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Bladder Carcinosarcoma: Histologic Variation in Metastatic Lesions
0022-534 7/83/1294-0829$02.00/0 Vol. 129, April Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
BLADDER CARCINOSARCOMA: HISTOLOGIC VARIATION IN METASTATIC LESIONS JOSEPH A. SMITH, JR.,* HARRY W. HERR
AND
RICHARD G. MIDDLETON
From the Department of Surgery, Division of Urology, University of Utah Medical Center, Salt Lake City, Utah, and Urologic Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
Carcinosarcoma is a tumor composed of malignant epithelial and mesenchymal elements, which occurs rarely in the bladder. Although the prognosis of bladder carcinosarcoma is known to be poor the histology of metastatic lesions is not well described. We report 2 cases of bladder carcinosarcoma with pelvic lymph node involvement. Pure sarcomatous metastasis was present in 1 patient and only carcinoma in the other. The histologic composition of metastatic lesions may be of significance in treatment planning in patients with bladder carcinosarcoma. Although the vast majority of bladder neoplasms are of epithelial origin (carcinoma) malignant bladder tumors of mesenchymal origin (sarcoma) do occur. Carcinosarcoma is a tumor comprised of malignant epithelial and mesenchymal elements, which is seen rarely in the bladder. In many instances carcinoma and sarcoma are known to vary in natural history, pattern of metastatic spread and response to therapy. Since bladder carcinosarcoma is generally a highly aggressive tumor, determining optimal adjuvant therapy or treatment of metastatic lesions may be difficult. Herein we report 2 cases of bladder tumors that on pathologic examination were found to have carcinomatous and sarcomatous components. Pelvic lymph node metastasis occurred in both patients but contained histologically pure sarcoma in 1 patient and only carcinoma in the other. CASE REPORTS
Case 1. G. H., a 67-year-old man, underwent distal right ureterectomy and ureteral reimplant in March 1979 for carcinosarcoma of the ureter. Gross hematuria developed 3 months postoperatively and cystoscopy showed a tumor on the right side wall of the bladder, which was resected transurethrally. Pathologic examination demonstrated a tumor comprised predominantly of epidermoid carcinoma but with foci of cartilaginous (chondrosarcoma) elements (fig. 1). A right pelvic mass was detected on physical examination 4 months later. An excretory urogram (IVP) showed displacement of the bladder by the mass but no upper tract obstruction. A pelvic computerized tomography scan showed the mass to be extending into the obturator and right pararectal region with a separate mass near the anterior bladder. A chest x-ray and bone scan showed no evidence of distant metastatic disease. Segmental cystectomy and partial excision of the right pelvic mass were performed along with removal of the regional lymph nodes. Histologic examination of the specimen showed extensive high grade chondrosarcoma. No carcinomatous elements were identified. The patient was treated postoperatively with pelvic irradiation and chemotherapy, consisting of 70 mg./m. 2 doxorubicin hydrochloride. Despite this, extensive pelvic and abdominal disease recurred and the patient died 3 months later. Case 2. A. B., a 51-year-old man, was first seen in June 1980 with irritative voiding symptoms and hematuria several months in duration. An IVP showed nonvisualization of the left kidney and an apparent mass on the left side of the bladder. The right kidney and collecting system appeared normal. Cystoscopy showed a large tumor occupying the left trigone and bladder Accepted for publication August 13, 1982. * Requests for reprints: 50 North Medical Drive, Salt Lake City, Utah 84132
FIG. 1. Case 1. Focus of malignant cartilage (chondrosarcoma) that was detected within tumor comprised predominantly of epidermoid carcinoma. Metastatic lesions contained only this sarcomatous element.
neck, and extending into the prostatic urethra. Transurethral resection of the tumor was performed and pathologic examination showed a malignant tumor of neoplastic cartilage and bone (fig. 2, A) with foci of keratinizing epidermoid carcinoma (fig. 2, B). Metastatic evaluation, including a bone scan, liver scan and chest x-ray, showed no distant disease. Bilateral pelvic lymph node dissection and radical cystectomy were performed. Pathologic examination again showed extensive carcinosarcoma of the bladder. Multiple lymph nodes were involved bilaterally but contained only elements of poorly differentiated carcinoma. No sarcomatous components were detected in any of the lymph nodes (fig. 2, C). The patient did well until 5 months later when weakness and malaise developed. A chest x-ray showed multiple pulmonary metastases. The patient was treated with a course of cyclophosphamide, doxorubicin hydrochloride and cisplatin but he did poorly and died 1 month later. DISCUSSION
Although a rare lesion in the bladder, carcinosarcoma is a well recognized tumor of other organs, particularly the uterine fundus. Nevertheless, the pathologic diagnosis may be difficult and confusing. Many poorly differentiated carcinomas may contain metaplastic areas with sarcomatoid changes. The spindle cell metaplasia seen in some renal cell carcinomas may have a striking resemblance to sarcoma. According to Meyer1 and Willis,2 carcinosarcoma can occur by 1 of 3 phenomena: 1)
829
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SMITH, HERR AND MIDDLETON
Fm. 2. Case 2. A, bladder tumor shows prominent osteoid formation along with osteoblastic cells. Sarcomatous pattern was predominant element of primary tumor. B, focus of epidermoid carcinoma with keratinization from bladder tumor. Similar foci were scattered throughout tumor. C, lymph node shows metastatic undifferentiated carcinoma. No sarcomatous elements of primary tumor were detected in any lymph nodes.
collision tumors in which 2 malignancies of separate origms intermingle, 2) combination tumors in which both elements are derived from a totipotent cell or 3) composition tumors in which both malignant elements occur simultaneously in the same tissue.
The epithelial component of most reported bladder carcinosarcomas is transitional cell carcinoma, while osteoid and cartilaginous tissues are the most frequent sarcomatous elements. However, various other combinations have been seen, such as rhabdomyosarcoma, 3 leiomyosarcoma, squamous cell carci-
BLA.DDEit CARCiN-OSAR :'.0MA 0
non1a .a.nd ader:ocarcinon1cL of rnetastatic lesions has been ;
in. th.is disease s,re treatrr1ent failures have to local and distant recurrence. In view of the variable that may be co,,.VU""'''"'°' and ,rnovv•o~,"~ aminatioIJ. of metastatic lesions may be useful before µ1,,wrn..uie. further treatment in these µ"''"'uc,,, REFERENCES 1. Meyer, R.: Beitrag zm
cmm,"v.u;; i.iber die Namengebung in der Geschwulstlehre. ZbL allg. 30: 291, 1920. 2. Willis, R. A.: Pathology of Tumours, 4th ed. London: Butterworths,
1967.
3. Holtz, F., Fox, J.E. and Abell, M. R: Carcinosarcoma of the urinary bladder. Cancer, 29: 294, 1972. 4. Schoborg, T. W., Saffos, R. 0., Rodriquez, A. P. and Scott, C., Jr.: Carcinosarcoma of the bladder. J. Urol., 124: 724, 1980. 5. Patterson, T. ff and Dale, G. A.: Carcinosarcoma of the bladder: case report and review of the literature. J. UroL, 115: 753, 1976. 6. Haddad, J. R. and Reyes, E. C.: Carcinosarcoma of the prostate with metastasis of both elements: case report. J. UroL, 103: 80, 1970.
THE JOURNAL OF UROLOGY
Copyright© 1983 by The Williams & Wilkins Co.
BLADDER CARCINOSARCOMA: HISTOLOGIC VARIATION IN METASTATIC LESIONS JOSEPH A. SMITH, JR.,* HARRY W. HERR
AND
RICHARD G. MIDDLETON
From the Department of Surgery, Division of Urology, University of Utah Medical Center, Salt Lake City, Utah, and Urologic Service, Memorial Sloan-Kettering Cancer Center, New York, New York
ABSTRACT
Carcinosarcoma is a tumor composed of malignant epithelial and mesenchymal elements, which occurs rarely in the bladder. Although the prognosis of bladder carcinosarcoma is known to be poor the histology of metastatic lesions is not well described. We report 2 cases of bladder carcinosarcoma with pelvic lymph node involvement. Pure sarcomatous metastasis was present in 1 patient and only carcinoma in the other. The histologic composition of metastatic lesions may be of significance in treatment planning in patients with bladder carcinosarcoma. Although the vast majority of bladder neoplasms are of epithelial origin (carcinoma) malignant bladder tumors of mesenchymal origin (sarcoma) do occur. Carcinosarcoma is a tumor comprised of malignant epithelial and mesenchymal elements, which is seen rarely in the bladder. In many instances carcinoma and sarcoma are known to vary in natural history, pattern of metastatic spread and response to therapy. Since bladder carcinosarcoma is generally a highly aggressive tumor, determining optimal adjuvant therapy or treatment of metastatic lesions may be difficult. Herein we report 2 cases of bladder tumors that on pathologic examination were found to have carcinomatous and sarcomatous components. Pelvic lymph node metastasis occurred in both patients but contained histologically pure sarcoma in 1 patient and only carcinoma in the other. CASE REPORTS
Case 1. G. H., a 67-year-old man, underwent distal right ureterectomy and ureteral reimplant in March 1979 for carcinosarcoma of the ureter. Gross hematuria developed 3 months postoperatively and cystoscopy showed a tumor on the right side wall of the bladder, which was resected transurethrally. Pathologic examination demonstrated a tumor comprised predominantly of epidermoid carcinoma but with foci of cartilaginous (chondrosarcoma) elements (fig. 1). A right pelvic mass was detected on physical examination 4 months later. An excretory urogram (IVP) showed displacement of the bladder by the mass but no upper tract obstruction. A pelvic computerized tomography scan showed the mass to be extending into the obturator and right pararectal region with a separate mass near the anterior bladder. A chest x-ray and bone scan showed no evidence of distant metastatic disease. Segmental cystectomy and partial excision of the right pelvic mass were performed along with removal of the regional lymph nodes. Histologic examination of the specimen showed extensive high grade chondrosarcoma. No carcinomatous elements were identified. The patient was treated postoperatively with pelvic irradiation and chemotherapy, consisting of 70 mg./m. 2 doxorubicin hydrochloride. Despite this, extensive pelvic and abdominal disease recurred and the patient died 3 months later. Case 2. A. B., a 51-year-old man, was first seen in June 1980 with irritative voiding symptoms and hematuria several months in duration. An IVP showed nonvisualization of the left kidney and an apparent mass on the left side of the bladder. The right kidney and collecting system appeared normal. Cystoscopy showed a large tumor occupying the left trigone and bladder Accepted for publication August 13, 1982. * Requests for reprints: 50 North Medical Drive, Salt Lake City, Utah 84132
FIG. 1. Case 1. Focus of malignant cartilage (chondrosarcoma) that was detected within tumor comprised predominantly of epidermoid carcinoma. Metastatic lesions contained only this sarcomatous element.
neck, and extending into the prostatic urethra. Transurethral resection of the tumor was performed and pathologic examination showed a malignant tumor of neoplastic cartilage and bone (fig. 2, A) with foci of keratinizing epidermoid carcinoma (fig. 2, B). Metastatic evaluation, including a bone scan, liver scan and chest x-ray, showed no distant disease. Bilateral pelvic lymph node dissection and radical cystectomy were performed. Pathologic examination again showed extensive carcinosarcoma of the bladder. Multiple lymph nodes were involved bilaterally but contained only elements of poorly differentiated carcinoma. No sarcomatous components were detected in any of the lymph nodes (fig. 2, C). The patient did well until 5 months later when weakness and malaise developed. A chest x-ray showed multiple pulmonary metastases. The patient was treated with a course of cyclophosphamide, doxorubicin hydrochloride and cisplatin but he did poorly and died 1 month later. DISCUSSION
Although a rare lesion in the bladder, carcinosarcoma is a well recognized tumor of other organs, particularly the uterine fundus. Nevertheless, the pathologic diagnosis may be difficult and confusing. Many poorly differentiated carcinomas may contain metaplastic areas with sarcomatoid changes. The spindle cell metaplasia seen in some renal cell carcinomas may have a striking resemblance to sarcoma. According to Meyer1 and Willis,2 carcinosarcoma can occur by 1 of 3 phenomena: 1)
829
1· !
830
SMITH, HERR AND MIDDLETON
Fm. 2. Case 2. A, bladder tumor shows prominent osteoid formation along with osteoblastic cells. Sarcomatous pattern was predominant element of primary tumor. B, focus of epidermoid carcinoma with keratinization from bladder tumor. Similar foci were scattered throughout tumor. C, lymph node shows metastatic undifferentiated carcinoma. No sarcomatous elements of primary tumor were detected in any lymph nodes.
collision tumors in which 2 malignancies of separate origms intermingle, 2) combination tumors in which both elements are derived from a totipotent cell or 3) composition tumors in which both malignant elements occur simultaneously in the same tissue.
The epithelial component of most reported bladder carcinosarcomas is transitional cell carcinoma, while osteoid and cartilaginous tissues are the most frequent sarcomatous elements. However, various other combinations have been seen, such as rhabdomyosarcoma, 3 leiomyosarcoma, squamous cell carci-
BLA.DDEit CARCiN-OSAR :'.0MA 0
non1a .a.nd ader:ocarcinon1cL of rnetastatic lesions has been ;
in. th.is disease s,re treatrr1ent failures have to local and distant recurrence. In view of the variable that may be co,,.VU""'''"'°' and ,rnovv•o~,"~ aminatioIJ. of metastatic lesions may be useful before µ1,,wrn..uie. further treatment in these µ"''"'uc,,, REFERENCES 1. Meyer, R.: Beitrag zm
cmm,"v.u;; i.iber die Namengebung in der Geschwulstlehre. ZbL allg. 30: 291, 1920. 2. Willis, R. A.: Pathology of Tumours, 4th ed. London: Butterworths,
1967.
3. Holtz, F., Fox, J.E. and Abell, M. R: Carcinosarcoma of the urinary bladder. Cancer, 29: 294, 1972. 4. Schoborg, T. W., Saffos, R. 0., Rodriquez, A. P. and Scott, C., Jr.: Carcinosarcoma of the bladder. J. Urol., 124: 724, 1980. 5. Patterson, T. ff and Dale, G. A.: Carcinosarcoma of the bladder: case report and review of the literature. J. UroL, 115: 753, 1976. 6. Haddad, J. R. and Reyes, E. C.: Carcinosarcoma of the prostate with metastasis of both elements: case report. J. UroL, 103: 80, 1970.