Vol. 115, May
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
SQUAMOUS CELL CARCINOMA OF THE BLADDER D. E. JOHNSON, M. B. SCHOENWALD, A.G. AYALA
AND
L. S. MILLER
From the Section of Urology, Departments of Surgery, Pathology and Radiation Therapy, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
ABSTRACT
Clinical and morphological features of 90 cases of squamous cell carcinoma of the bladder have been reviewed. The lesions were solitary in 90 per cent of the patients, developed without a history of vesical malignant disease in 82 per cent and were invasive at the time of diagnosis in all cases. Ureteral obstruction was demonstrated in 42 per cent of the group. The over-all survival rate at 5 years was only 10.6 per cent. There were 17 patients who received no therapy, all of whom were dead before 2 years. Unassisted supervoltage radiation therapy for patients with stages B 2 and C lesions yielded a 5-year survival rate of only 17.7 per cent. However, preoperative radiotherapy followed by simple total cystectomy and urinary diversion in a small number of patients with stages B 2 and C lesions resulted in a 5-year survival rate in excess of 34 per cent. We are encouraged by this finding and believe that combination therapy warrants further clinical trial. Primary squamous cell carcinoma of the bladder is uncommon, accounting for approximately 3 to 6.7 per cent of all vesical malignant disease. 1• 3 This rarity has prevented unanimity of opinion as to the origin of the disease and to the methods for treatment. To better define the natural history and to formulate plans for therapy we have reviewed our experience with 90 cases of squamous cell carcinoma of the bladder. MATERIALS AND METHODS
The records were reviewed of 2,010 patients with bladder carcinoma admitted to our hospital between August 1944 and July 1974. In 90 patients (4.5 per cent) the tumors were composed entirely of squamous cell carcinomas arising primarily within the bladder. Adequate clinical staging of the disease, using the usual methods of endoscopic and palpable findings, was recorded in 85 patients according to Marshall's modification of the Jewett and Strong classification. 4 Although diagnosis was substantiated in all cases by histologic examination at the time of initial evaluation, microsections for current review were available in only 69 patients. Histologic typing and grading were performed according to the general criteria proposed by Mostofi and associates.• RESULTS
Clinical findings. The series consisted of 50 men and 40 women, ranging in age from 37 to 86 years (median 66.6 years). The disease tended to occur in men at a slightly younger age than in women. The median age for men at the time of diagnosis was 65.2 years, as opposed to a median age of 68.2 years for women (fig. 1). There were no significant racial distributions. The most common presenting symptom was hematuria (63 per cent), with irritative bladder symptoms as part of the symptom complex occurring in 60 per cent. A urinary tract infection was present in 93 per cent of the patients at the time of diagnosis. The duration of symptoms ranged from 1 to 48 months, with a median of only 4 months. In 74 patients (82 per cent) there was no history of vesical malignant disease, whereas 10 had a history of squamous cell carcinoma and 6 had a history of transitional cell carcinoma of the bladder. Accepted for publication September 12, 1975. Read at annual meeting of Southeastern Section, American Urological Association, Atlanta, Georgia, April 13-16, 1975. 542
The tumor was solitary in 81 patients and it arose from the lateral wall in 38. In only 2 cases did the tumor arise from bladder diverticula. The remaining lesions varied somewhat equally in distribution over the dome, anterior wall, trigone and posterior wall. The lesions at the time of initial diagnosis were classified clinically as stage B, in 7 patients, B 2 in 12, C in 24, D 1 in 37 and D 2 in 5. The stage of disease was not recorded in 5 patients. However, infiltration by the tumor into the muscular wall could not be demonstrated histologically in 22 of the 77 patients (29 per cent) in whom the depth of penetration had been assessed adequately (table 1). Excretory urograms (IVPs) were obtained in 77 patients at the time of diagnosis and were normal in only 58 per cent of these patients. Pathology. In specimens obtained by partial or complete cystectomy the tumors were predominantly ulcerating and infiltrating in character. Rarely were they of an exophytic or fungating nature. Histological material was graded in accordance with the degree of anaplasia present on a I to III scale. Grade I was assigned to tumors with a well differentiated pattern and minimal pleomorphism. The cells were large and polygonal with abundant keratin granules and keratin formation. Intercellular bridges were present'. As a general rule mitoses were rare. Grade II was assigned to lesions displaying mild to moderate pleomorphism. While many of the cells were large and polygonal other cells were irregular with hyperchromatic nuclei and prominent nucleoli. However, the general features were still retained and keratin formation was prominent. Grade III was assigned to lesions in which anaplasia was obvious and mitotic figures were numerous. Although the lesions were poorly differentiated, keratin formation and squamoid cellular features were still retained in areas. Squamous metaplasia of the mucosa adjacent to the tumor was found in 15 cases and transition from the metaplastic mucosa into tumor could be seen in some instances. Von Brunn nesting, cystitis cystica and cystitis glandularis also were present occasionally in the specimens. Treatment. Treatment for these patients varied considerably (table 2). Seventeen patients received no therapy. Of the 73 treated patients radiation alone was given to 38. An operation alone was used in 15 patients and consisted of transurethral resection in 4 instances, partial cystectomy in 3 instances, total cystectomy and urinary diversion in 4 instances and suprapubic cystostomy with electroresection in 4 instances. Preoperative irradiation followed by operation was used in 11 patients and operation plus postoperative irradiation was administered
543
SQtJAivlOUS CELL CARCINCl\JlA OF BLADDER AGE DlSTR!BUTiOt~ BY SEX
20
Males
N•50
Females N • 40 C
ID 0 Q_
0
10
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z
0
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:,
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Stage 81 N=7
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.,
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., C:
u
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u
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.,
>
>
;
~ :::,
:::,
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Stage 82 N=12
:::,
u
E
I I I I I I I I I 75 I I I I I I I I I 50 I I I I I I I I \
:::,
u
25
SQUAMOUS CARCINOMA OF BLADDER CUMULATIVE PERCENT SURVIVAL XRT ALONE vs PREOP XRT AND CYSTECTOMY - STAGE B2C
25
Stage C N=20 Stage D2 N=5
Pre op XRT + Cystectom y N=7
''
''
' ' ~----------------------XRT Alone N= 17
Stage D1 N=27
0
THE JOURNAL OF UROLOGY
Printed in U.S.A.
Copyright© 1976 by The Williams & Wilkins Co.
SQUAMOUS CELL CARCINOMA OF THE BLADDER D. E. JOHNSON, M. B. SCHOENWALD, A.G. AYALA
AND
L. S. MILLER
From the Section of Urology, Departments of Surgery, Pathology and Radiation Therapy, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
ABSTRACT
Clinical and morphological features of 90 cases of squamous cell carcinoma of the bladder have been reviewed. The lesions were solitary in 90 per cent of the patients, developed without a history of vesical malignant disease in 82 per cent and were invasive at the time of diagnosis in all cases. Ureteral obstruction was demonstrated in 42 per cent of the group. The over-all survival rate at 5 years was only 10.6 per cent. There were 17 patients who received no therapy, all of whom were dead before 2 years. Unassisted supervoltage radiation therapy for patients with stages B 2 and C lesions yielded a 5-year survival rate of only 17.7 per cent. However, preoperative radiotherapy followed by simple total cystectomy and urinary diversion in a small number of patients with stages B 2 and C lesions resulted in a 5-year survival rate in excess of 34 per cent. We are encouraged by this finding and believe that combination therapy warrants further clinical trial. Primary squamous cell carcinoma of the bladder is uncommon, accounting for approximately 3 to 6.7 per cent of all vesical malignant disease. 1• 3 This rarity has prevented unanimity of opinion as to the origin of the disease and to the methods for treatment. To better define the natural history and to formulate plans for therapy we have reviewed our experience with 90 cases of squamous cell carcinoma of the bladder. MATERIALS AND METHODS
The records were reviewed of 2,010 patients with bladder carcinoma admitted to our hospital between August 1944 and July 1974. In 90 patients (4.5 per cent) the tumors were composed entirely of squamous cell carcinomas arising primarily within the bladder. Adequate clinical staging of the disease, using the usual methods of endoscopic and palpable findings, was recorded in 85 patients according to Marshall's modification of the Jewett and Strong classification. 4 Although diagnosis was substantiated in all cases by histologic examination at the time of initial evaluation, microsections for current review were available in only 69 patients. Histologic typing and grading were performed according to the general criteria proposed by Mostofi and associates.• RESULTS
Clinical findings. The series consisted of 50 men and 40 women, ranging in age from 37 to 86 years (median 66.6 years). The disease tended to occur in men at a slightly younger age than in women. The median age for men at the time of diagnosis was 65.2 years, as opposed to a median age of 68.2 years for women (fig. 1). There were no significant racial distributions. The most common presenting symptom was hematuria (63 per cent), with irritative bladder symptoms as part of the symptom complex occurring in 60 per cent. A urinary tract infection was present in 93 per cent of the patients at the time of diagnosis. The duration of symptoms ranged from 1 to 48 months, with a median of only 4 months. In 74 patients (82 per cent) there was no history of vesical malignant disease, whereas 10 had a history of squamous cell carcinoma and 6 had a history of transitional cell carcinoma of the bladder. Accepted for publication September 12, 1975. Read at annual meeting of Southeastern Section, American Urological Association, Atlanta, Georgia, April 13-16, 1975. 542
The tumor was solitary in 81 patients and it arose from the lateral wall in 38. In only 2 cases did the tumor arise from bladder diverticula. The remaining lesions varied somewhat equally in distribution over the dome, anterior wall, trigone and posterior wall. The lesions at the time of initial diagnosis were classified clinically as stage B, in 7 patients, B 2 in 12, C in 24, D 1 in 37 and D 2 in 5. The stage of disease was not recorded in 5 patients. However, infiltration by the tumor into the muscular wall could not be demonstrated histologically in 22 of the 77 patients (29 per cent) in whom the depth of penetration had been assessed adequately (table 1). Excretory urograms (IVPs) were obtained in 77 patients at the time of diagnosis and were normal in only 58 per cent of these patients. Pathology. In specimens obtained by partial or complete cystectomy the tumors were predominantly ulcerating and infiltrating in character. Rarely were they of an exophytic or fungating nature. Histological material was graded in accordance with the degree of anaplasia present on a I to III scale. Grade I was assigned to tumors with a well differentiated pattern and minimal pleomorphism. The cells were large and polygonal with abundant keratin granules and keratin formation. Intercellular bridges were present'. As a general rule mitoses were rare. Grade II was assigned to lesions displaying mild to moderate pleomorphism. While many of the cells were large and polygonal other cells were irregular with hyperchromatic nuclei and prominent nucleoli. However, the general features were still retained and keratin formation was prominent. Grade III was assigned to lesions in which anaplasia was obvious and mitotic figures were numerous. Although the lesions were poorly differentiated, keratin formation and squamoid cellular features were still retained in areas. Squamous metaplasia of the mucosa adjacent to the tumor was found in 15 cases and transition from the metaplastic mucosa into tumor could be seen in some instances. Von Brunn nesting, cystitis cystica and cystitis glandularis also were present occasionally in the specimens. Treatment. Treatment for these patients varied considerably (table 2). Seventeen patients received no therapy. Of the 73 treated patients radiation alone was given to 38. An operation alone was used in 15 patients and consisted of transurethral resection in 4 instances, partial cystectomy in 3 instances, total cystectomy and urinary diversion in 4 instances and suprapubic cystostomy with electroresection in 4 instances. Preoperative irradiation followed by operation was used in 11 patients and operation plus postoperative irradiation was administered
543
SQtJAivlOUS CELL CARCINCl\JlA OF BLADDER AGE DlSTR!BUTiOt~ BY SEX
20
Males
N•50
Females N • 40 C
ID 0 Q_
0
10
ID ~
E ~
z
0
.;::
-"' " E
:,
u
25
2 >
> >
:::, Cf)
~
Stage 81 N=7
~
.,
Cf)
., C:
u
~
Q.
u
50
~
.,
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.,
>
>
;
~ :::,
:::,
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Stage 82 N=12
:::,
u
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I I I I I I I I I 75 I I I I I I I I I 50 I I I I I I I I \
:::,
u
25
SQUAMOUS CARCINOMA OF BLADDER CUMULATIVE PERCENT SURVIVAL XRT ALONE vs PREOP XRT AND CYSTECTOMY - STAGE B2C
25
Stage C N=20 Stage D2 N=5
Pre op XRT + Cystectom y N=7
''
''
' ' ~----------------------XRT Alone N= 17
Stage D1 N=27
0
