POSTOPERATIVE SPINDLE CELL NODULE OF BLAD K. VEKEMANS, M.D. A. VANNESTE, M.D.

E MICHIELSSEN, M,D. H. DENYS, M.D,

R VAN ()YEN, M.D.

R. VERGISON, M.D.

From the Division of Urology and Patholog3q A.Z. Sint Jan, Bruges, Belgium

A B S T R A C T - I~4: describe a ~eu tumor (ff the bladder resemblh, g sarcoma. 7"he t,~mor develops after damage to ihe bladder u'all, a~d the eli~icopathologic jeatures make f~ p recog~ize it as a benign lesioT~ rather tha~ the malignant Ivsions for which it can be mis

Postoperative spindle cell no&ties are benign lesions that* appear five weeks to three months after surgical procedures in the lower urogenital tract. The lesion was first described by Proppe, Seully, and Rosai in 1984 ~ as a benign proliferative lesi(m resembling leiomyosareoma and Kapost sarcoma. We report: a case in a fifty-eightyea>old woman who underwent an operation for a huge o\ arian tumor and in whom hematuria developed seven weeks postoperatively Case Report A fifty-eight-year-old w o m a n was seen because of respiratory insufficiency due lo extreme abdominal distention. Intubation bec a m e necessary, and f u r t h e r investigation revealed a distended abdomen from a large tumor that also caused kidney insufficiency from pressure on the ureters. The patient became oliguric and septicemia wi~h leukopenia and metabolic acidosis developed. A computerized tomography (CT) scan and ultrasonic studies revealed a large multieystic tumor that seemed to arise from the ovary. An urgent explorative laparotomy with a xyphopubie midline incision was done. The abdominal mass corresponded with a large encapsulated tumor of the ovary; which weigl~ed 9 kg and was excised together with a Meck~ 1 diverticulum, During this operation ;&e bladder wall was incised ineidentall) for which an Autosuture self-resorbing staple was applied. Microscopically the tumor was diagnosed as a benign mutinous cystadenoma.

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The patient was later ref, for evaluation of a painless veloped seven weeks post( scopieally we four, d a sma] of the bladder dome. Furth~ urinary tract by intravenou: trasonic studies did not she transurethral resection of t formed along with biopsies lesion. The postoperative followThe patient will be fotlowe cystoscopie evaluation, Palhologic ,#at~trex Cross appearance of the spe~ of a 2-3-era nodule, poorly deft yellow color. Microscopic exam intersecting fascicles of p l u m (Fig. 1A), In some areas the cell a pseudoepitheliai paftern. The lying ulceration with superfiei lent infiltrate. The lesion wa with a polymorphous inflamm and demonstrated a network of: sels (Fig. IB). A diffuse edema v croscopic examinations of the bladder walt showed a focal u mueosa wi~h a marked thickenfl lying submueosa by a !umoral intersecting fascicles of phnn I w h i c h in some areas dei pseudoepitheIial pattern. The i highly edematous and cor~tai

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F~:;uaE: 1. (..t) tntersecti,~g bundles O~,rpi~zdte cdts intermi~gled u~ith iRflammatory infiltrate. (1~) Lesion shou;s delicate network oJ" dilated small blood vessels. (C) Plump spindle cells with oval ~uclei containing one or two nucleoIi. O~e mitotic figure is evident. Note striking edema. (Origi~aI magnijications, x 100, x 250, x 400, respe,.:~iveI!A)

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,,g t a moderate nonspecifie e.

n i n a t i o n the spindle cells pleomorphism without a ytologie atypia. The cells lant eosinophilic to amT h e nuclei varied only val and pale, with orle or Mitotic figures were nu~sir>r the avidin-biotin xldas.'e method with the hie prirnary polyelonal (Da kopatts) and monoentin and desmin (Da ko2 spindle cells stained posind all were negative for inee the lesion developed l a d d e r wall with a histouishaMe from the postopn o d u l e as described by [nosis of benign reactive as proposed. This diagnorof. Scully v, ho ;~as kind

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enough to review our slides. The absence of toeat r e c u r r e n c e without further treatment, in a follow-up period of four months aiso favored the benign nature of this lesion. Comment Postoperative spindle cell nodules of the genitouriuary tract were first described by Proppe, Scull> and Bosai in 1984.~ Their description of the clinieopathologie features warranted the introduction of a new benign lesion resembling sarcoma. The initial diagnosis varied from a spind]e cell sarcoma (leiomyosareoma) to a reactive proliferative lesion (hypertrophic sear, atypieaI fibrous histioeytoma, nodular faseiitis). However, 6 patients whose lesions were treated inadequakely on the assumption that |:hey were sarcomas were free of disease nine to sixty months postoperativel 5 and 2 patients treated by radical procedures were well eighteen and sixty months later. The most decisive clue to the favorable prognosis of these lesions v,'as the clinical setting in which they arose--all were small and developed shortl> five weeks f:o three months, after an operation for diseases other

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than sarcoma. Also they were located in areas where sarcomas are rarely encountered (t:he vagdna, prostate gland, and urinary bladder). There was no male or female predominance. On microscopic examination Proppe e t al~ ~ found a striking similarity with reports of nodular faseiitis of the vulva and vagina &~seribed by Gaffney, Majmudar, and Bryan, :~ and by P,oberts and Daly. 4 Also Nochomovitz and Orenstein 5 suggested that a histogenetic relation exists between nodular faseiitis, the postoperative spindle cell nodule of Proppe, and the inflammatory pseudotumor of the bladder. Itowever, there seem to be some histologic differencs~s, In nodular faseiitis there is a typical layering of loose tissue with palisading capillaries and matnre dense collagen fibers and no eornpaet gTowth. This is in contrast with spindle cell nodules. ]bo few ultrastruetural examinations have been performed to state that the absence of myofibroblasts is typical for spindle cell nodules in contrast to their presence in nodular {aseiitis and inflammatory pseudotumot. Also there is a discordance in the clinical setting. Although a history of local nonsurgical trauma was elicited in only 30 percent of the eases of nodular faseiitis in one large series, all

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the tesions described by Proppe et sites of previous damage. It is im these lesions be adequat:ety reeogn they cause a real diagnostic proble~ benign clinical ew~lution in eontra lignant lesions for which they can In retrospect the question rem~ the leiomyosarcomas of the genito~ that have been treat:ed with goc published in the literature were r or were in fact reactive proliferati Br

Re{erences I. Proppc KM, Scull) BE aid ttosai J: Post{ cell nodules of genitourinary tract resembling Surg Pathol 8:101 (t98.'~). 2. tlsu S-M, Raine I,, and Fanger H: The u bed} and a~id~n-biotin~p(loxidase complex in imrntmotmrox~ teeImiq les, Am ] Clin PathoI 75: 8i~; (i981). 3 (-;affne? ER Maimudar B. and Bryan ]A: No~mlar [a~N (pseudosareon a ous fasciieis) ~ff tl~e vulva. Int J Cvi ecol p a { i ~ 307 (1982). :¢~:~'~ 4. l~lobeits "\~,!and Daly JW: Pseudosar~omat,:~Ns fasciitis 6~li~!! :, ne ol O,,,,oI H : 38:

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5. Noehomovitz LE, and Orens~ein JM: Inflammatoryp~i{l!;~[~ tumor ot: t:he urinary }:,ladder--o.possible relationship t0 hoiit~J~ fascii!is, \ m J Surg Pa{hol 9: 3(i(~ (1985).

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Postoperative spindle cell nodule of bladder.

We describe a new tumor of the bladder resembling sarcoma. The tumor typically develops after damage to the bladder wall, and the clinicopathologic fe...
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