Pathology Page
Adenocarcinoma Arising from a Bladder Diverticulum BLADDER diverticula are mucosal outpouchings of bladder without a muscle layer. Stasis of carcinogens in bladder diverticula predisposes the epithelium of the bladder to neoplasm formation.1 Neoplasms in the bladder diverticulum are rare with an incidence of 2% to 7%.2 Urothelial carcinoma and squamous cell carcinoma are the most frequently encountered histological types.1,2 Adenocarcinoma arising from bladder diverticula is extremely rare with few cases reported.3,4 The clinical presentation of patients with adenocarcinoma in diverticula is nonspecific. Some patients present with asymptomatic hematuria.3,4 Abdominopelvic computerized tomography and cystoscopy may help detect the diverticulum and the carcinoma in it.3,4 However, detecting a neoplasm in the diverticulum may be difficult due to the relative size of the diverticulum and the tumor.2 Histologically adenocarcinoma of bladder diverticula shows a glandular growth pattern of carcinoma cells replacing the urothelium with or without invasion of the diverticular wall.3,4 Rare cases of clear cell adenocarcinoma in a bladder diverticulum showing tubulocystic architecture with visible clear cells have also been reported.5 A 67-year-old man presented with gross hematuria and was diagnosed as positive for high grade urothelial carcinoma on urine cytology. Computerized tomography of the abdomen and pelvis revealed a large bladder diverticulum with a nodular appearance that was concerning for tumor. Subsequent cystoscopy and transurethral resection of bladder tumor revealed adenocarcinoma invading into the lamina propria (fig. 1) and adjacent urothelial carcinoma in situ with glandular differentiation. There was no muscularis propria present. Random bladder biopsies were also obtained and were negative for malignancy. Hematuria resolved after the procedure. One month later he underwent repeat cystoscopic examination of the bladder diverticulum and transurethral resection of tumor for tumor staging and surgical planning. Histopathology showed urothelial carcinoma in situ with glandular differentiation only. Two months later
0022-5347/15/1942-0527/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
cystoprostatectomy was performed, which revealed invasive adenocarcinoma in the diverticulum extending through the diverticular wall and into peridiverticular adipose tissue (fig. 2). It is believed that primary adenocarcinomas of the bladder arise from the urothelium, which maintains the potential to undergo glandular metaplasia and further become neoplastic.3 Primary adenocarcinomas of the bladder diverticula often present at advanced stage due to the thinner wall of the diverticula, which may allow the tumor to invade outside earlier and more easily.3 A tumor originating from diverticula and adenocarcinoma are considered to be factors indicating a poor prognosis.3 Treatment options include diverticulectomy/ partial cystectomy and radical cystectomy depending on the location of the diverticulum, the risk of positive margin, the presence of carcinoma in situ and the risk of local recurrence. Metastasis must be excluded before a diagnosis of primary adenocarcinoma of the bladder diverticula
Figure 1. Adenocarcinoma in bladder diverticulum involving lamina propria. Note glandular growth pattern and adjacent urothelial carcinoma in situ with glandular differentiation. H&E, reduced from 100.
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PATHOLOGY PAGE
nests or glandular metaplasia, or there is coexistence of urothelial and squamous carcinoma.6,7 Li-Ying Fu and Adebowale J. Adeniran Department of Pathology Yale University School of Medicine New Haven, Connecticut
1. Faysal MH and Freiha FS: Primary neoplasm in vesical diverticula. A report of 12 cases. Br J Urol 1981; 53: 141. 2. Dondalski M, White EM, Ghahremani GG et al: Carcinoma arising in urinary bladder diverticula: imaging findings in six patients. AJR Am J Roentgenol 1993; 161: 817. 3. Shigehara K, Taya T and Hisazumi H: Primary adenocarcinoma in the bladder diverticulum. Scand J Urol Nephrol 2008; 42: 481. Figure 2. Invasive adenocarcinoma extending peridiverticular adipose tissue. H&E, reduced from 200.
into
4. Lam KY, Ma L and Nicholls J: Adenocarcinoma arising in a diverticulum of the urinary bladder. Pathology 1992; 24: 40. 5. Moinzadeh A, Latini J and Hamawy KJ: Clear cell adenocarcinoma of the urinary bladder within a diverticulum. Urology 2003; 62: 145.
is made. Adenocarcinomas from other primary sites such as the stomach can metastasize to bladder diverticula.6 A primary lesion is favored if the adjacent mucosa contains polypoid formation, Brunn
6. Matsuhashi N, Yamaguchi K, Tamura T et al: Adenocarcinoma in bladder diverticulum, metastatic from gastric cancer. World J Surg Oncol 2005; 3: 55. 7. Ganem EJ and Batal JT: Secondary malignant tumors of the urinary bladder metastatic from primary foci in distant organs. J Urol 1956; 75: 965.
Adenocarcinoma Arising from a Bladder Diverticulum BLADDER diverticula are mucosal outpouchings of bladder without a muscle layer. Stasis of carcinogens in bladder diverticula predisposes the epithelium of the bladder to neoplasm formation.1 Neoplasms in the bladder diverticulum are rare with an incidence of 2% to 7%.2 Urothelial carcinoma and squamous cell carcinoma are the most frequently encountered histological types.1,2 Adenocarcinoma arising from bladder diverticula is extremely rare with few cases reported.3,4 The clinical presentation of patients with adenocarcinoma in diverticula is nonspecific. Some patients present with asymptomatic hematuria.3,4 Abdominopelvic computerized tomography and cystoscopy may help detect the diverticulum and the carcinoma in it.3,4 However, detecting a neoplasm in the diverticulum may be difficult due to the relative size of the diverticulum and the tumor.2 Histologically adenocarcinoma of bladder diverticula shows a glandular growth pattern of carcinoma cells replacing the urothelium with or without invasion of the diverticular wall.3,4 Rare cases of clear cell adenocarcinoma in a bladder diverticulum showing tubulocystic architecture with visible clear cells have also been reported.5 A 67-year-old man presented with gross hematuria and was diagnosed as positive for high grade urothelial carcinoma on urine cytology. Computerized tomography of the abdomen and pelvis revealed a large bladder diverticulum with a nodular appearance that was concerning for tumor. Subsequent cystoscopy and transurethral resection of bladder tumor revealed adenocarcinoma invading into the lamina propria (fig. 1) and adjacent urothelial carcinoma in situ with glandular differentiation. There was no muscularis propria present. Random bladder biopsies were also obtained and were negative for malignancy. Hematuria resolved after the procedure. One month later he underwent repeat cystoscopic examination of the bladder diverticulum and transurethral resection of tumor for tumor staging and surgical planning. Histopathology showed urothelial carcinoma in situ with glandular differentiation only. Two months later
0022-5347/15/1942-0527/0 THE JOURNAL OF UROLOGY® Ó 2015 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
cystoprostatectomy was performed, which revealed invasive adenocarcinoma in the diverticulum extending through the diverticular wall and into peridiverticular adipose tissue (fig. 2). It is believed that primary adenocarcinomas of the bladder arise from the urothelium, which maintains the potential to undergo glandular metaplasia and further become neoplastic.3 Primary adenocarcinomas of the bladder diverticula often present at advanced stage due to the thinner wall of the diverticula, which may allow the tumor to invade outside earlier and more easily.3 A tumor originating from diverticula and adenocarcinoma are considered to be factors indicating a poor prognosis.3 Treatment options include diverticulectomy/ partial cystectomy and radical cystectomy depending on the location of the diverticulum, the risk of positive margin, the presence of carcinoma in situ and the risk of local recurrence. Metastasis must be excluded before a diagnosis of primary adenocarcinoma of the bladder diverticula
Figure 1. Adenocarcinoma in bladder diverticulum involving lamina propria. Note glandular growth pattern and adjacent urothelial carcinoma in situ with glandular differentiation. H&E, reduced from 100.
http://dx.doi.org/10.1016/j.juro.2015.05.033 Vol. 194, 527-528, August 2015 Printed in U.S.A.
www.jurology.com
j
527
528
PATHOLOGY PAGE
nests or glandular metaplasia, or there is coexistence of urothelial and squamous carcinoma.6,7 Li-Ying Fu and Adebowale J. Adeniran Department of Pathology Yale University School of Medicine New Haven, Connecticut
1. Faysal MH and Freiha FS: Primary neoplasm in vesical diverticula. A report of 12 cases. Br J Urol 1981; 53: 141. 2. Dondalski M, White EM, Ghahremani GG et al: Carcinoma arising in urinary bladder diverticula: imaging findings in six patients. AJR Am J Roentgenol 1993; 161: 817. 3. Shigehara K, Taya T and Hisazumi H: Primary adenocarcinoma in the bladder diverticulum. Scand J Urol Nephrol 2008; 42: 481. Figure 2. Invasive adenocarcinoma extending peridiverticular adipose tissue. H&E, reduced from 200.
into
4. Lam KY, Ma L and Nicholls J: Adenocarcinoma arising in a diverticulum of the urinary bladder. Pathology 1992; 24: 40. 5. Moinzadeh A, Latini J and Hamawy KJ: Clear cell adenocarcinoma of the urinary bladder within a diverticulum. Urology 2003; 62: 145.
is made. Adenocarcinomas from other primary sites such as the stomach can metastasize to bladder diverticula.6 A primary lesion is favored if the adjacent mucosa contains polypoid formation, Brunn
6. Matsuhashi N, Yamaguchi K, Tamura T et al: Adenocarcinoma in bladder diverticulum, metastatic from gastric cancer. World J Surg Oncol 2005; 3: 55. 7. Ganem EJ and Batal JT: Secondary malignant tumors of the urinary bladder metastatic from primary foci in distant organs. J Urol 1956; 75: 965.
