522 Proc. roy. Soc. Med. Volume 68 August 1975

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Squamous Carcinoma in a Squamous-lined Bladder Iain G Kidson MB, Ann Savage MB and J C Gingell FRCS (Southmead Hospital, Bristol) Woman, aged 58. Housewife History: Presented in July 1974 with marked frequency of micturition and dysuria. She had had these symptoms intermittently, to a less severe degree, for many years. She had undergone left nephrectomy for pyonephrosis in 1934 (aged 18), and in 1956 she presented as an emergency with calculous obstruction of her remaining kidney, requiring urgent nephrostomy. Subsequent pyelolithotomy with lower pole partial nephrectomy was performed but a portion of the obstructing staghorn-type calculus remained in a middle calyx. In 1966, in view of the increasing severity of her lower tract symptoms, she underwent radical urethral dilatation. Considerable urethral narrowing was observed at this time. Minor easily controlled urinary infection occurred periodically and, because of deteriorating renal function, from 1970 she required some dietary restriction of protein and an increased fluid intake. The more recent severe frequency and burning on micturition was associated with a sterile pyuria and she was admitted for further assessment. Investigations: Excretion urography showed the residual calculus to be unchanged but there was increased calyceal and pelvic dilatation of the

Fig 2 Well-differentiated squamous carcinoma. x 215

solitary kidney and considerable distension and tortuosity of the ureter throughout its length. At endoscopy'urethral dilatation was necessary to allow instrumentation. There was a large, irregular, pale, necrotic tumour at the dome of the bladder which was palpable on bimanual examination. It was approximately 7 x 4 x 4 cm in size and biopsies showed well differentiated squamous carcinoma with no transitional element. Operation: Total cystectomy was performed (Fig 1) and the dilated ureter anastomosed end to end to an ileal conduit with mimimal spatulation. Renal function returned to the preoperative level. Histology of the bladder tumour confirmed the biopsy findings (Fig 2). There was -no demonstrable transitional epithelial lining to the bladder, which was entirely lined with squamous epithelium. This was partly of the typical keratinizing type but there were areas of the non-keratinizing (vaginal' type both in the trigonal area and remote from it (Fig 3). Discussion

Fig 1 Excised bladder showing carcinoma at dome, with infiltration of wall (scale in inches)

Squamous carcinoma of the bladder is unusual, with an incidence of 1.6-10 % of bladder tumours. It is generally regarded as highly malignant and invasive. One recent series gives a one-year survival rate of 41 % and a four-year survival of 15 % (Newman et al. 1968). It is most commonly found in association with chronic obstruction and infection (Ashton Miller et al. 1969). These factors were

Section of Urology

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trigone and its immediate area, or of its occurrence in association with the keratinizing type. Attention has been drawn to the usual presentation of squamous carcinoma of the bladder with symptoms of severe cystitis without frank hematuria (Ashton Miller et al. 1969). When such symptoms become severe and unresponsive in patients with recurrent cystitis, particularly if squamous metaplasia has been noted previously, early cystoscopy is mandatory. REFERENCES Miller A, Mitchell J P & Brown N J (1969) British Journal of Urology 41, No. 1, Suppl. Newman D M, Brown J R, Jay A C & Pontius E E (1968) Journal of Urology 100, 470-473 O'Flynn J D & Mullaney J (1967) British Journal of Urology 39, 461-471 Rokitansky C F von (1861) In: Lehrbuch der pathologischen Anatomie. Ed. W Braumuller. Wien; 3,354 Tyler D E (1962) American Journal of Anatomy 111, 319-325

Multiple Aneurysms in a Child J L Williams FRCS (Department of Urology, Hallamshire Hospital, Sheffield) Fig 3 A junction between vacuolated'vaginal' type epithelium and keratinizing squamous epithelium. x 215

present in our patient with long-standing urethra'l stenosis and intermittent bacteriuria. Nonkeratinizing 'vaginal' type squamous epithelium is commonly present in the female bladder in and just outside the trigone and must be distinguished from squamous metaplasia (Tyler 1962). This

K B, boy, born 3.12.61 Respiratory infection at age of 5l; chest X-ray showed an enlarged heart. There was a loud systolic murmur over the precordium; blood pressure 150/100 mmHg. Small aneurysms were detected on both radial arteries and left brachial artery. Femoral pulses were present and equal.

term is reserved for keratinizing squamous epithelium which is always abnormal and is described as leukoplakia when visible endoscopically. In the bladder the term leukoplakia implies metaplasia only, without suggestion of cellular atypia. Leukoplakia was first described in 1861 by Rokitansky and is usually regarded as

due to chronic obstruction and infection. There is some controversy about the condition being premalignant. We have reviewed about 200 cases in the literature and it is clear that about 15%Y have shown malignant change and many have had only a relatively short period of follow up. We feel that because of this tendency to malignant change squamous metaplasia of the bladder requires the same careful review as known bladder tumours. Our patient is particularly interesting because of the complete replacement of the normal transitional epithelium of the bladder. Previous authors have described a few cases of complete replacement with the keratinizing type of squamous epithelium (Rokitansky 1861, O'Flynn & Mullaney 1967) but we have found no reports of the presence of the 'vaginal' type of squamous epithelium away from the

Fig 1 Aortogram at'age 5i years