid UCa is an aggressive form of UCa that frequently expresses epithelial-to-mesenchymal transition markers, suggesting a possible mechanism associated with aggressive tumor behavior.

Spontaneous carcinosarcoma originating from the renal pelvis ina rat

Carcinosarcoma is a rare neoplasm composed of malignant epithelial and stromal elements, and, for rats, carcinosarcomas in the kidney have not been reported. In a long-term study to gather background data, we encountered a spontaneous carcinosarcoma originating from the renal pelvis with metastasis to the lung. At necropsy, a mass was observed in the abdominal cavity, and white nodules were scattered in lung lobes. Microscopically, there was polypoid hyperplasia of the urothelium accompanied by hyperplasia of spindle stromal cells in the pelvis. The intra-abdominal tumor was composed of epithelial and stromal elements; in the lung, the tumor cells invaded along alveoli/bronchi and occasionally invaded the parenchyma from the blood vessels. Immunohistochemical and electron microscopic examinations revealed that the epithelial element consisted of transitional epithelial cells and that the stromal element consisted of lipoblasts. The tumor was diagnosed as a carcinosarcoma originating from the renal pelvis, and this is the first report of a carcinosarcoma originating from the renal pelvis in a rat.

Cytologic features of sarcomatoid carcinoma of the urinary bladder: a case report

Sarcomatoid carcinoma of the urinary bladder is a rare entity, whose histogenesis and biological behavior remain controversial. The cytological literature on sarcomatoid carcinoma in voided urine is very scarce. Clinically, the diagnosis of this tumor can be made by computed tomography (CT), magnetic resonance imaging (MRI), cytology, and biopsy material. In this study, cytology, histopathology, and radiological imaging were employed in order to reach a diagnosis of sarcomatoid carcinoma. CT imaging showed increased thickness of the bladder wall associated to a polypoid mass. MRI showed a 4-cm sized, broadly necked polypoid mass with calcification and ulceration at the right side of the bladder wall. T2W1 imaging showed low signal. Voided urinary cytology showed a scattered cellular presentation. The tumor cells had a high nucleo- cytoplasmic ratio, with elongated cytoplasm with faint with indistinct cytoplasm border. The nucleus was oval to round, with large and irregular nucleoli and irregular nuclear membrane. These tumor cells were positive for cytokeratin (CKAE1/AE3), vimentin, p53, carcinoembryonic antigen (CEA), α1-smooth muscle actin (SMA) by the immunoperoxidase staining. Histopathology showed spindle-shaped and clumped large tumor cells with abundant cytoplasm. Mitotic figures were frequently seen and varied from area to area (50% of the tumor cells were positive for MIB1).

Sarcomatoid Urothelial Carcinoma: A Single Cancer Center Experience

Background

Sarcomatoid bladder cancer is a rare and aggressive variant of urothelial carcinoma.

Methods

A retrospective review of our experience in managing patients with sarcomatoid bladder cancer (SRBC) between 1997 and 2011 was performed to better define the behavior and outcomes of this disease.

Results

The median age of the patients was 63 years. All patients presented with high grade histology. Eighty-five percent of the patients presented with muscle invasive disease and fifty percent presented with stage IV carcinoma. Ten of 14 (71%) of patients underwent a cystectomy. Patients with SRBC was younger (P < 0.01), more commonly presented with higher grade histology (P < 0.01) and advanced stage disease (P < 0.01), in comparison with patients with Urothelial carcinoma (UC). At a median follow-up of 7 months (range 1.3 - 112), five (35.7%) patients have died in last follow-up. Two-year survival was 53.5%. Three patients with long term survival were reported.

Conclusions

Sarcomatoid bladder cancer is associated with poor prognosis. Multimodality therapy may improve these patients outcome.

Clinical features of sarcomatoid carcinoma (carcinosarcoma) of the urinary bladder: analysis of 221 cases

Background. Urinary bladder sarcomatoid carcinoma (carcinosarcoma) is rare. The objective of this study was to examine the epidemiology, natural history, and prognostic factors of urinary bladder carcinosarcoma using population-based registry. Methods. The Surveillance, Epidemiology, and End Results (SEER) Program database was used to identify cases by tumor site and histology codes. The association between clinical and demographic characteristics and long-term survival was examined. Results. A total of 221 histology confirmed cases were identified between 1973 and 2004, this accounted for approximately 0.11% of all primary bladder tumors during the study period. Median age of the patients was 75 years (range 41–96). Of the patients with a known tumor stage (N = 204), 72.5% had a regional or distant stage; 98.4% of patients with known histology grade (N = 127), had poorly or undifferentiated histology. Multiple primary tumors were indentified in about 40% of study subjects. The majority of patients (95.9%) received cancer directed surgery, 35.8% had radical or partial cystectomy, 15.8% of patients received radiation therapy combination with surgery. The median overall survival was 14 months (95% CI 7–21 months). 1-, 5-, and 10-year cancer specific survival rate were 53.9%, 28.4% and 25.8%. In a multivariate analysis, only tumor stage was found to be a significant prognostic factor for disease-specific survival. Conclusions. Urinary bladder carcinosarcoma commonly presented as high grade, advanced stage and aggressive behavior with a poor prognosis. Emphasis on early detection, including identification of risk factors is needed to improve the outcome for patients with this malignancy.

Sarcomatoid carcinoma of the urinary bladder treated with adjuvant radiotherapy: a case report

Sarcomatoid carcinoma is a rare tumor of the urinary bladder accounting for less than 0.5% of all primary urinary bladder tumors. Since the patients were presented with large tumor with extended stages, outcome was found to be poor. In order to improve local control, adjuvant local treatment may be practical. We report a rare case with sarcomatoid carcinoma of the urinary bladder diagnosed with immunuhistochemical (IHC) study and treated with 3D-conformal radiotherapy (3DCRT) post-operatively. A 55-year old female patient complained about painless hematuria for 2 months. Computed tomography of the pelvic region revealed tumor and wall thickening at the left posterolateral side of the bladder. Total cystectomy with lymph node dissection and total abdominal hysterectomy and bilateral salphingo-oopherectomy was performed and histopathological and immunohistochemical findings strongly correlate with sarcomatoid carcinoma. The patient was treated with 3D conformal radiotherapy (3DCRT) with a total dose of 59.4 Gy with 1.8 Gy fractional daily doses. Patient was alive without any local recurrence and distant metastasis 10 months after surgery.

Differences in survival among patients with sarcomatoid carcinoma, carcinosarcoma and urothelial carcinoma of the bladder

PURPOSE

Sarcomatoid carcinoma and carcinosarcoma of the bladder are rare tumors that contain epithelial and mesenchymal elements, and may portend a worse prognosis than conventional urothelial carcinoma. We investigated the survival of patients with the 2 tumor subtypes compared to survival in those with urothelial carcinoma.

MATERIALS AND METHODS

Cases of sarcomatoid carcinoma, carcinosarcoma and high grade urothelial carcinoma of the bladder were identified from the Surveillance, Epidemiology and End Results Program. Demographic and pathological characteristics were compared. Differences in survival based on histological subtype were estimated using Kaplan-Meier analysis and multivariate Cox proportional hazards regression.

RESULTS

Overall unadjusted survival rates for 46,515 patients with urothelial carcinoma, 135 with sarcomatoid carcinoma and 166 with carcinosarcoma were 77%, 54% and 48% at 1 year, and 47%, 37% and 17% at 5 years, respectively. Sarcomatoid carcinoma and carcinosarcoma presented at a similar age but at a higher T stage and with more frequent regional and distant metastases compared to urothelial carcinoma. On multivariate analysis patients with sarcomatoid carcinoma (HR 1.18, 95% CI 0.91-1.52) and carcinosarcoma (HR 2.00, 95% CI 1.65-2.41) were at higher risk for death compared to those with urothelial carcinoma. Overall mortality was worse with carcinosarcoma than with sarcomatoid carcinoma (HR 1.70, 95% CI 1.23-2.34).

CONCLUSIONS

Compared to patients with urothelial carcinoma those with sarcomatoid carcinoma and carcinosarcoma present at a more advanced stage and are at greater risk for death even after adjusting for stage at presentation. The survival rate of sarcomatoid carcinoma is better than that of carcinosarcoma, offering some justification for the continued differentiation of these tumor types for clinical prognostication.

Clinical Outcomes Following Radical Cystectomy for Primary Nontransitional Cell Carcinoma of the Bladder Compared to Transitional Cell Carcinoma of the Bladder

PURPOSE

The effect of bladder cancer histological subtypes other than transitional cell carcinoma (nonTCC) on clinical outcomes remains uncertain. We conducted a multi-institutional retrospective study of patients with bladder cancer treated with radical cystectomy to assess the impact of nonTCC histology on bladder cancer specific outcomes.

MATERIALS AND METHODS

A total of 955 consecutive patients underwent radical cystectomy with bilateral pelvic lymphadenectomy for bladder cancer at 3 academic institutions. TCC was present in the radical cystectomy specimen in 888 patients (93%). NonTCC histology was present in 67 patients (7%), including squamous cell carcinoma in 26, adenocarcinoma in 13, small cell carcinoma in 10 and other nonTCC subtypes (ie spindle cell carcinoma, carcinosarcoma and undifferentiated carcinoma) in 18. For patients alive at last followup median followup was 39 and 23 months for patients with TCC and nonTCC histologies, respectively. Bladder cancer specific progression and survival were assessed using Kaplan-Meier and multivariate Cox proportional hazards analyses.

RESULTS

Bladder cancer specific progression and mortality did not differ significantly between patients with SCC and TCC histologies. Patients with nonTCC and nonSCC bladder cancer were at significantly increased risk for progression and death compared to patients with TCC or SCC (p <0.001). This association remained statistically significant in patients with organ confined disease (stage pT2 or lower) and patients with nonorgan confined disease (stage pT3 or higher) (p <0.001). In a multivariate analysis nonTCC and nonSCC histology was associated with an increased risk of bladder cancer progression and death (OR 2.272 and 2.585, respectively, p <0.001), even after adjusting for final pathological stage, lymph node status, lymphovascular invasion and neoadjuvant or adjuvant treatments.

CONCLUSIONS

NonTCC and nonSCC histological subtype is an independent predictor of bladder cancer progression and mortality in patients undergoing radical cystectomy for bladder cancer. Patients with bladder TCC and SCC share similar stage specific clinical outcomes.

Periurethral carcinosarcoma: a report of 2 cases with a review of the literature

Carcinosarcomas are rare, aggressive tumors that can arise in various sites of the body, especially the genitourinary system. In this system, the most common location for the tumor is the uterus in the female and the urinary bladder in the male. To our knowledge, only 2 cases with a periurethral location for this tumor have been previously described in the English literature. We describe 2 additional cases in this location, one in either sex, with a review of the relevant literature.

Gemcitabine and cisplatin following surgical treatment of urinary bladder carcinosarcoma

The clinical case of a 73-year-old man with a history of transitional cell carcinoma of the bladder, an ulcerated mass on the left hemitrigone and left hydronephrosis who underwent radical cystoprostatectomy and urinary diversion followed by cisplatin-gemcitabine chemotherapy is presented. Pathological examination revealed a biphasic mixed tumor characterized by an epithelial and a mesenchymal component. At 24 months of follow-up the patient is alive and free from recurrent disease, with good quality of life and preserved renal function. Carcinosarcoma is highly aggressive and often has a dismal outcome regardless of treatment. Among all the studied prognostic factors, pathological stage is the main predictor of survival. The outcome of our patient suggests that the relatively well tolerated gemcitabine-cisplatin regimen after surgical treatment of invasive carcinosarcoma of the bladder might improve the currently dismal prognosis of selected elderly patients.

[Carcinosarcoma of the bladder: report of our cases and review of the literature]

Carcinosarcomas of the bladder are rare. As a result, the natural history of them and the best methods of treatment remain uncertain. These tumors tend to be rapidly growing, invasive and recur locally. We reviewed our experience with four patients presenting between 1995 and 2002. Epidemiology findings, clinical aspects, histological features, diagnostic methods, treatment and survival are discussed in relation to literature.

Carcinosarcoma with a large cell neuroendocrine epithelial component: first report of an unusual biphasic tumour of the urinary bladder

This article describes the first reported case of carcinosarcoma of the urinary bladder with a large cell neuroendocrine epithelial component. A 61 year old man presented with gross haematuria and underwent resection of a biphasic bladder tumour. The malignant epithelial component showed large cell neuroendocrine differentiation with immunohistochemical reactivity for neurone specific enolase, synaptophysin, and chromogranin. The malignant mesenchymal component did not show specific differentiation by histological or immunohistochemical examination. The differential diagnosis of biphasic tumours in the urinary bladder is discussed, along with a review of the literature.

Carcinosarcoma of the urinary bladder: dynamic contrast-enhanced MR imaging with clinical and pathologic correlation

OBJECTIVE

This article describes the MR imaging features of carcinosarcoma of the urinary bladder with clinical presentation and pathologic correlation in three adults.

CONCLUSION

Carcinosarcoma of the urinary bladder is a rare and aggressive tumor that has a clinical presentation similar to that of transitional cell carcinoma of the bladder. Dynamic gadolinium-enhanced MR imaging features are discussed.

Leiomyosarcoma in urinary bladder after cyclophosphamide therapy for retinoblastoma and review of bladder sarcomas

We report an unusual case of a leiomyosarcoma of the urinary bladder after chemotherapy for retinoblastoma and the results of a review of the published reports of bladder sarcomas. A 22-year-old man presented with hematuria and was found to have a mass in his urinary bladder on computed tomography. Transurethral resection of the mass revealed a leiomyosarcoma. The patient underwent radical cystectomy and an ileal conduit was created. The final pathologic examination confirmed high-grade leiomyosarcoma. Prospective randomized combination trials similar to the Intergroup Rhabdomyosarcoma Study in the pediatric population are necessary to better understand and manage these potentially curable sarcomas.

A carcinosarcoma/sarcomatoid carcinoma arising in a urinary bladder diverticulum

We describe an invasive polypoid carcinosarcoma/sarcomatoid carcinoma arising within a urinary bladder diverticulum in a 65-year-old patient with synchronous, moderately differentiated prostatic adenocarcinoma. Histologically, the diverticular tumor exhibits an admixture of different morphologic components, including invasive high-grade urothelial carcinoma, malignant glandular structures in a cellular background of malignant spindle cells, and areas formed exclusively by spindle and pleomorphic cells. There was full-thickness involvement of the diverticulum with extension of the tumor into the perivesical fat and ipsilateral seminal vesicle. In view of the early invasive behavior of carcinosarcoma/sarcomatoid carcinoma combined with the paucity of the muscular layer in the diverticulum wall, a graver prognosis was expected for this aggressive tumor that occurred in this unusual site.

Molecular pathogenesis of pulmonary carcinosarcoma as determined by microdissection-based allelotyping

Pulmonary carcinosarcoma is a rare, biphasic tumor composed of malignant epithelial and mesenchymal elements. Its histogenesis is controversial in light of the presence of divergent cell lineages and the clonal nature of malignancy. To address these issues, we performed an extensive comparative genotypic analysis using microdissection to secure representative mesenchymal and epithelial components from each of six cases of pulmonary carcinosarcoma. Loss of heterozygosity was analyzed with a panel of 12 polymorphic microsatellite markers designed to indicate allelic loss and situated in proximity to known tumor suppressor genes located on 1p, 3p, 5q, 9p, 10q, and 17p. In accordance with the relatively greater biologic aggressiveness of this tumor type, both the epithelial and mesenchymal components showed extensive allelic loss, most notably for 3p, 5q, and 17p. More importantly, we found overall equivalent patterns of acquired allelic loss between the two components on an individual case basis, strongly supporting the monoclonal origin of these neoplasms. Minor differences in the allelic fingerprint between the two cell lineages could be explained by progressive accumulation of allelic loss alterations that appear to occur more frequently in the mesenchymal component of the tumor. The data support the efficacy of microdissection-based allelic fingerprinting to delineate the relationship between different morphologic components of a single neoplasm.

Malignant islet cell tumor with sarcomatous differentiation

Malignant mesenchymal neoplasms of the pancreas are rare and malignant islet cell tumors with sarcomatous dedifferentiation are rarer still. We present a case of malignant islet cell tumor with sarcomatous differentiation, which to our knowledge is only the second reported case showing such a combination of morphologic features. Clinically, the neoplasm was not hormonally active and immunohistochemical staining was negative for gastrin, glucagon, insulin and somatostatin. The sarcomatous component strongly reacted with an antibody directed against vimentin, and a minority of cells stained strongly with antisera directed against desmin and smooth muscle actin. The spindle cell component was nonreactive with antibodies directed against Factor VIII. The myogenous direction of differentiation in the present tumor is similar to that seen in the prior case report of malignant islet cell tumor with rhabdomyosarcomatous differentiation.

Osteosarcoma of the urinary bladder occurring simultaneously with prostate and bowel carcinomas: report of a case and review of the literature

Osteosarcoma is a very rare tumor of the urinary bladder, with only 28 well-documented cases reported in the literature to date. The tumors have characteristically been large and polypoid and most commonly have been located in the trigone. An abdominal mass has occasionally been palpated, and rectal examination has frequently revealed a mass in the region of the bladder. The prognosis for this tumor is very poor. In this report, a 75-year-old man with hematuria was found to have a primary osteosarcoma of the urinary bladder with superficial invasion. Radical cystoprostatectomy and ileal conduit urinary diversion were performed. During surgery, a synchronous mucinous adenocarcinoma of the ascending colon was found, and a right hemicolectomy was performed. Prostatic adenocarcinoma was discovered from the histology. The patient died 7 months after surgery with systemic spread of the osteosarcoma. Osteosarcoma of the bladder should be distinguished from other bladder tumors that may be associated with bone formation, such as carcinosarcomas and transitional cell carcinomas with osseous metaplasia of their stroma, both of which have a better prognosis than osteosarcoma.

Synchronous occurrence of bladder carcinosarcoma and testicular seminoma

We report a case of urinary bladder carcinosarcoma with simultaneous testicular seminoma. A 60-year-old male presented with painless gross hematuria and a left testicular mass. The bladder tumor was deeply infiltrating muscular tissue and had histologic features of both carcinoma and sarcoma. Testicular tumor was diagnosed as classical seminoma. Radical cystectomy, pelvic and left-modified retroperitoneal lymphadenectomy were performed. The lymph nodes did not show metastasis. At the 26 months follow-up, the patient is free of disease.

Carcinosarcoma with rhabdoid features of the urinary bladder in a 2-year-old girl: possible histogenesis of stem cell origin

A case of carcinosarcoma of the urinary bladder in a 2-year-old girl is reported. The tumor, measuring 34 x 20 x 18 mm, was located in the peri-trigone area of the urinary bladder with polypoid features. Histologic examination revealed transitional cell carcinoma at the tumor surface with downward invasion. Concurrently, a sarcomatous area was found beneath the carcinoma, with these two different malignant components sharing on apparent transition without distinct boundaries. Sarcomatous components included immature round cells focally showing rhabdoid features. No rhabdomyomatous component was observed. Immunohistochemistry disclosed vimentin and cytokeratin-double positive cells at the transposition between carcinoma and sarcomatous components. In addition, ultrastructural analysis revealed that the epithelial cells had a distinct junctional complex, and the sarcomatous cells occasionally had a meshwork of cytoplasmic intermediate filaments, indicating bidirectional cytodifferentiation to epithelial and mesenchymal elements. The extremely young age at which this case of carcinosarcoma occurred suggests that the tumor may be of mesodermal stem cell origin.

Carcinosarcoma of the urinary bladder--an aggressive tumor with diverse histogenesis. A clinicopathologic study of 4 cases and review of the literature

OBJECTIVE

Carcinosarcomas of urinary bladder are rare malignant neoplasms. Seventy-eight cases have been previously described. The histologic composition of these tumors is variable, but diagnosis requires the presence of both epithelial and mesenchymal malignant components. We report 4 additional cases, with an emphasis on unusual histologic features.

METHODS

Histologic and immunohistochemical examinations were performed on bladder tumors from 4 patients. Clinicopathologic features of previously reported and current cases were reviewed and summarized.

RESULTS

Four patients (3 men, 1 woman) age 54 to 77 years were found to have polypoid masses in the urinary bladder. In all cases, histologic examination showed biphasic neoplasms with distinct mesenchymal and epithelial components. The morphologic and immunohistochemical characteristics of the tumors varied. One of the cases was remarkable for the presence of liposarcoma, malignant peripheral nerve sheath tumor, and micropapillary urothelial carcinoma. Two of the patients died 2 years after diagnosis, which is consistent with the previously reported aggressive nature of urinary bladder carcinosarcomas.

CONCLUSIONS

Carcinosarcomas of the urinary bladder are rare, aggressive malignant neoplasms. To our knowledge, a liposarcomatous component has been reported in only 1 case previously, and components of micropapillary urothelial carcinoma and malignant peripheral nerve sheath tumor have not been reported previously in carcinosarcomas of the urinary bladder. Because of the aggressive biologic behavior of these tumors, they should be identified promptly and treated appropriately.

Sarcomatoid carcinoma of the renal pelvis: a case report

A case of sarcomatoid carcinoma of the renal pelvis is reported. A 72-year-old male was admitted with a chief complaint of right flank pain. Clinical imaging studies revealed marked dilation of the right renal pelvis caused by a tumor at the pyeloureteric region. Right nephrectomy was performed in June 1999. The 8.4 x 6.5 cm tumor was grossly polypoid in appearance and protruded into the renal pelvis. Histologically, sarcomatoid spindle cells predominated over the carcinomatous component (mainly transitional cell carcinoma, partly associated with squamous cell and adenocarcinoma components). Osteoclast-like CD68-positive multinucleated giant cells were scattered. The sarcomatoid component was immunoreactive for both cytokeratin and vimentin. Sarcomatoid cells negative for cytokeratin were also noted. In both the sarcomatoid and carcinomatous components, nuclear overexpression of p53 oncoprotein was confirmed. The histogenesis of sarcomatoid carcinoma of the renal pelvis is discussed.

Primary carcinosarcoma of the skin: report of a case and review of the literature

BACKGROUND

Carcinosarcoma is a biphasic tumor composed of intimately admixed epithelial and mesenchymal elements, both of which are malignant. Primary cutaneous involvement is extremely rare. Therefore it has been difficult to characterize the clinical course of carcinosarcoma of the skin.

OBJECTIVE

To describe a further case of carcinosarcoma of the skin and to provide a review of the literature.

METHODS

The clinical records of the patient and histopathology of the neoplasm are reviewed. In addition, the results of all previously reported cases of carcinosarcoma of the skin are compiled for reexamination.

RESULTS

After complete excision of the carcinosarcoma, the patient shows no evidence of disease for 9 months. Long-term follow-up is needed because of the risk of recurrence or metastasis that may occur with this neoplasm.

CONCLUSION

Carcinosarcoma of the skin appears to be associated with a good prognosis when compared with similar tumors located elsewhere. Metastasis (with or without documented mortality) has been reported in 3 of 16 patients (16.7%). Death from local disease has been reported in one additional patient (6.3%). However, further cases with long-term follow-up are needed in order to better understand the nature of this cutaneous neoplasm.

Carcinosarcoma and sarcomatoid carcinoma of the bladder: clinicopathological study of 41 cases

PURPOSE

Carcinosarcoma of the bladder is a rare neoplasm characterized by an intimate admixture of carcinoma and malignant soft tissue neoplasm. The clinical usefulness of separating carcinosarcoma (carcinoma with sarcomatous component) from sarcomatoid carcinoma (carcinoma with spindle cell carcinomatous component) is uncertain, and it comprises the subject of this report.

MATERIALS AND METHODS

We reviewed the clinical and pathological records of 10 men and 5 women a mean of 66 years old with carcinosarcoma, and 21 men and 5 women a mean of 66.5 years old with sarcomatoid carcinoma of the bladder, as documented in the files of the Mayo Clinic between 1936 and 1995.

RESULTS

Of the 15 patients in the carcinosarcoma group 9 had urothelial carcinoma, small cell carcinoma, 3 had squamous cell carcinoma and 2 had more than 1 type. The sarcomatous component included chondrosarcoma in 3 cases, leiomyosarcoma in 3, malignant fibrous histiocytoma in 3, osteosarcoma in 2, fibrosarcoma in 1, rhabdomyosarcoma in 1 and more than 1 type in 2. All disease was high stage at presentation. Treatment included cystectomy in 11 patients with (4) and without (7) radiation therapy, and transurethral resection in 4 with (1) and without (3) radiation therapy. Mean followup available in 14 cases was 34 months (range 1 to 144). A total of 11 patients died of cancer at 1 to 48 months (mean 17.2) and 2 survived for 8 to 131 months. Of the 26 patients in the sarcomatoid carcinoma group 18 had urothelial carcinoma, 1 had squamous carcinoma, 2 had urothelial carcinoma combined with squamous cell carcinoma and 5 had spindle cells only with no recognizable epithelium. All but 1 case was high stage at diagnosis. Treatment included transurethral resection in 17 patients with (7) and without (10) radiation therapy, including 1 who also received chemotherapy, and only cystectomy in 5, including 2 who also underwent radiation therapy and 1 who also received chemotherapy. Mean followup available in 21 cases was 49 months (range 1 to 420). A total of 17 patients died of cancer at 1 to 73 months (mean 9.8), 1 was alive at 140 months and 3 died of unrelated causes.

CONCLUSIONS

Carcinosarcoma and sarcomatoid carcinoma of the bladder are highly aggressive malignancies with a similar outcome regardless of histological findings and treatment. Pathological stage is the best predictor of survival.

Sarcomatoid carcinoma of the ureter: a case report

We report a case of sarcomatoid carcinoma of the ureter in a 60-year-old woman who presented at our hospital with right flank pain. She had undergone total ovariectomy and radiation therapy for ovarian cancer at the age of 40 years. A diagnosis of ureteral tumor (cTsN0M0) led to radical right nephroureterectomy and partial cystectomy. Microscopic examination showed a tumor that contained areas of both sarcoma and transitional cell carcinoma. The carcinomatous tissues were blended into the sarcomatous areas and there was a transitional zone between the 2 components. Immunohistochemical examination showed that the spindle cells were positive for cytokeratin, so the final diagnosis was sarcomatoid carcinoma of the ureter. The patient has remained well without any evidence of recurrence for 5 months since the operation. There is no effective adjunctive therapy, so constant careful monitoring will be necessary. Sarcomatoid carcinoma of the ureter is a rare tumor and this is only the sixth case reported in Japan.

Pathology of transitional cell carcinoma of the bladder and its clinical implications

Transitional cell carcinomas are divided into superficial and muscle-invasive tumors. Most of them are superficial tumors, and approximately 15-20% are muscle-invasive carcinomas. Pathologists play a significant role in diagnosing bladder tumors and in reporting features important for determining prognosis. We will review the cytologic and histopathologic features that help determine prognosis, including depth of invasion, tumor grade, multicentricity, tumor size, and the presence of vascular/lymphatic invasion, blood group antigen expression, proliferative indices, and molecular markers. Brief mention will be made of specimen handling, interpretation, reporting, and histologic variants of transitional cell carcinoma.

Primary metaplastic carcinoma (carcinosarcoma) of the skin. A clinicopathologic study of four cases and review of the literature

Metaplastic carcinoma (carcinosarcoma, sarcomatoid carcinoma, malignant mixed tumor) is a biphasic tumor comprising malignant epithelial and heterologous mesenchymal elements. Primary cutaneous cases are rare, with only seven cases documented in the English literature to date. We present four further cases, including three that developed in association with squamous cell carcinoma and one in an eccrine porocarcinoma. Heterologous malignant mesenchymal elements included malignant osteosarcoma, chondrosarcoma, leiomyosarcoma, and rhabdomyosarcomas. In contrast to metaplastic carcinomas arising in visceral sites, those primarily arising in the skin do not appear to behave in a very aggressive manner (Recurrence rate 22%, metastasis rate 22%, overall mortality 11%). However, the numbers involved are small and the follow-up period is short. In view of recent developments and progress in our understanding of the possible histogenesis of such tumors, we suggest that metaplastic carcinoma rather than carcinosarcoma is the most appropriate term with which to describe these very rare cutaneous neoplasms.

Carcinosarcoma in the region of the female urethra

A 61-year-old woman with acute urinary retention was found to have a carcinosarcoma in the region of the urethra. Evaluation of the computed tomogram suggested a urethral tumor, which was resected by a transperineal approach. She received local radiotherapy after surgery, and is alive at 1-year follow-up with a tumor metastasis to the pelvis.

Carcinosarcoma of the urinary bladder: expression of epithelial markers and different expression of heat shock proteins between epithelial and sarcomatous elements

A case of carcinosarcoma composed of both adenocarcinoma and sarcomatous elements in the non-trigone region of the urinary bladder is presented. The epithelial element was a well to poorly differentiated adenocarcinoma with focal squamous metaplasia. The sarcomatous elements disclosed spindle cell sarcoma with focal epithelioid pattern and myxoid change in the stroma, together with chondrosarcomatous and rhabdomyosarcomatous elements. By immunohistochemical examination, not only the carcinoma element but also the sarcomatous elements showed a positive immunoreaction for cytokeratin (CK), epithelial membrane antigen (EMA) and carcinoembryonic antigen. Some population of sarcomatous elements expressed smooth muscle actin and muscle specific actin (MSA) and a limited portion of epithelioid area showed a positive immunoreaction for desmin, MSA and myoglobin, indicating leiomyosarcomatous and rhabdomyosarcomatous differentiation, respectively. Unexpectedly, tumor cells in the chondrosarcomatous element revealed a simultaneous positivity of CK and EMA as well as S-100 protein. Both epithelial and sarcomatous elements showed an intensive positive immunoreaction for p53 and heat shock protein (HSP) 70. However, HSP27 and HSP60 were detected in most epithelial elements and only in a small number of tumor cells in the sarcomatous area. These findings indicate that sarcomatous elements, including heterologous elements, may derive from epithelial elements with partial or complete loss of epithelial features, and different factors other than p53 and HSP70 may associate with the morphological alteration of carcinoma.

Sarcomatoid transitional cell carcinoma of the renal pelvis. A report of five cases with clinical, pathological, immunohistochemical and DNA ploidy analysis

Sarcomatoid transitional cell carcinoma of the renal pelvis is a rare neoplasm with only 7 well illustrated examples reported. These tumours can assume a partial or complete spindle cell pattern of growth, leading to the erroneous classification as sarcomas. We describe the clinic-pathologic features of five additional examples of sarcomatoid carcinoma of the renal pelvis observed in three males and two females. The age ranged from 65-to-82 years-old (mean 71.6). All these patients were treated by nephrectomy and died of disease between 6 and 20 months (mean 11.2) after the onset of symptoms. An immunohistochemical study demonstrated coexpression of keratins, epithelial membrane antigen and vimentin. The image DNA ploidy of all the tumours showed an aneuploid pattern.

Carcinosarcoma of the urinary bladder

A case of carcinosarcoma of the urinary bladder is reported. Transurethral resection was performed. Histologically the tumorous mass was composed of osteosarcoma, squamous cell carcinoma and transitional cell carcinoma. The histological findings, immunohistochemical features and clinical manifestations of bladder carcinosarcoma are discussed in relation to the literature.

Carcinosarcoma of the bladder

We present a case of carcinosarcoma of the bladder, the first in our experience. This tumour is generally considered to be a rare one, has uncertain aetiology and poor prognosis. At present, radical cystectomy is the treatment of choice.

Fine-needle aspiration cytology of recurrent and metastatic mixed mesodermal tumors

We report the cytological and clinical findings of 16 fine-needle aspirates (FNAs) performed on recurrent (n = 6) and metastatic (n = 10) mixed mesodermal tumors (MMMTs). The median interval between the primary diagnosis and FNA was 16 mo. Primary sites were the endometrium (n = 11), the ovary (n = 3), the cervix (n = 1), and pelvic soft tissue (n = 1). Primary tumors showed carcinoma with homologous mesenchymal components in 13 cases and focal heterologous elements in three (two chondrosarcomas and one rhabdomyosarcoma). The FNAs showed carcinoma in all 16 cases, with adenocarcinoma differentiation in three. Mesenchymal elements were identified in aspirates of three recurrent and two metastatic lesions. They were all homologous. aspirates. We conclude that mesenchymal components in FNAs of MMMTs are less likely to be seen in metastatic lesions, and that heterologous mesenchymal components are rarely seen in these aspirates even in recurrent disease. These findings confirm that the epithelial component is responsible for the malignant behaviour of MMMTs, and suggest that these lesions may need to be classified as sarcomatoid carcinomas rather than true carcinosarcomas.

Carcinosarcoma in a bladder diverticulum

A 47-year-old man presented with hematuria and dysuria. He was found to have a carcinosarcoma originating from a bladder diverticulum. He underwent a partial cystectomy and received postoperative chemotherapy. One year later, he presented with a large local recurrence and died shortly afterward. We believe this to be the second case of a carcinosarcoma originating in a bladder diverticulum.

Primary osteogenic sarcoma of the urinary bladder successfully treated with combination therapy

A 54-year-old woman presented with a large bladder mass and left hydroureteronephrosis. At radical cystectomy (with ileal loop urinary diversion), an unresectable left obturator mass was found. Combination chemotherapy postoperatively resulted in significant shrinkage, and she underwent excision of the residual mass. No residual cancer was seen. The patient remains free of disease 56 months after cystectomy and 51 months after resection of the residual mass. Primary osteogenic sarcoma of the urinary bladder may respond to combination chemotherapy and surgery. All patients found to have advanced disease should be considered for this approach.

Malignant mesenchymoma of the prostate: immunohistochemical and ultrastructural observations

A case of malignant mesenchymoma of the prostate is reported. Immunohistochemical and ultrastructural examination revealed malignant chondro-osteoblastic and rhabdomyoblastic features. A separate incidental prostatic adenocarcinoma was also seen. These lesions should be differentiated from carcinosarcoma in which adenocarcinoma is intermingled with malignant mesenchymal components.

Primary mesenchymal tumors of the urinary bladder. A histological and immunohistochemical study of 30 cases

The light microscopic and immunohistochemical features of 30 primary mesenchymal neoplasms of the urinary bladder are reported. Half of the cases represented smooth and striated muscle tumors (five leiomyomas, seven leiomyosarcomas including epithelioid and myxoid subtypes, one rhabdomyoma, one embryonal rhabdomyosarcoma and one alveolar rhabdomyosarcoma). One third of the tumors were of fibrohistiocytic origin (one fibrous histiocytoma and eight malignant fibrous histiocytomas including fascicular and storiform, inflammatory and pleomorphic subtypes). In addition, a malignant epithelioid schwannoma, a round cell liposarcoma, two hemangiomas and two mixed mesodermal tumors were observed. The morphology of the vesical mesenchymal tumors was identical to that of their counterparts known to occur in other sites, particularly in the soft tissue. Muscle-specific actin, alpha-1-antichymotrypsin, S-100-protein and neuron-specific enolase proved to be useful and reliable immunomarkers for differential diagnosis of poorly differentiated leio- and rhabdomyosarcomas, malignant fibrous histiocytomas and malignant schwannomas. Since some tumors coexpressed several classes of intermediate filaments, diagnostic immunocytochemistry should only be used considering a larger panel of antibodies and in close correlation with the histological and cytological features of the neoplasms.

Carcinosarcoma of urinary bladder: report of 5 cases with immunohistologic study

We studied 5 cases of carcinosarcoma of the urinary bladder. Immunoperoxidase studies were performed to identify the nature of the tumor and to establish the diagnosis. We suggest that these tumors represent a transition of epithelial to mesenchymal malignancy. Three of our patients had a history of radiation therapy prior to development of carcinosarcoma; of which 2 had a long interval between exposure to radiation and tumor development. Radiation is a risk factor for endometrial carcinosarcoma, and in this report we strongly suggest such an association for the urinary bladder.

Sarcomatoid carcinoma of the urinary tract

Sarcomatoid carcinoma is a rare variant of malignant tumor arising from the urinary tract. This tumor had been termed carcinosarcoma because of its carcinomatous and sarcomatous components. There is still some confusion in the terminology between true carcinosarcoma and sarcomatoid carcinoma; however, the latter is now regarded as primarily a malignant epithelial tumor with pseudosarcomatous transformation. Four cases of sarcomatoid carcinoma arising from the urinary tract are reported. The patients were a 77 year old female, and three males aged 62, 69 and 80 years. All but the eldest patient complained of gross hematuria. Surgical removal was performed in the younger three cases, and an autopsy was done in the remaining case. All the tumors were macroscopically polypoid. Histopathologic examination revealed fasciculated spindle-cell tumors with myxoid stroma or malignant fibrous histiocytoma-like spindle cell tumors. The epithelial nature was proven in these sarcomatous cells by immunohistochemical and/or electron-microscopic examinations. Only a small amount of squamous cell carcinoma components was also evident in the latter three cases. Although the younger three patients were alive at 44, 23 and 39 months' follow-up, respectively, constant careful monitoring is recommended.

Epithelioid osteosarcoma of bone. Immunocytochemical evidence suggesting divergent epithelial and mesenchymal differentiation in a primary osseous neoplasm

BACKGROUND

The combination of a primary osteosarcoma of bone with a second carcinomatous cell type has been recognized, although immunohistochemical studies currently have not been performed in an attempt to understand the histogenesis of such a tumor.

METHODS

In this report, the authors performed immunohistochemical studies on a primary osseous carcinosarcoma. Using a biotin-streptavidin peroxidase conjugate technique, the expression of keratin, epithelial membrane antigen, and vimentin was analyzed.

RESULTS

The epithelial cells expressed cytokeratin and epithelial membrane antigen but did not express vimentin. The mesenchymal cells strongly expressed vimentin, and only rare cells expressed cytokeratin.

CONCLUSIONS

The clinical, morphologic, and immunophenotypic data in this instance strongly suggest divergent differentiation of a primitive multipotential uncommitted stem cell in a primary osseous tumor.

Carcinosarcoma of the urinary bladder: a distinct variant characterized by small cell undifferentiated carcinoma with neuroendocrine features

The clinicopathological features of two carcinosarcomas of the urinary bladder are reported. The tumours occurred in a 64- and a 66-year-old patient presenting with haematuria and both were polypoid. The epithelial component was consistent with small cell undifferentiated carcinoma with neuroendocrine differentiation, whereas the sarcomatous component did not display specific features. The carcinomatous component showed immunohistochemical reactivity for different epithelial markers as well as for chromogranin and neuron specific enolase. Conversely, the sarcomatous cells stained strongly for vimentin and in one case for muscle actin and smooth muscle actin. The differential diagnosis of biphasic tumours of the bladder is discussed and the literature reviewed.

Sarcomatoid carcinoma of the lung. Immunohistochemical and ultrastructural studies of 14 cases

The authors retrospectively reviewed data regarding 14 patients with sarcomatoid carcinomas of the lung seen and treated at M.D. Anderson Cancer Center from 1955 to 1986. The following were the histologic criteria for inclusion in the study: (1) the concurrent presence of malignant epithelial and sarcomatoid spindle cell components, and (2) positive immunoreactivity for antikeratin antibody or ultrastructural demonstration of epithelial differentiation in sarcomatoid tumors in which the epithelial component was inconspicuous. For the sarcomatoid components, the most frequent pattern was malignant fibrous histiocytoma, which was present in ten tumors. An unclassified sarcomatoid pattern was found in two cases and a fibrosarcomatous pattern in two remaining cases. Clinically, the median patient age was 59 years; 12 patients were male and 2 were female; 13 were smokers and 1 used snuff. Three patients had Stage I, ten had Stage III, and one had Stage IV disease. One patient with Stage I, seven with Stage III, and one with Stage IV disease died of their carcinomas 2 to 26 months after diagnosis (median survival time 12 months). All patients who had lymph node metastases at presentation died of disease. The authors concluded the following: (1) patients with sarcomatoid carcinoma of the lung usually presented at an advanced stage; (2) lymph node metastasis, as with a usual carcinoma of the lung, is an important prognostic factor; and (3) for all lung tumors with a sarcomatoid pattern, especially a malignant fibrous histiocytoma pattern, extensive samples should be obtained and immunoperoxidase or ultrastructural studies done to identify epithelial differentiation.

Prostatic carcinosarcoma: case report and review of literature

True carcinosarcoma of the prostate is a rare neoplasm, with only 9 cases well documented by immunocytochemistry and ultrastructural examination. We report a case of an unresectable pelvic tumor studied at autopsy. The primary prostatic neoplasm and pulmonary metastases were composed of well differentiated adenocarcinoma admixed with foci of leiomyosarcoma and osteosarcoma. The sarcomatous components showed reactivity with vimentin and desmin, did not express prostatic acid phosphatase (PAP) and prostate specific antigen (PSA), and contained myofilaments on electron microscopic examination. Positive staining of the carcinomatous component for PAP and PSA was noted. These findings confirm the mixed epithelial and mesenchymal components in primary and metastatic sites, and support the diagnosis of true prostatic carcinosarcoma.