Pathology Page
Primary Small Cell Carcinoma Arising from a Bladder Diverticulum A 66-year-old Caucasian male with a 48 pack-year smoking history presented with gross hematuria and worsening pelvic pain. Laboratory results revealed low grade disseminated intravascular coagulation. Imaging was significant for a bladder diverticulum and lytic lesions of the femurs, pelvis and vertebra. Cystoscopy of the diverticulum revealed a mass larger than 5 cm and transurethral resection was performed. Histopathology of the bladder lesion showed sheets and nests of small neuroendocrine cells with dense intervening fibrous stroma (figs. 1 and 2). Necrosis was present and tumor cells stained positive for synaptophysin. No evidence of urothelial carcinoma (UC) was seen and the final diagnosis was small cell carcinoma of the bladder. Bladder diverticula are formed by herniation of the urothelial mucosa through the detrusor muscle.1 Bladder diverticula can result in urinary stasis which can lead to infection and resultant inflammation.2 In recent case series diverticula
were found to harbor a variety of metaplastic changes as well as precursors to malignancy, suggesting that inflammation in the diverticula was a risk factor for rare UC variants and nonUC malignancies.1e3 In 1 series diverticular UC displayed an increased incidence of neuroendocrine differentiation when compared to typical UC of the bladder.3,4 Further corroboration of diverticular inflammation as a risk factor was found in a recent study, which suggests that inflammatory mediators are involved in neuroendocrine differentiation of prostate cancer.5 Bladder diverticula contain a greater percentage of nonUC neoplasms such as pure squamous cell carcinoma, adenocarcinoma and small cell carcinoma.1e3,6 Interestingly squamous cell carcinoma of the bladder is common in Egypt, attributed to the chronic inflammation of schistosomiasis.6 Diverticular inflammation may be analogous and consequently bears a similar increased risk of squamous cell carcinoma. Bladder diverticula and
Figure 1. Small cell carcinoma with loosely cohesive sheets of small tumor cells with minimal cytoplasm, and areas of necrosis and calcification. H&E, reduced from 100.
Figure 2. Small cell carcinoma. Tumor cells exhibit high nuclearto-cytoplasmic ratios, fine chromatin, indistinct nucleoli and nuclear molding. Frequent mitotic figures and apoptotic bodies are present. H&E, reduced from 400.
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associated inflammation appear to increase the risk of rare bladder tumors.
2. Kong MX, Zhao X, Kheterpal E et al: Histopathologic and clinical features of vesical diverticula. Urology 2013; 82: 142.
James Tudor
3. Tamas EF, Stephenson AJ, Campbell SC et al: Histopathologic features and clinical outcomes in 71 cases of bladder diverticula. Arch Pathol Lab Med 2009; 133: 791.
University of Toledo School of Medicine
Richard L. Cantley Department of Pathology and
4. Xylinas E, Rink M, Robinson BD et al: Impact of histological variants on oncological outcomes of patients with urothelial carcinoma of the bladder treated with radical cystectomy. Eur J Cancer 2013; 49: 1889.
Department of Urology University of Toledo Medical Center Toledo, Ohio
5. Tawadros T, Alonso F, Jichlinski P et al: Release of macrophage migration inhibitory factor by neuroendocrine-differentiated LNCaP cells sustains the proliferation and survival of prostate cancer cells. Endocr Relat Cancer 2013; 20: 137.
1. Idrees MT, Alexander RE, Kum JB et al: The spectrum of histopathologic findings in vesical diverticulum: implications for pathogenesis and staging. Hum Pathol 2013; 44: 1223.
6. Rogers CG, Palapattu GS, Shariat SF et al: Clinical outcomes following radical cystectomy for primary nontransitional cell carcinoma of the bladder compared to transitional cell carcinoma of the bladder. J Urol 2006; 175: 2048.
Samay Jain
Primary Small Cell Carcinoma Arising from a Bladder Diverticulum A 66-year-old Caucasian male with a 48 pack-year smoking history presented with gross hematuria and worsening pelvic pain. Laboratory results revealed low grade disseminated intravascular coagulation. Imaging was significant for a bladder diverticulum and lytic lesions of the femurs, pelvis and vertebra. Cystoscopy of the diverticulum revealed a mass larger than 5 cm and transurethral resection was performed. Histopathology of the bladder lesion showed sheets and nests of small neuroendocrine cells with dense intervening fibrous stroma (figs. 1 and 2). Necrosis was present and tumor cells stained positive for synaptophysin. No evidence of urothelial carcinoma (UC) was seen and the final diagnosis was small cell carcinoma of the bladder. Bladder diverticula are formed by herniation of the urothelial mucosa through the detrusor muscle.1 Bladder diverticula can result in urinary stasis which can lead to infection and resultant inflammation.2 In recent case series diverticula
were found to harbor a variety of metaplastic changes as well as precursors to malignancy, suggesting that inflammation in the diverticula was a risk factor for rare UC variants and nonUC malignancies.1e3 In 1 series diverticular UC displayed an increased incidence of neuroendocrine differentiation when compared to typical UC of the bladder.3,4 Further corroboration of diverticular inflammation as a risk factor was found in a recent study, which suggests that inflammatory mediators are involved in neuroendocrine differentiation of prostate cancer.5 Bladder diverticula contain a greater percentage of nonUC neoplasms such as pure squamous cell carcinoma, adenocarcinoma and small cell carcinoma.1e3,6 Interestingly squamous cell carcinoma of the bladder is common in Egypt, attributed to the chronic inflammation of schistosomiasis.6 Diverticular inflammation may be analogous and consequently bears a similar increased risk of squamous cell carcinoma. Bladder diverticula and
Figure 1. Small cell carcinoma with loosely cohesive sheets of small tumor cells with minimal cytoplasm, and areas of necrosis and calcification. H&E, reduced from 100.
Figure 2. Small cell carcinoma. Tumor cells exhibit high nuclearto-cytoplasmic ratios, fine chromatin, indistinct nucleoli and nuclear molding. Frequent mitotic figures and apoptotic bodies are present. H&E, reduced from 400.
0022-5347/14/1921-0236/0 THE JOURNAL OF UROLOGY® © 2014 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
236
j
www.jurology.com
AND
RESEARCH, INC.
http://dx.doi.org/10.1016/j.juro.2014.04.044 Vol. 192, 236-237, July 2014 Printed in U.S.A.
PATHOLOGY PAGE
237
associated inflammation appear to increase the risk of rare bladder tumors.
2. Kong MX, Zhao X, Kheterpal E et al: Histopathologic and clinical features of vesical diverticula. Urology 2013; 82: 142.
James Tudor
3. Tamas EF, Stephenson AJ, Campbell SC et al: Histopathologic features and clinical outcomes in 71 cases of bladder diverticula. Arch Pathol Lab Med 2009; 133: 791.
University of Toledo School of Medicine
Richard L. Cantley Department of Pathology and
4. Xylinas E, Rink M, Robinson BD et al: Impact of histological variants on oncological outcomes of patients with urothelial carcinoma of the bladder treated with radical cystectomy. Eur J Cancer 2013; 49: 1889.
Department of Urology University of Toledo Medical Center Toledo, Ohio
5. Tawadros T, Alonso F, Jichlinski P et al: Release of macrophage migration inhibitory factor by neuroendocrine-differentiated LNCaP cells sustains the proliferation and survival of prostate cancer cells. Endocr Relat Cancer 2013; 20: 137.
1. Idrees MT, Alexander RE, Kum JB et al: The spectrum of histopathologic findings in vesical diverticulum: implications for pathogenesis and staging. Hum Pathol 2013; 44: 1223.
6. Rogers CG, Palapattu GS, Shariat SF et al: Clinical outcomes following radical cystectomy for primary nontransitional cell carcinoma of the bladder compared to transitional cell carcinoma of the bladder. J Urol 2006; 175: 2048.
Samay Jain
