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Granular Cell Myoblastoma of the Bladder: Report of a Case
Vol. 100, I.kc.
J OURN~\..L OF UROLOGY Copyright © 1968 by The Williams & Wilkins Co.
THE
Printed in U.S.A..
GRANULAR CELL l\IYOBLASTO~IA OF THE BLADDER: REPORT OF ,\ CASE WILLIAlvI H. SEERY
From the Department of SI,rgery, Division of Urology, Long Island Jewish Hospital, Jamaica, New York
Considerable dispute has ari~en as to the histogene~is of myoblastoma since it was first described by Abrikossoff in 1926 as a rnyoblastic tumor as~ociated with striated muscle. 1 Fibrous tissue, myoepithelial tissue, neurological tissue, smooth muscle, striated muscle and histiocytes have been advanced as possible sources of origin. Even though no positive proof has been shown, the preponderance of e,·idcnce seems to rest 1Yith either myogenic' or neurogenic 3 • 4 origin. Tumors of similar cellular characteristics have been reported in almost all locations \\·ith the exception of parenchy1natous organs as the liver and kidney. Both benign and malignant myoblastomas have been cle~cribed, and benign tumors have undergone malignant transformation. 5 Only 5 cases, 4 malignant 6• 8 and 1 benign,9 have been associated with the bladder. CASE REPORT
J. G., a 31-year-old ,Yhite man, first noticed gross painless hematuria in 1947. He was told "an ulcer of the bladder" had been fulgurated by endoscopic means. The man remained asymptoAccepted for publication December 15, 1967. Abrikossoff, A.: Myomas originating from transversely striated volnntary musculature. Virchows Arch. f. path. Anat., 260: 215-233, 1926. 2 Maximow, A. A. and Bloom, W.: A Textbook of Histology. Philadelphia: \Y. B. Saunders Co., 4th ed., 1942. 3 Bangle, R., Jr.: A morphological and histochemical study of the granular-cell m:rnblastoma. Cancer, 5: 950-965, 1952. 4 Fisher, E. R. and Wechsler, H.: Granular cell myoblastoma-a misnomer. Electron microscopic and histochemical evidence concerning its Schwa1111 cell derivation and nature (granular cell schwannoma). Cancer, 15: 936-954, 1962. 5 Ravich, A., Stout, A. P. and Ravich, R. A .. Malignant granular cell myoblastoma involving the urinary bladder. Ann. Surg., 121: 361-372, 1945. 6 Hirsch, E. F. and Brown, B. :;'1.1.: Myoblastic sarcoma of the urinary bladder. Arch. Surg., 37: 562-569, 1938. 7 Howe, C. W. and Warren, S .. Myoblastoma. Surgery, 16: 319-347, 1944. 8 Murray, M. R: Cultural characteristics of three granular-cell myoblastomas. Cancer, 4: 857865, 1951. 9 Andersen, R. and Hoeg, K .. .:\Ivoblastoma of the bladder neck: report of a case. ·Brit. J. Urol., 33: 76-79, 1961. 1
matic until 6 weeks before admi,sion t,o om hospital when he again had total, gross hematuria. There was no further recurrence until 24 hours before admi.ssion to 1he hospital on March 20, 1949. Physical finding;; ,rnre normal exeept, for a large, hard, irregular, mo,·able mas~ palpable, above the prostate glaud on bimauual examination. The hemogram, blood urea nitrogen, chesi" x-ra:r, excretory urogram and barium enema were normal. Cystoscopy revealed a 1 cm. ulcerated area above the trigone in the midline. The Purrounding mucosa was hypertrophied anrl marked by several distended tortuou~ blood ve.,,;ck Biopsies taken from this area ,rnre reporter! chronic cystitis. Proctoscopie examination revealed no abnormalities. The peritoneal cavity wa~ entered in the midline through a suprapubic incision. A large, hard, irregular vascular tumor was found attacher! to the funrlus and dome of the bladder. The bladder \Yas opened aud the previous!~- clescribecl ulcer 1rns seen 4 cm. above the interureteral ridge. The tumor and a wide cuff of normal bladder 1rnn' removed by sharp clissectiou. The remaining bladder was closed over a suprapubic tube. Convalescence was uneventful and the patient is well 18 years after the operation. The tumor consisted of a large (6 by 7 by 6 cm.) irregular mass with a nodular surface. The mass; \\'as gray and surrounded by a thick fibrous capsule. A 1 cm. ulcerated area of the bladder wa" noted overlying the mass. At this point tlw mucosa was roug;heued. On section, the tumor was vascular. There was an area in its center of apparent hemorrhagic degeneration, 1.5 cm. iu diameter, filled with fresh blood clots. The parenchyma was made up of soft gray fibrous strand,:, with a haphazard arrangement. J\1icroscopic examination revealed large polyhedral or round cells arranged in Golunrns and pseudo-alveolar formation separated by fine strands of connective tissue. In most areas the cellular borders were relatively distinct. The cytoplasm was abundant and contained il\llll(ffous pink-stained granules of varying c;izes. The small nuclei were fairly uniform in size and
73,5
736
SEERY
A, section of tumor shows cells arranged in columns and pseudo-alveolar formation separated by fine strands of connective tissue. 90X. B, section of tumor shows large polyhedral cells with abundant cytoplasm containing numerous granules of varying sizes. 500X
usually centrally located. Vacuoles were present but did not constitute a major feature. Striations were not evident and mitotic activity was at a minimum (figure). COMMENTS
It is not the province of this report to delve deeply into the histogenesis of myoblastomas, particularly since excellent papers are available.3 · 4 • s, 10- 12 If this tumor is of myogenic origin, 10 Sobel, H. J. and Churg, J.: Granular cells and granular cell lesions. Arch. Path., 77: 132-141,
1964. 11
Ross, R. C., Miller, T. R. and Foote, F. W.,
it occurs in areas where striated muscle does not normally appear. However, if it is of neurogenic origin, it has not been found in the liver or kidney where nerve tissue is normally present. The exact histogenesis must await more definitive evidence. Although the tumor was large, it could easily have been missed had not a bimanual examination been done. The only evidence in the bladder of its presence was a small ulcer which revealed chronic cystitis on cup biopsy. In retrospect, the roughened mucosa seen on cystoscopy was conJr.: Malignant granular-cell myoblastoma. Cancer, 5: 112-121, 1952. 12 Herbut, P.A.: Urological Pathology. Philadelphia: Lea & Febiger, vol. 1, 1952.
GRANULAR CELL MYOBLASTOMA OF THE BLADDER
sistent with the reported epithelial changes occurring with this tumor. The only other case of a similar benign tumor of the bladder, reported by Anderson and Hoeg, presented with hematuria and an ulcer of "most unusual appearance". 9 SUMMARY
Granular cell myoblastomas are relatively rare and usually benign tumors found in almost all locations of the body. The exact histogenesis has not been established, although striated muscle
737
or nerve tissue is the most accepted source of origin. One benign and four malignant granular cell myoblastomas have been associated with the bladder. This report presents a patient without recurrence 18 years following the removal of a large granular cell myoblastoma from his bladder. Diagnosis was made by Dr. Irene Garrow, Department of Pathology, Flushing Hospital, Flushing, New York and confirmed by the Armed Forces Institute of Pathology.
J OURN~\..L OF UROLOGY Copyright © 1968 by The Williams & Wilkins Co.
THE
Printed in U.S.A..
GRANULAR CELL l\IYOBLASTO~IA OF THE BLADDER: REPORT OF ,\ CASE WILLIAlvI H. SEERY
From the Department of SI,rgery, Division of Urology, Long Island Jewish Hospital, Jamaica, New York
Considerable dispute has ari~en as to the histogene~is of myoblastoma since it was first described by Abrikossoff in 1926 as a rnyoblastic tumor as~ociated with striated muscle. 1 Fibrous tissue, myoepithelial tissue, neurological tissue, smooth muscle, striated muscle and histiocytes have been advanced as possible sources of origin. Even though no positive proof has been shown, the preponderance of e,·idcnce seems to rest 1Yith either myogenic' or neurogenic 3 • 4 origin. Tumors of similar cellular characteristics have been reported in almost all locations \\·ith the exception of parenchy1natous organs as the liver and kidney. Both benign and malignant myoblastomas have been cle~cribed, and benign tumors have undergone malignant transformation. 5 Only 5 cases, 4 malignant 6• 8 and 1 benign,9 have been associated with the bladder. CASE REPORT
J. G., a 31-year-old ,Yhite man, first noticed gross painless hematuria in 1947. He was told "an ulcer of the bladder" had been fulgurated by endoscopic means. The man remained asymptoAccepted for publication December 15, 1967. Abrikossoff, A.: Myomas originating from transversely striated volnntary musculature. Virchows Arch. f. path. Anat., 260: 215-233, 1926. 2 Maximow, A. A. and Bloom, W.: A Textbook of Histology. Philadelphia: \Y. B. Saunders Co., 4th ed., 1942. 3 Bangle, R., Jr.: A morphological and histochemical study of the granular-cell m:rnblastoma. Cancer, 5: 950-965, 1952. 4 Fisher, E. R. and Wechsler, H.: Granular cell myoblastoma-a misnomer. Electron microscopic and histochemical evidence concerning its Schwa1111 cell derivation and nature (granular cell schwannoma). Cancer, 15: 936-954, 1962. 5 Ravich, A., Stout, A. P. and Ravich, R. A .. Malignant granular cell myoblastoma involving the urinary bladder. Ann. Surg., 121: 361-372, 1945. 6 Hirsch, E. F. and Brown, B. :;'1.1.: Myoblastic sarcoma of the urinary bladder. Arch. Surg., 37: 562-569, 1938. 7 Howe, C. W. and Warren, S .. Myoblastoma. Surgery, 16: 319-347, 1944. 8 Murray, M. R: Cultural characteristics of three granular-cell myoblastomas. Cancer, 4: 857865, 1951. 9 Andersen, R. and Hoeg, K .. .:\Ivoblastoma of the bladder neck: report of a case. ·Brit. J. Urol., 33: 76-79, 1961. 1
matic until 6 weeks before admi,sion t,o om hospital when he again had total, gross hematuria. There was no further recurrence until 24 hours before admi.ssion to 1he hospital on March 20, 1949. Physical finding;; ,rnre normal exeept, for a large, hard, irregular, mo,·able mas~ palpable, above the prostate glaud on bimauual examination. The hemogram, blood urea nitrogen, chesi" x-ra:r, excretory urogram and barium enema were normal. Cystoscopy revealed a 1 cm. ulcerated area above the trigone in the midline. The Purrounding mucosa was hypertrophied anrl marked by several distended tortuou~ blood ve.,,;ck Biopsies taken from this area ,rnre reporter! chronic cystitis. Proctoscopie examination revealed no abnormalities. The peritoneal cavity wa~ entered in the midline through a suprapubic incision. A large, hard, irregular vascular tumor was found attacher! to the funrlus and dome of the bladder. The bladder \Yas opened aud the previous!~- clescribecl ulcer 1rns seen 4 cm. above the interureteral ridge. The tumor and a wide cuff of normal bladder 1rnn' removed by sharp clissectiou. The remaining bladder was closed over a suprapubic tube. Convalescence was uneventful and the patient is well 18 years after the operation. The tumor consisted of a large (6 by 7 by 6 cm.) irregular mass with a nodular surface. The mass; \\'as gray and surrounded by a thick fibrous capsule. A 1 cm. ulcerated area of the bladder wa" noted overlying the mass. At this point tlw mucosa was roug;heued. On section, the tumor was vascular. There was an area in its center of apparent hemorrhagic degeneration, 1.5 cm. iu diameter, filled with fresh blood clots. The parenchyma was made up of soft gray fibrous strand,:, with a haphazard arrangement. J\1icroscopic examination revealed large polyhedral or round cells arranged in Golunrns and pseudo-alveolar formation separated by fine strands of connective tissue. In most areas the cellular borders were relatively distinct. The cytoplasm was abundant and contained il\llll(ffous pink-stained granules of varying c;izes. The small nuclei were fairly uniform in size and
73,5
736
SEERY
A, section of tumor shows cells arranged in columns and pseudo-alveolar formation separated by fine strands of connective tissue. 90X. B, section of tumor shows large polyhedral cells with abundant cytoplasm containing numerous granules of varying sizes. 500X
usually centrally located. Vacuoles were present but did not constitute a major feature. Striations were not evident and mitotic activity was at a minimum (figure). COMMENTS
It is not the province of this report to delve deeply into the histogenesis of myoblastomas, particularly since excellent papers are available.3 · 4 • s, 10- 12 If this tumor is of myogenic origin, 10 Sobel, H. J. and Churg, J.: Granular cells and granular cell lesions. Arch. Path., 77: 132-141,
1964. 11
Ross, R. C., Miller, T. R. and Foote, F. W.,
it occurs in areas where striated muscle does not normally appear. However, if it is of neurogenic origin, it has not been found in the liver or kidney where nerve tissue is normally present. The exact histogenesis must await more definitive evidence. Although the tumor was large, it could easily have been missed had not a bimanual examination been done. The only evidence in the bladder of its presence was a small ulcer which revealed chronic cystitis on cup biopsy. In retrospect, the roughened mucosa seen on cystoscopy was conJr.: Malignant granular-cell myoblastoma. Cancer, 5: 112-121, 1952. 12 Herbut, P.A.: Urological Pathology. Philadelphia: Lea & Febiger, vol. 1, 1952.
GRANULAR CELL MYOBLASTOMA OF THE BLADDER
sistent with the reported epithelial changes occurring with this tumor. The only other case of a similar benign tumor of the bladder, reported by Anderson and Hoeg, presented with hematuria and an ulcer of "most unusual appearance". 9 SUMMARY
Granular cell myoblastomas are relatively rare and usually benign tumors found in almost all locations of the body. The exact histogenesis has not been established, although striated muscle
737
or nerve tissue is the most accepted source of origin. One benign and four malignant granular cell myoblastomas have been associated with the bladder. This report presents a patient without recurrence 18 years following the removal of a large granular cell myoblastoma from his bladder. Diagnosis was made by Dr. Irene Garrow, Department of Pathology, Flushing Hospital, Flushing, New York and confirmed by the Armed Forces Institute of Pathology.