Mucoid cytoplasmic inclusions in urothelial carcinomas

Intracytoplasmic Lumen in Urine Cytology Predicts Worse Prognosis in Non-Muscle-Invasive Bladder Cancers

BACKGROUND

Intracytoplasmic lumina (ICL) are observed in several cancers, including urothelial carcinoma (UC). We have reported that ICL in urine cytology (cICL) is more frequent in high-grade UCs than in low-grade UCs; however, the correlation between the presence of ICL and prognosis is unclear.

OBJECTIVES

The aim of this work was to determine the association between cICL and prognosis in bladder cancer.

METHOD

We retrospectively investigated 87 patients with bladder cancer who received a histological diagnosis within 3 months of urine cytology at Kanazawa Medical University between 2003 and 2007. The cytological diagnosis and the number of cICL, histological diagnosis, tumor grade or variant, pT stage, ICL in histological specimens, and immunohistochemistry for mucins were evaluated. Data on the treatment type, recurrence, survival, cause of death, and length of follow-up were collected from electronic medical records.

RESULTS

Muscle invasion, high-grade UC, lymph node metastasis, distant metastasis, adjuvant therapy, and disease-related mortality were more frequent in patients with cICL-positive bladder cancer than in those without cICL-positive bladder cancer. Immunohistochemistry revealed the expression of Muc-1 and Muc-4 in patients with cICL-positive bladder cancer. Univariate analysis revealed that cytological diagnosis by the Paris system and the 2015 version of the Japanese reporting system, muscle invasion, high-grade UC, lymph node metastasis, distant metastasis, and adjuvant chemotherapy and/or radiotherapy were significant factors associated with prognosis. Furthermore, survival was shorter in patients with cICL-positive non-muscle-invasive bladder cancer than in those with cICL-negative non-muscle-invasive bladder cancer. In the multivariate analysis, only distant metastasis was significantly associated with survival.

CONCLUSIONS

cICL predicted shorter survival in patients with non-muscle-invasive bladder cancer, suggesting that ICL is one of the important diagnostic features of high-grade UC with a worse prognosis in urine cytology.

[Renal urothelial carcinoma mainly composed of signet-ring cells]

Autopsy study of an 80-year-old man has identified his renal tumor metastasizing to the heart, lung, and liver as urothelial car- cinoma; at the same time some cells in the main tumor and all cells in the metastases had a signet-ring phenotype, but neither mucicarcimine nor alcian blue stained the cell cytoplasm. The paper provides the histological and immunohistochemical pattern of the tumor and emphasizes its exclusive rarity. Attention is drawn to the possibility of signet-ring cell transformation in the cells of different tumors, including nonepithelial ones.

Microcystic variant of urothelial carcinoma

Background. Microcystic variant of urothelial carcinoma is one of the new variants of urothelial carcinoma that was added to the WHO classification in 2004. Aims. To review the literature on microcystic variant of urothelial carcinoma. Methods. Various internet search engines were used to identify reported cases of the tumour. Results. Microscopic features of the tumour include: (i) Conspicuous intracellular and intercellular lumina/microcysts encompassed by malignant urothelial or squamous cells. (ii) The lumina are usually empty; may contain granular eosinophilic debris, mucin, or necrotic cells. (iii) The cysts may be variable in size; round, or oval, up to 2 mm; lined by urothelium which are either flattened cells or low columnar cells however, they do not contain colonic epithelium or goblet cells; are infiltrative; invade the muscularis propria; mimic cystitis cystica and cystitis glandularis; occasionally exhibit neuroendocrine differentiation. (iv) Elongated and irregular branching spaces are usually seen. About 17 cases of the tumour have been reported with only 2 patients who have survived. The tumour tends to be of high-grade and high-stage. There is no consensus opinion on the best option of treatment of the tumour. Conclusions. It would prove difficult at the moment to be dogmatic regarding its prognosis but it is a highly aggressive tumour. New cases of the tumour should be reported in order to document its biological behaviour.

Urothelial carcinoma with abundant myxoid stroma

Urothelial carcinomas with abundant myxoid stroma have thus far been only briefly reported in a couple of textbooks yet not in the peer-reviewed literature. Thirteen cases of urothelial carcinoma with myxoid features were collected over 9 years. Cases with any distinct adenocarcinoma component were excluded from the study. The mean age of the patients was 64 years (range, 45-84 years). Nine of the 13 were male. All cases involved the bladder with one of the cases involving a bladder diverticulum. Treatment included transurethral resection of the bladder only in 6 patients, transurethral resection of the bladder with subsequent intravesical bacillus Calmette-Guérin treatment in 4 patients, radical cystectomy only in 2 patients, and neoadjuvant chemotherapy followed by cystectomy in 1 patient. In all cases, the myxoid stroma was associated with invasive urothelial carcinoma. The 2 most common patterns of cancer with myxoid stroma were small- or medium-sized nests seen in 10 cases followed by filiform cancer seen in 4 cases. Other patterns of invasive cancer associated with myxoid stroma were short cords and individual cells. The percentage of invasive urothelial carcinoma that had myxoid stroma ranged from 5% to 95% (mean, 50%). An unusual finding was the presence of invasive low-grade urothelial carcinoma associated with myxoid stroma in 5 cases, 4 of which had an overlying low-grade papillary urothelial carcinoma component. All cases were uniformly positive for cytokeratin 7 and negative for CDX2 with 5 cases also positive for cytokeratin 20. Urothelial carcinoma associated with the extracellular myxoid matrix was positive for MUC5 in 3 cases and for MUC2 in 2 cases. Two of the MUC5-positive cases were also positive in the urothelium for polyclonal CEA. Histochemical stains for Alcian blue with and without hyaluronidase, periodic acid-Schiff, and mucicarmine showed positivity in the areas of myxoid differentiation. The current study describes a rare variant of urothelial carcinoma that may be confused with primary or secondary adenocarcinoma of the bladder, which can have therapeutic and prognostic implications.

Multicystic urothelial carcinoma of the bladder with gland-like lumina and with signet-ring cells. A case report

We present the case of 80-year-old male with superficial papillary urothelial carcinoma of the urinary bladder with striking multicystic architecture with a combination of features of urothelial carcinoma with gland-like lumina, with signet-ring cell differentiation and microcystic pattern. However, the tumor shared the morphologic features of several variants of urothelial carcinoma, the most important differential diagnosis covered so-called florid Brunneriosis, cystitis cystica, and primary adenocarcinomas of the urinary bladder.

Histologic Variants of Infiltrating Urothelial Carcinoma

Context.—The spectrum of urothelial carcinoma is broad, and variant morphologies are being reported continually. Many of these variants have been extensively documented and even established as subclasses of urothelial carcinoma.

Objective.—To review the established and more recently described variants of urothelial carcinoma. The significance of recognizing these variants is discussed.

Data Sources.—The literature is reviewed in conjunction with our experience pertaining to urothelial carcinomas of the bladder and ureters.

Conclusions.—Urothelial carcinoma displays many forms, and some of these variant morphologies may introduce diagnostic difficulties because of their similarity to other malignancies and/or benign lesions. Additionally, it is important to recognize variants that are associated with different outcomes from conventional urothelial carcinoma. For these reasons, familiarity with the diverse morphology of urothelial carcinoma is not simply an academic exercise but is important in providing quality care for patients affected by this disease.

Bovine papillomavirus type-2 (BPV-2) infection and expression of uroplakin IIIb, a novel urothelial cell marker, in urinary bladder tumors of cows

Several immunohistochemical markers have been used to define the differentiation pattern of urothelial cell tumors of the urinary bladder. We investigated the expression of the recently characterized uroplakin (UP) IIIb, an urothelium-specific and differentiation-dependent protein, in 39 urothelial tumors of the urinary bladder in cows that had suffered from chronic enzootic hematuria for several years. Bovine papillomavirus type 2 DNA was amplified and UP IIIb protein was detected in all these tumors. In papillomas and papillary carcinomas, UP IIIb expression was mostly seen as superficial staining; luminal and peripheral patterns were also observed. In nonpapillary carcinomas, UP IIIb appeared to define clearly the cell membrane lining intercellular and intracellular lumina as well as the cell borders in deeper cell layers. In benign and malignant lesions, an intracytoplasmic immunoreactivity was also detected. Coarse intracytoplasmic UP IIIb-positive material close to the nucleus occurred in some malignant cells. Focally strong membraneous immunostaining that marked single cells with complete ringlike peripheral pattern was seen. Although UP IIIb expression does not seem to correlate with the biological behavior of urothelial tumors, it appears to be a highly sensitive marker for bovine urothelial tumors.

Transitional Cell Carcinoma of the Ovary

Transitional cell carcinoma (TCC) of the ovary is a recently recognized subtype of ovarian surface epithelial-stromal cancer, and studies of its morphology are few. As a result, the criteria for its diagnosis and spectrum of its morphology are not clearly established. One hundred consecutive consultation cases of ovarian carcinoma with a pure or partial transitional cell pattern (excluding malignant Brenner tumor) diagnosed between 1989 and 2001 were evaluated for the frequency of various pathologic features and the relation of TCC to other surface epithelial-stromal carcinomas. The women were 33 to 94 years of age (mean, 56 years). A total of 47 tumors were stage I, 21 stage II, 31 stage III, and 1 stage IV; 13% of the stage I tumors and 41% of tumors of all stages were bilateral. The tumors ranged from 3.0 to 30 cm in greatest dimension (mean, 10 cm); 60% of them were solid and cystic, 24% solid, and 16% cystic. TCC was the exclusive or predominant component in 93% of the tumors and showed undulating (93%), diffuse (57%), insular (55%), and trabecular (43%) patterns. In four tumors with an insular growth, the pattern focally mimicked a Brenner tumor. Necrosis was present in 57% of the cases. Features that were seen in the tumors that in aggregate produced a relatively consistent appearance were "punched out" microspaces (87%), often the size of Call-Exner bodies, large cystic spaces (73%), and large blunt papillae (63%). Features that were sometimes seen, usually as a focal finding, included slit-like fenestrations (49%), bizarre giant cells (35%), small filiform papillae (18%), gland-like tubules (17%), squamous differentiation (13%), and psammoma bodies (4%). In 23 cases, TCC was a component of a mixed epithelial carcinoma, the additional components being serous adenocarcinoma in 16, endometrioid in 5, mucinous in 1, and clear cell carcinoma in 1. The tumor cells of the TCC component often were relatively monomorphic; 6% of the tumors were grade 1, 43% grade 2, and 51% grade 3. The nuclei were oblong or round and often had large single nucleoli (69%) or longitudinal grooves (48%). The cytoplasm was typically pale and granular but was rarely strikingly clear or oxyphilic. TCC of the ovary usually occurs in pure form but is also common as a component of a surface epithelial carcinoma of mixed cell type. In either situation, TCC has a constellation of architectural and cytologic features that readily distinguish it in most cases from other types of ovarian cancer. Recognition of these features will lead to a more consistent diagnosis of this tumor and aid in determining whether it has distinctive clinical features, particularly with regard to its behavior.

Expression of c-erbB-2 and cytokeratins 7 and 20 in urothelial carcinoma with gland-like lumina

Urothelial carcinoma with gland-like lumina is an uncommon type of tumor, reported only occasionally in literature. Its diagnosis usually does not offer any difficulties, and its prognosis is determined by the accompanying classic transitional or squamous component. It is important though, not to misdiagnose it as a mixed transitional cell adenocarcinoma. In that respect, features such as the type of epithelium lining, the gland-like structures, as well as the type of luminal mucin have been used to make the diagnosis. Recently, an immunohistochemical panel of antibodies has proven helpful in differentiating primary and metastatic adenocarcinomas of urothelial tract from urothelial carcinoma with gland differentiation. In their series of 16 cases, Tamboli et al included only one case of transitional cell carcinoma with gland differentiation. We present two additional cases of urothelial carcinoma with gland-like lumina in two men, 60 and 79 years old, respectively. Both tumors were grade 2 of Ash-Bergkvist, and the stage was pT(1) in both cases. Immunohistochemical study with cytokeratins 7 and 20, and with c-erbB-2, was performed. Both tumors expressed cytokeratins 7 and 20; c-erbB-2 was only expressed in one, in spite of the same staging. Although some relation has been found in animals between gland-like lumina phenotype and expression of epidermal growth factor (the receptor of which is homologous to c-erbB-2), it seems that this relationship might not be constant in humans.

Renal pelvic carcinoma with unusual appearance simulating amyloidosis (myeloma kidney): a report of five cases

We describe 5 cases of urothelial carcinoma (UC) of the renal pelvis, which grew in a distinctive gross and microscopical pattern into the renal parenchyma. Five patients (2 men and 3 women, mean age 67.4 years) underwent nephrectomy for vague clinical findings. The cut surface of the tumor was white to light gray and the consistency was elastic. The corticomedullary border was indistinct, resulting in an appearance that suggested amyloidosis or myeloma. The renal pelvis showed normal mucosa with areas of dysplastic changes. The tumors spread from the renal pelvis in a diffuse and irregular, infiltrative pattern and surrounded intact glomeruli. Detailed sampling of invasive tumor component showed foci of UC with transitions to clear squamous cells. The predominant clear squamous neoplastic cells had foci of granular eosinophilic cytoplasm and resembled conventional renal cell carcinoma. Four patients were alive and without signs of the disease for 5 months to 4 years after nephrectomy; 1 died of generalized tumor 7 months after nephrectomy. The unusual gross and microscopic features result in varied problems in differential diagnosis, which are discussed herein.

Histogenesis of nonurothelial carcinomas in the human and rat urinary bladder

The histogenesis of nonurothelial carcinomas (squamous cell carcinoma, common adenocarcinoma, clear cell adenocarcinoma, signet ring cell adenocarcinoma and undifferentiated carcinomas) of the urinary bladder is difficult to understand, since the bladder is normally lined exclusively by transitional cell epithelium and contains no otherwise specified epithelia. In the present study we analysed the morphology and development of nontransitional cell carcinomas of the human and comparatively of the rat urinary bladder in an attempt to elucidate their histogenetic derivation. There is strong evidence that the underlying histogenetic principle consists in the well-known pluripotent metaplastic potency (squamous, columnar, goblet and signet ring cell, glandular and so-called nephrogenic metaplasia) of the normal and neoplastic urothelium as well, due to the complex embryologic origin of the bladder. Our findings indicate that squamous cell carcinomas, common and clear cell adenocarcinomas, and signet ring cell adenocarcinomas mainly arise secondarily from preexisting, predominantly solid transitional cell carcinomas by focally beginning and diffusely progressing metaplastic changes of various types. The second histogenetic pathway consists in the formation from primary metaplasias of the transitional cell epithelium in situ. Undifferentiated carcinomas (small, large and sarcomatoid subtypes) develop from preexistent solid urothelial carcinomas by a cellular dedifferentiation. Recognition of transitional cell carcinomas characterised by focal metaplastic processes or cellular dedifferentiation seems to be important from a clinical point of view, because of their probably more malignant biologic behaviour compared with uniformly differentiated pure urothelial carcinomas. Our comparative morphologic analysis of nonurothelial carcinomas and their histogenesis has demonstrated that the findings in the human and rat urinary bladder are largely identical. The experimental models used permit reliable extrapolation of the results obtained to the situation in man.

Fine needle aspiration biopsy of the penis: transitional cell carcinoma of the urinary bladder with mucinous differentiation

We report a case of transitional cell carcinoma of the urinary bladder metastatic to the penis. The diagnosis was established by fine needle aspiration biopsy (FNAB). Malignant cells showed mucinous differentiation. Ancillary studies carried out in the FNA material as well as in the primary bladder carcinoma suggested transitional cell carcinoma with mucinous differentiation. FNAB proved to be effective in diagnosing a secondary neoplasm to the penis. Mucoid differentiation of urothelial cells can be seen in FNAB specimens and might pose a problem in differential diagnosis.

Primary adenocarcinoma of the ureter. Case report with immunohistochemical characterization

Genuine adenocarcinomas of the ureter are rare tumors and have to be distinguished from other gland-forming malignancies arising from the transitional epithelium, due to the poor clinical outcome. The histopathological features of a tumor combined with intestinal metaplasia of the adjacent urothelium are described. The tumor has to be distinguished from transitional cell cancer with glandular metaplasia, muco-urothelial cancer, microcystic transitional cell cancer and transitional cell cancer with mucoid cytoplasmatic inclusions. Immunohistochemical analysis of the cancer shows positivity for carcinoembryonic antigen and a staining pattern characteristic for adenocarcinomas. The expression of keratin types 7 and 13, which is typically found in transitional cell carcinomas, is lost.

Intracytoplasmic lumina and mucinous inclusions in ovarian carcinomas

Intracytoplasmic mucinous inclusions and lumina have been previously described in non-glandular neoplasms such as urothelial carcinoma. We describe their presence in 93% of non-mucinous ovarian carcinomas. They were found in abundance in all 25 cases (100%) of clear cell carcinoma, in 48 of 50 cases (96%) of serous carcinoma and 20 of 25 cases (80%) of endometrioid carcinoma. The degree of the differentiation of the tumour did not influence the number of inclusions or lumina observed. These results suggest that the presence of intracytoplasmic lumina and mucinous inclusions is more widespread than hitherto appreciated. Their presence in an otherwise poorly differentiated metastatic carcinoma might, at the very last, prompt one to consider the ovary as a possible primary site. In addition, an abundance of intracytoplasmic mucinous inclusion and lumina with microcyst formation, in an otherwise poorly differentiated malignant primary ovarian epithelial tumour, might suggest the possibility of a clear cell carcinoma.

Intracytoplasmic lumina in ependymomas: an ultrastructural study

Intracytoplasmic lumina (ICL) are rarely described in tumors of the central nervous system. The morphogenesis of ICL remains incompletely characterized. Ultrastructural features of ICL in six ependymomas (one from lateral ventricle, three from fourth ventricle, and two from spinal cord) and three myxopapillary ependymomas of the filum terminale were analyzed. Two types of ICL were identified: ICL with both microvilli and cilia, and ICL with only microvilli. Some ICL also contained granulofibrillary or condensed material. Ciliated ICL were common in ependymomas of the ventricles, whereas nonciliated ICL were frequently seen in the myxopapillary variant. Various stages of formation and development were observed in ciliated ICL. They seemed to originate from distended periciliary cisterns, to enlarge by fusion with cytoplasmic vesicles or other ICL, and subsequently to open into the intercellular space. The last process may be the mechanism by which the intercellular microrosettes are formed. Ciliated ICL have not been described in other neoplasms. They may represent a characteristic ultrastructural feature of ependymomas. The morphogenesis of nonciliated ICL remains unknown. They may represent a degenerative form of ciliated ICL or pseudolumina resulting from invagination of the extracellular space within the cytoplasm.