Bone and cartilage in malignant tumours of the urinary bladder

Stromal osseous metaplasia in urothelial carcinoma of the bladder: a rare case report and literature review

BACKGROUND

The bone formation within bladder tumors could be encountered in 3 conditions. These might consist of malignant bone formation in mesenchymal tumors; mixed mesenchymal and epithelial tumors; and epithelial tumors with stromal osseous metaplasia (SOM). This last is relatively rare. According to the English literature, only 12 cases have been reported in primary tumor and 7 in metastatic deposits of bladder primaries. Herein, we presented an additional case.

CASE PRESENTATION

An 83-year-old man was admitted 13 years ago for prostatic adenocarcinoma, treated with radical prostatectomy. Biochemical recurrence was detected 2 years after surgery (prostate-specific-antigen (PSA) level: 4.60 ng/mL) and progressively normalized (<1.0 ng/mL) after adjuvant radiotherapy and annual injection of leuprorelin (enantoneR). He was referred after 8 years for hematuria, PSA level having slightly increased (0.60 ng/ml). Cystoscopy showed a nodular growth in the bladder wall, visualized as a calcified tumor on computed tomography (CT) and removed with transurethral resection. Histologically, the tumor consists of a non-muscle-invasive high grade papillary urothelial carcinoma with metaplastic bone within the stroma. Immunohistochemical analysis particularly demonstrated positive expression of respectively CD56 on osteoblasts, and CD68 on osteoclasts. MDM2 and CDK4 were negatives on osteoid and bone tissue. Six courses of Bacillus Calmette-Guerin (BCG) therapy have been administered. Two local recidives have occurred during an 8-month follow-up period after immunotherapy and were treated with six further courses of BCG therapy. At one-month follow-up, the patient was well without remaining symptoms.

CONCLUSION

SOM is a rare benign condition whose pathogenesis remains uncompletely defined. Sarcomatoïd carcinoma represents the main differential diagnosis that influences therapeutic procedures. Prognosis depends essentially on the extent of the carcinomatous component .

Carcinosarcoma of the bladder: case report and review of the literature

Primary osteosarcomas of the bladder account for about 0.04% of bladder neoplasms. Most of the patients in the literature expired within 6 months and, in almost all of the cases in the literature, radical cystectomy with postoperative chemotherapy was the treatment choice. A 79-year-old gentleman presented with gross hematuria. Cystoscopy demonstrated a 2- to 3-cm tumour along the lateral wall of the bladder. The tumour was resected incompletely via initial transurethral resection of bladder tumour (TURBT), and a second TURBT was subsequently performed to fully resect the residual mass. Surgical pathology from these 2 resections revealed osteosarcoma with invasion into the muscularis propria. A cystoprostatectomy was performed and final pathologic specimen revealed high-grade CIS without evidence of residual osteosarcoma. Postoperatively, the patient did not receive chemotherapy or radiation and currently remains disease-free 2 years post-radical cystectomy. Only 33 well-documented cases of primary osteosarcoma of the bladder have been reported to date. However, there are only 3 cases in which TURBT resulted in complete resection.

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.

Primary osteosarcoma of the spermatic cord with synchronous bilateral renal cell carcinoma

Primary extraskeletal osteosarcoma of the spermatic cord is an extremely rare tumor with only two other cases being reported in the world literature. We describe a patient with this lesion who also had concomitant bilateral renal cell carcinoma. The management of this case and a review of this subject are presented.

Human urinary bladder-carcinoma cells are non-osteoinductive

Small pieces (ca. 2-3 x 3-5 mm) of the urinary-tract mucosa from noninvasive papillary transitional-cell carcinomas of the bladder (ca. urotheliale papillare, n = 33), invasive transitional-cell carcinomas of the bladder (ca. urotheliale papillare infiltrans, n = 6, papillary transitional-cell carcinomas of the bladder with squamous metaplasia (ca. urotheliale papillare cum metaplasia planoepitheliale, n = 4), transitional-cell carcinomas in situ (ca. urotheliale in situ, n = 2), and squamous-cell carcinomas of the bladder (ca. planoepitheliale, n = 2) were grafted intramuscularly into cortisone-immunosuppressed mice to test the ability of transformed transitional epithelium to induce heterotopic osteogenesis. Altogether, 156 implants from 47 cases of urinary bladder carcinoma were performed. Histological examination of implants, excised 10-17 days later, revealed relatively good survival of the grafted epithelium, which had proliferated and, in some cases, formed cysts and islands but failed to induce heterotopic osteogenesis in the surrounding host tissues. In nine implants prepared from four cases (noninvasive papillary transitional-cell carcinoma of the bladder and invasive papillary transitional-cell carcinoma of the bladder, two cases each) a small amount of cartilage and/or bone was found in the stroma of grafted tissue. The rarity of this phenomenon--together with the observation that implants of normal human urinary-tract mucosa have never induced the formation of cartilage/bone, whereas in a similar system, dog or guinea-pig grafts are osteogenic--suggests that the cartilage/bone present in the stroma of implanted cancers is the result of metaplasia of the stroma of the neoplasm and not the product of any osteoinductive potency of human urothelium.

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.

Unusual forms of carcinoma of the urinary bladder

Carcinomas of the urinary bladder, which differ histologically from the usual transitional cell carcinoma of the bladder, are reviewed. These tumors, which account for approximately 15% of all bladder carcinomas, have diverse microscopic appearances. They fall into four major categories: variant forms of urothelial (transitional cell) carcinoma, squamous cell carcinoma, adenocarcinoma, and undifferentiated carcinoma. In the first category, the most common are carcinomas with glandular or squamous differentiation. Less common, but more troublesome diagnostically, are variants in which the cells are spindle shaped (sarcomatoid carcinoma), form small cysts (microcystic carcinoma), or differentiate toward trophoblast. In other variants, the stroma has unusual features that may lead to diagnostic difficulty. These are carcinomas with pseudosarcomatous stroma, osseous or cartilaginous metaplasia, or osteoclast-type giant cells. Also reviewed are squamous cell carcinoma and its variant, verrucous carcinoma. Vesical adenocarcinoma has several variants, including signet-ring cell and clear cell types. Finally, the category of undifferentiated carcinoma, including small cell carcinoma, giant cell carcinoma, and lymphoepithelioma-like carcinoma, is discussed.

Stromal osseous metaplasia in carcinoma of the bladder

Osseous metaplasia of the stroma of carcinomas of the bladder is a rare finding that must be distinguished from osteosarcoma and carcinosarcoma. We report a case of multifocal osseous metaplasia in a high grade urothelial carcinoma with extensive glandular differentiation, arising in the base of the bladder of an 84-year-old man. Reports of 11 other cases of stromal osseous metaplasia in primary bladder carcinomas and of 5 cases of stromal osseous metaplasia in metastases of bladder carcinoma are reviewed.

Transitional cell carcinoma of the urinary bladder with osteoclast-type giant cells: a report of two cases and review of the literature

We report two transitional cell carcinomas of the urinary bladder containing numerous osteoclast-type giant cells that stained for vimentin and acid phosphatase (with and without tartrate) and were negative for cytokeratin and lysozyme. One tumour, in a 65-year-old man, was composed of papillary transitional cell carcinoma, invasive poorly differentiated carcinoma with a prominent spindle cell component and numerous osteoclast-type giant cells; repeat curettage 2 months later showed no residual tumour. The second tumour occurred in a 75-year-old woman who underwent a radical cystectomy for a deeply invasive transitional cell carcinoma with a spindle and anaplastic giant cell component and areas containing numerous osteoclast-type giant cells. Osteoclast-type giant cells, which appear to be reactive, should be distinguished from the neoplastic giant cells of giant cell carcinoma.

Promotion of osteogenesis by extra-embryonic epithelial in maxillary mesenchyme of the embryonic chick

Maxillary mesenchyme (HH stages 19-21), separated from its epithelium and grown as a graft on the chorioallantoic membranes of host chick embryos, did not form membrane bone. However, when isolated maxillary mesenchyme was recombined directly with chorioallantoic endoderm or chorioallantoic ectoderm and then grafted, it did form membrane bone in 87.5 and 70% of cases, respectively. This novel finding of extra-embryonic epithelia eliciting an osteogenic response from membrane bone-forming mesenchyme indicates that the germ-layer origin of an epithelium does not necessarily restrict its potential to promote membrane bone formation.

Carcinosarcoma of the urinary bladder. Case report

A case of carcinosarcoma in the urinary bladder is presented. On basis of a review of the most recent literature and referring to our own case, radical cystectomy appears to be the most effective treatment of this tumour.

Carcinosarcoma of the urinary bladder

The clinical and pathologic features of three new and 35 previously reported carcinosarcomas of the urinary bladder were reviewed. This type of tumor is three times more common in men than women, and has occurred in patients from 33 to 82 years of age (average, 62 years), most of whom presented with hematuria of short duration. The tumors are usually large and polypoid, and on microscopic examination contain an intimate admixture of malignant epithelial and mesenchymal elements. The former may resemble transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma or undifferentiated carcinoma; and the latter, fibrosarcoma, leiomyosarcoma, or undifferentiated sarcoma: skeletal muscle, osseous, and/or cartilaginous differentiation has occurred in from 25% to 50% of the tumors. Sixteen patients died as a result of their tumors; four others had metastatic disease and three were lost to follow-up. Twelve patients were alive and free of disease from 5 months to 7 years postoperatively. Most of the 12 underwent radical cystectomy, preceded in some cases by radiation therapy, but four underwent a more conservative operation.

Osteosarcoma of the urinary bladder. Report of a case and review of the literature

A 65-year-old man with hematuria had a large polypoid tumor of the urinary bladder which on microscopic examination was an osteosarcoma, only the 22nd example reported in this organ. The tumor was initially misinterpreted as a transitional cell carcinoma because of an absence of osteoid in the initial slide prepared from a biopsy of the neoplasm. Most of the patients with osteosarcoma of the bladder have been male; they have ranged from 41 to 83 (average 62) years of age. The tumors have characteristically been large and polypoid and have most commonly been located in the trigone. Follow-up is available for 21 patients; 18 of them died within 6 months or less. Three patients were still alive 14 months, 18 months, and 2 years postoperatively. 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.

Primary osteogenic sarcoma of the bladder. Case report and review of the literature

Primary osteogenic sarcoma of the bladder is an extremely rare disease. Fewer than 30 cases of tumors of the bladder containing bone or cartilage have been reported. Only 14 cases of well-documented primary osteogenic sarcoma of the bladder appear in the world's literature. The authors describe the first detailed description of such a patient treated with radiotherapy and chemotherapy as well as provide a review of this rare and interesting entity.

Giant cell tumor of the bladder associated with transitional cell carcinoma

We report in detail the first giant cell tumor associated with transitional cell carcinoma of the bladder. The giant cell tumor was composed of multinucleated giant and mononuclear stromal cells, and was morphologically indistinguishable from giant cell tumor of the bone. The giant and transitional cell carcinomas showed no evidence of recurrence or metastasis 8 months after transurethral resection. No histogenetic correlation between the cancers was found.

The epithelial origin of a malignant mesodermal mixed tumor of the bladder: report of a case with long-term survival

Malignant mesodermal mixed tumors of the bladder are complex neoplasms consisting of elements of carcinoma and differentiated sarcoma. They are rare, aggressive and usually rapidly fatal. We report on a patient who remained free of disease 7 years after resection by partial cystectomy of a malignant mesodermal mixed tumor. Only 1 other long-term survivor has been reported. Our case is of particular interest because urothelial carcinoma in situ was found in the bladder epithelium on the surface and at the periphery of the invasive tumor, strongly suggesting an epithelial origin of this and similar tumors of other organs.

Carcinosarcoma of the bladder

We report a case of carcinosarcoma of the bladder. Total cystectomy with ileal loop urinary diversion was performed. Histologically, the bulk of the tumor tissue was rhabdomyosarcoma and adenocarcinoma. At distant areas from the bulk tumor transitional cell carcinoma was noted. The literature is reviewed and the clinicopathologic condition of carcinosarcoma of the bladder is discussed.

Mixed mesodermal tumor of urinary bladder: a light and electron microscopic study

Light and ultrastructural findings in a mixed mesodermal tumor of the urinary bladder are reported. The mesenchymal component of the tumor contained undifferentiated mesenchymal cells and cells with chondroblastic differentiation. The neoplastic chondrocytes displayed an abundance of cytoplasmic microfilaments and had a scalloped cell surface.

Mixed mesodermal tumors of urinary bladder: prognosis and management

Three cases of mixed mesodermal tumors of the urinary bladder characterized by the simultaneous occurrence of malignant epithelial and mesenchymal elements in the same tumor are reported. Integrated therapy consisting of preoperative radiotherapy followed by radical cystectomy is recommended. Chemotherapy is best withheld until the nature of any metastatic disease has been confirmed histologically in order that the appropriate drugs can be administered.

Carcinosarcoma of the urinary bladder in an adult male

Carcinosarcoma of the urinary bladder in a 64-year-old man is described. Total cystectomy with bilateral ureteroileostomy was performed. The patient is in good health 12 months after the operation. Histologically the main bulk of the tumour tissue was rhabdomyosarcomatous, but in some areas atypical glands were intermingled with the rhabdomyoblasts. This histologic pattern has not previously been described. The histologic features, clinical manifestations and treatment of these rare bladder tumours are discussed in relation to the literature.

Carcinosarcoma of the bladder: case report and review of the literature

A 36-year-old man with carcinosarcoma of the bladder is described. The literature is reviewed and the clinicopathology is discussed. These tumors tend to be bulky, rapidly growing, invasive and recur locally. Metastases are generally hematogenous and may rarely involve regional nodes. Deaths are commonly owing to local invasion and sepsis. Preoperative overstaging may occur and pelvic arteriography and exploration are recommended in questionable cases. Because of the difficulty in locally extirpating these tumors radical cystectomy and urinary diversion are recommended.