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A Report of a Case of Leiomyosarcoma of the Bladder1
A REPORT OF A CASE OF LEIOMYOSARCOMA OF THE BLADDER 1 BENJALYIIN H. HAGER
AND
VERNE C. HUNT
Mayo Clinic, Rochester, Minnesota
True sarcoma of the bladder is an extremely rare form of neoplasm. Scholl, in a review of cases in The Mayo Clinic from January, 1910, to January, 1920, mentioned one sarcoma in a series of 262 neoplasms of the bladder. Caulk reported 1 case of spindle-cell sarcoma among 330 neoplasms of the bladder which he had studied. Cecil reported a case of sarcoma of the bladder and reviewed the cases of sarcoma cited in the literature. Parmenter reported an unusual case of sarcocarcinoma of the bladder in which the surface of the sarcomatous tumor was invaded by irregular masses of stratified squamous epithelium producing the characteristic picture of so-called epithelial pearls. The following case of leiomyosarcoma of the bladder is reported because of the rather early recognition and prospects of complete cure from segmental resection. A woman, aged fifty-three came to The Mayo Clinic because of hematuria of ten days' duration. Two weeks previously she had experienced pain similar to that occurring during menstrual periods. Approximately ten days previously she had first noticed blood in the urine, at first only a little, but later at each time she urinated. The amount varied from slight discoloration to much blood. She had not had frequency or pain. N octuria had been present for many years but had not increased in severity. She was somewhat constipated. The patient was somewhat obese and anemic. The systolic blood pressure was 155, the diastolic 85. The specific gravity of the urine was 1.019; albumin was graded 3, pus, 4, and blood, 2. The blood urea, was 16 mgm. for each 100 cc. The hemoglobin was 62 per cent, erythrocytes numbered 3,500,000, the color index was 0.8, and leukocytes 1
Submitted for publication November 3, 1928. 129
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130
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BENJAMIN H. HAGER AND VERNE C. HUNT
Fm. 1.
Fm. 2.
GRoss SPECIMEN
INTERLACING WHORLS OF SPINDLE CELLS
~---~
.FIG.
Fm. 4.
3.
LONG SPINDLE CELLS
TUMOR CELLS SURROUNDING MuscLE BUNDLES IN UPPER RIGHT· HAND CORNER OF THE FIELD
131
132
BENJAMIN H. HAGER AND VERNE C. HUNT
numbered 6,700. The roentgenograms of the kidneys, ureters and bladder were negative. Cystoscopic examination revealed an unusual neoplasm of the bladder, approximately 3 by 3 cm., in the posterior wall. It had the appearance of a solid tumor with a smooth surface and was definitely circumscribed except for a small adjacent granuloma 0.5 by 0.5 cm. Specimens removed from the larger tumor were identified as inflam-
Fm.
5.
MITOTIC FIGURE IN UPPER PART OF THE FIELD
matory tissue with a small area suggestive of myoma or myosarcoma. Because of the cystoscopic data it was decided that the interpretation of myosarcoma was probably correct. Exploration, with segmental resection if the extent of the growth permitted, was therefore advised. ' Under paravertebral anesthesia the bladder was opened. The growth was found to be nearly 3 cm. in diameter and situated fairly high on the posterior wall. Transperitoneal segmental resection of the
LEIOMYOSARCOMA OF THE BLADDER
133
bladder was made after the bladder had been mobilized, the peritoneum opened, and a large portion of the posterior wall of the bladder elevated out of the peritoneum. The edges of the opened peritoneum were attached to the lower posterior wall of the bladder, thereby facilitating extraperitoneal resection of the posterior wall including its entire thickness and the peritoneum over it. Resection included healthy mucous membrane for at least 1 cm. about the tumor. The bladder was reconstructed with two rows of plain catgut. The pathologist reported leiomysarcoma, graded 1. The tumor was shaped somewhat like a truncated cone and measured 2.5 by 2.5 by 2 cm. in its greatest dimensions. The surface of the tumor was smooth except for a small area of ulceration of the mucosa of the bladder at its apex approximately 5 mm. in diameter. Spreading from this were multiple areas of hemorrhage which covered a large part of the portion of the tumor that presented into the bladder. The former lesion was the site from which the biopsy specimens had been removed. The most striking elements in microscopic sections of the tumor were intertwining unstriated muscle fibers, in places interspersed with fibrous connective tissue, in other areas concentrated into definite muscle bundles. The nuclei of the cells of the muscle fibers were conspicuous and a few mitotic figures were present in these cells (figs. 1 to 5). Convalescence was uneventful and the patient left the hospital on the twenty-fourth day. REFERENCES (1) CAULK, J. R.: Sarcoma of the bladder. Jour. Urol., 1926, xvi, 211-223. (2) CECIL, H. L.: Sarcoma of the bladder. Jour. Urol., 1926, xvi, 471-495. (3) PARMENTER, F. J.: Report of a case of sarco-carcinoma of bladder. Bull. Buffalo Gen. Hosp., 1927, v, p. 19. (4) SCHOLL, A. J.: Histology and mortality in cases of tumor of the bladder. Surg., Gynecol., and Obstet., 1922, xxxiv, 189-198.
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AND
VERNE C. HUNT
Mayo Clinic, Rochester, Minnesota
True sarcoma of the bladder is an extremely rare form of neoplasm. Scholl, in a review of cases in The Mayo Clinic from January, 1910, to January, 1920, mentioned one sarcoma in a series of 262 neoplasms of the bladder. Caulk reported 1 case of spindle-cell sarcoma among 330 neoplasms of the bladder which he had studied. Cecil reported a case of sarcoma of the bladder and reviewed the cases of sarcoma cited in the literature. Parmenter reported an unusual case of sarcocarcinoma of the bladder in which the surface of the sarcomatous tumor was invaded by irregular masses of stratified squamous epithelium producing the characteristic picture of so-called epithelial pearls. The following case of leiomyosarcoma of the bladder is reported because of the rather early recognition and prospects of complete cure from segmental resection. A woman, aged fifty-three came to The Mayo Clinic because of hematuria of ten days' duration. Two weeks previously she had experienced pain similar to that occurring during menstrual periods. Approximately ten days previously she had first noticed blood in the urine, at first only a little, but later at each time she urinated. The amount varied from slight discoloration to much blood. She had not had frequency or pain. N octuria had been present for many years but had not increased in severity. She was somewhat constipated. The patient was somewhat obese and anemic. The systolic blood pressure was 155, the diastolic 85. The specific gravity of the urine was 1.019; albumin was graded 3, pus, 4, and blood, 2. The blood urea, was 16 mgm. for each 100 cc. The hemoglobin was 62 per cent, erythrocytes numbered 3,500,000, the color index was 0.8, and leukocytes 1
Submitted for publication November 3, 1928. 129
---
130
·-· -------.
-,----------
BENJAMIN H. HAGER AND VERNE C. HUNT
Fm. 1.
Fm. 2.
GRoss SPECIMEN
INTERLACING WHORLS OF SPINDLE CELLS
~---~
.FIG.
Fm. 4.
3.
LONG SPINDLE CELLS
TUMOR CELLS SURROUNDING MuscLE BUNDLES IN UPPER RIGHT· HAND CORNER OF THE FIELD
131
132
BENJAMIN H. HAGER AND VERNE C. HUNT
numbered 6,700. The roentgenograms of the kidneys, ureters and bladder were negative. Cystoscopic examination revealed an unusual neoplasm of the bladder, approximately 3 by 3 cm., in the posterior wall. It had the appearance of a solid tumor with a smooth surface and was definitely circumscribed except for a small adjacent granuloma 0.5 by 0.5 cm. Specimens removed from the larger tumor were identified as inflam-
Fm.
5.
MITOTIC FIGURE IN UPPER PART OF THE FIELD
matory tissue with a small area suggestive of myoma or myosarcoma. Because of the cystoscopic data it was decided that the interpretation of myosarcoma was probably correct. Exploration, with segmental resection if the extent of the growth permitted, was therefore advised. ' Under paravertebral anesthesia the bladder was opened. The growth was found to be nearly 3 cm. in diameter and situated fairly high on the posterior wall. Transperitoneal segmental resection of the
LEIOMYOSARCOMA OF THE BLADDER
133
bladder was made after the bladder had been mobilized, the peritoneum opened, and a large portion of the posterior wall of the bladder elevated out of the peritoneum. The edges of the opened peritoneum were attached to the lower posterior wall of the bladder, thereby facilitating extraperitoneal resection of the posterior wall including its entire thickness and the peritoneum over it. Resection included healthy mucous membrane for at least 1 cm. about the tumor. The bladder was reconstructed with two rows of plain catgut. The pathologist reported leiomysarcoma, graded 1. The tumor was shaped somewhat like a truncated cone and measured 2.5 by 2.5 by 2 cm. in its greatest dimensions. The surface of the tumor was smooth except for a small area of ulceration of the mucosa of the bladder at its apex approximately 5 mm. in diameter. Spreading from this were multiple areas of hemorrhage which covered a large part of the portion of the tumor that presented into the bladder. The former lesion was the site from which the biopsy specimens had been removed. The most striking elements in microscopic sections of the tumor were intertwining unstriated muscle fibers, in places interspersed with fibrous connective tissue, in other areas concentrated into definite muscle bundles. The nuclei of the cells of the muscle fibers were conspicuous and a few mitotic figures were present in these cells (figs. 1 to 5). Convalescence was uneventful and the patient left the hospital on the twenty-fourth day. REFERENCES (1) CAULK, J. R.: Sarcoma of the bladder. Jour. Urol., 1926, xvi, 211-223. (2) CECIL, H. L.: Sarcoma of the bladder. Jour. Urol., 1926, xvi, 471-495. (3) PARMENTER, F. J.: Report of a case of sarco-carcinoma of bladder. Bull. Buffalo Gen. Hosp., 1927, v, p. 19. (4) SCHOLL, A. J.: Histology and mortality in cases of tumor of the bladder. Surg., Gynecol., and Obstet., 1922, xxxiv, 189-198.
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