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Granular Cell Myoblastoma of the Bladder: Report of an Additional Case
Vol. 110, October
THE ,Jot!RNAL OF UROLCGJ:
Copyright© 197:) by The \VilliarnB
1/Vilkins
Co.
Printed in U.S.A.
GRANULAR CELL MYOBLASTOMA OF THE BLADDER: REPORT OF AN ADDITIONAL CASE SHUTARO MIZUTANI, NOBORU OKUDA
AND
TAKAO SONODA
From the Department of Urology, Osaka University Hospital, Osaka, Japan
Granular cell myoblastomas are relatively rare tumors which are usually benign and are found in all parts of the body except the parenchymatous organs. 1 • 2 The histogenesis has not been established, although striated muscle or nerve tissue is the most accepted source of origin. There have been reports of 7 such tumors associated with the bladder. 2 - 7 A case of granular cell myoblastoma without recurrence 5 years postoperatively is presented herein. CASE REPORT
A. N., a 49-year-old married Japanese woman, was first seen on May 14, 1968 because of recurrent gross, painless hematuria. Physical findings were normal except for an anemic appearance and for a large, movable mass palpable on the right lower portion of the abdomen. Laboratory examination disclosed hemoglobin 9.6 gm. per cent, a red blood count of 312 times 10 4 mm. 3 , urinary albumin 3 plus and massive red and white blood cells per high power field. Blood chemistry studies and liver function tests were normal. Cystoscopy revealed a golf ball-size tumor on the right lateral wall, the surface of which was coated well with a smooth whitish-gray capsule accompanied a few distended tortuous blood vessels without ulceration. The trigone was normal. Chest x-ray and excretory urography were negative. A cystogram revealed a round negative shadow. Selective arteriography subsequent to air insufflation into the bladder showed that the tumor was nourished mainly through an inferior vesical artery and did not reveal much hypervascularity. The tumor and a wide cuff of normal bladder were removed by sharp fOT publication
A. P. and Lattes,
dissection. The remaining bladder was closed with a catheter inserted through the urethra. Convalescence was uneventful and the catheter was removed 10 days postoperatively. A total of 4,000R cobalt 60 was given for 30 days. The patient was discharged from the hospital 55 days postoperatively and is doing well 5 years later. The tumor consisted of a large mass ( 4.5 by 3.5 by 3.0 cm.), weighing 29 gm. The mass was gray, soft and surrounded by a thin fibrous capsule. On section the tumor was yellowish-white, solid and showed little vascularity. Microscopic examination revealed large spindle-shaped cells arranged in columns and pseudo-alveolar formation separated by fine strands of connective tissue (fig. 1). In most areas the cell membrane was relatively indistinct. The cytoplasm was abundant and contained numerous eosinophilic granules of varying sizes. The small nuclei, which were poor in chromatin, were usually uniform in size and centrally located. Vacuoles were not evident and mitotic activity was minimal. Eosinophilic granules were stained positive on periodic acid, Schiff. With phosphotungstic acid-hematoxylin the tumor showed no muscular component. On the other hand, the fine strands of connective tissue were positive on silver impregnation for neurofibrils (fig. 2). COMMENTS
Since Abrikossoff described a myoblastic tumor associated with striated muscle, several tissues have been advanced as the possible source of origin for granular cell myoblastoma, such as fibrous tissue, myo-epithelial tissue, neurological tissue, smooth muscle, striated muscle and histiocytes. 8 Even though no positive proof has been given, the preponderance of evidence seems to rest with a neurogenic rather than myogenic origin. 9 • 10 In the present case we found no striated muscle component in the mass on phosphotungstic acidhernatoxylin stain and only fine strands of connective tissue were stained with silver impregnation. Dr. Robert M. Jr. of the Brooke General
4, 1973.
· Tumors of the soft tissues. In: Atlas of Tumour Pathology. Washington, D. C .. Armed Forces Institute of Patholog,;, 2nd series, fasc. 1, pp. 92-93 and 180-183, 1967. 2 Seery, W. H.: cell myoblastoma of the 100: 1968. bladder: of a case. . D. F. and Montgomery, · On rhabdomyoma and myoblastoma. J. Path. 44: 517, 1937.
'Hirsch, E. F. and Brown, B. M.: Myoblastic sarcoma of the urinary bladder. Arch. Surg., 37: 562, 1938. 5 Ravich, A., Stout, A. P. and Ravich, R. A.: Malignant granular cell myoblastoma involving the urinary bladder. Ann. Surg., 121: 361, 1945. 6 Andersen, A. and Hoeg, K.: Myoblastoma of the bladder neck: report of a case. Brit. J. Urol., 33: 76, 1961. 7 Marsh, R. J. and Ceccarelli, F. E.: Ten-year analysis of primary bladder tumors at Brooke General Hospital. J. Urol., 91: 530, 1964.
'Abrikossoff, A.: Myomas originating from transversely striated voluntary musculature. Virchows Arch. f. path. Anat., 260: 215, 1926. •Sobel, H. J. and Churg, J.: Granular cells and granular cell lesions. Arch. Path., 77: 132, 1964. 1 °Fisher, E. R. and Wechsler, H.: Granular cell myoblastoma-a misnomer. Electron microscopic and histochemical evidence concerning its Schwann cell derivation and nature (granular cell schwannoma). Cancer, 15: 936, 1962.
403
404
MIZUTANI, OKUDA AND SONODA
FIG. 1. Large spindle-shaped cells separated by fine strands of connective tissue. Cytoplasm was abundant and contained numerous and strongly acidophilic granules. H & E, reduced from x400.
FIG. 2. Tissue impregnated with silver for neurofibrils. Fine strands of connective tissue show positive on silver impregnation. Reduced from x400.
Hospital sent us a followup report on the case reported by Marsh and Ceccarelli, 7 showing that the patient died of a cerebrovascular accident 13 years after total cystectomy and ureterosigmoidostomy because of granular cell myoblastoma. At autopsy, a pre-aortic mass was found 2 cm. from the bifurcation of the aorta and pheochromocytoma was the final diagnosis. Although it is not evident that the bladder tumor had been gran-
ular cell myoblastoma or pheochromocytoma, it cannot be denied that it was of neural origin. Although the facts cited intensify the histogenesis of neural origin, definite proof is lacking. These myoblastomas are believed to be benign. 11 11 Paskin, D. L., Hull, J. D. and Cookson, P. J.: Granular cell myoblastoma: a comprehensive review of 15-years experience. Ann. Surg., 175: 501, 1972.
GRANULAR CELL MYOBLASTOJ'!IA OF BLADDER
However, 4 of 7 granular cell myoblastomas were malignant when associated with the bladder. 2 Moreover, areas of the tumor surface are ulcerated and covered with vascular granulation in most of the cases reported to be involved with the bladder. Treatment of the tumor might include local excision with wide cuff and postoperative irradiation.
SUMMARY
A case of granular cell myoblastoma of the bladder without recurrence 5 years postoperatively is reported. Although the preponderance of neurogenic origin as histogenesis is prevailing, proof is indefinite. Dr. Kohji Watanabe made the diagnosis in this case.
THE ,Jot!RNAL OF UROLCGJ:
Copyright© 197:) by The \VilliarnB
1/Vilkins
Co.
Printed in U.S.A.
GRANULAR CELL MYOBLASTOMA OF THE BLADDER: REPORT OF AN ADDITIONAL CASE SHUTARO MIZUTANI, NOBORU OKUDA
AND
TAKAO SONODA
From the Department of Urology, Osaka University Hospital, Osaka, Japan
Granular cell myoblastomas are relatively rare tumors which are usually benign and are found in all parts of the body except the parenchymatous organs. 1 • 2 The histogenesis has not been established, although striated muscle or nerve tissue is the most accepted source of origin. There have been reports of 7 such tumors associated with the bladder. 2 - 7 A case of granular cell myoblastoma without recurrence 5 years postoperatively is presented herein. CASE REPORT
A. N., a 49-year-old married Japanese woman, was first seen on May 14, 1968 because of recurrent gross, painless hematuria. Physical findings were normal except for an anemic appearance and for a large, movable mass palpable on the right lower portion of the abdomen. Laboratory examination disclosed hemoglobin 9.6 gm. per cent, a red blood count of 312 times 10 4 mm. 3 , urinary albumin 3 plus and massive red and white blood cells per high power field. Blood chemistry studies and liver function tests were normal. Cystoscopy revealed a golf ball-size tumor on the right lateral wall, the surface of which was coated well with a smooth whitish-gray capsule accompanied a few distended tortuous blood vessels without ulceration. The trigone was normal. Chest x-ray and excretory urography were negative. A cystogram revealed a round negative shadow. Selective arteriography subsequent to air insufflation into the bladder showed that the tumor was nourished mainly through an inferior vesical artery and did not reveal much hypervascularity. The tumor and a wide cuff of normal bladder were removed by sharp fOT publication
A. P. and Lattes,
dissection. The remaining bladder was closed with a catheter inserted through the urethra. Convalescence was uneventful and the catheter was removed 10 days postoperatively. A total of 4,000R cobalt 60 was given for 30 days. The patient was discharged from the hospital 55 days postoperatively and is doing well 5 years later. The tumor consisted of a large mass ( 4.5 by 3.5 by 3.0 cm.), weighing 29 gm. The mass was gray, soft and surrounded by a thin fibrous capsule. On section the tumor was yellowish-white, solid and showed little vascularity. Microscopic examination revealed large spindle-shaped cells arranged in columns and pseudo-alveolar formation separated by fine strands of connective tissue (fig. 1). In most areas the cell membrane was relatively indistinct. The cytoplasm was abundant and contained numerous eosinophilic granules of varying sizes. The small nuclei, which were poor in chromatin, were usually uniform in size and centrally located. Vacuoles were not evident and mitotic activity was minimal. Eosinophilic granules were stained positive on periodic acid, Schiff. With phosphotungstic acid-hematoxylin the tumor showed no muscular component. On the other hand, the fine strands of connective tissue were positive on silver impregnation for neurofibrils (fig. 2). COMMENTS
Since Abrikossoff described a myoblastic tumor associated with striated muscle, several tissues have been advanced as the possible source of origin for granular cell myoblastoma, such as fibrous tissue, myo-epithelial tissue, neurological tissue, smooth muscle, striated muscle and histiocytes. 8 Even though no positive proof has been given, the preponderance of evidence seems to rest with a neurogenic rather than myogenic origin. 9 • 10 In the present case we found no striated muscle component in the mass on phosphotungstic acidhernatoxylin stain and only fine strands of connective tissue were stained with silver impregnation. Dr. Robert M. Jr. of the Brooke General
4, 1973.
· Tumors of the soft tissues. In: Atlas of Tumour Pathology. Washington, D. C .. Armed Forces Institute of Patholog,;, 2nd series, fasc. 1, pp. 92-93 and 180-183, 1967. 2 Seery, W. H.: cell myoblastoma of the 100: 1968. bladder: of a case. . D. F. and Montgomery, · On rhabdomyoma and myoblastoma. J. Path. 44: 517, 1937.
'Hirsch, E. F. and Brown, B. M.: Myoblastic sarcoma of the urinary bladder. Arch. Surg., 37: 562, 1938. 5 Ravich, A., Stout, A. P. and Ravich, R. A.: Malignant granular cell myoblastoma involving the urinary bladder. Ann. Surg., 121: 361, 1945. 6 Andersen, A. and Hoeg, K.: Myoblastoma of the bladder neck: report of a case. Brit. J. Urol., 33: 76, 1961. 7 Marsh, R. J. and Ceccarelli, F. E.: Ten-year analysis of primary bladder tumors at Brooke General Hospital. J. Urol., 91: 530, 1964.
'Abrikossoff, A.: Myomas originating from transversely striated voluntary musculature. Virchows Arch. f. path. Anat., 260: 215, 1926. •Sobel, H. J. and Churg, J.: Granular cells and granular cell lesions. Arch. Path., 77: 132, 1964. 1 °Fisher, E. R. and Wechsler, H.: Granular cell myoblastoma-a misnomer. Electron microscopic and histochemical evidence concerning its Schwann cell derivation and nature (granular cell schwannoma). Cancer, 15: 936, 1962.
403
404
MIZUTANI, OKUDA AND SONODA
FIG. 1. Large spindle-shaped cells separated by fine strands of connective tissue. Cytoplasm was abundant and contained numerous and strongly acidophilic granules. H & E, reduced from x400.
FIG. 2. Tissue impregnated with silver for neurofibrils. Fine strands of connective tissue show positive on silver impregnation. Reduced from x400.
Hospital sent us a followup report on the case reported by Marsh and Ceccarelli, 7 showing that the patient died of a cerebrovascular accident 13 years after total cystectomy and ureterosigmoidostomy because of granular cell myoblastoma. At autopsy, a pre-aortic mass was found 2 cm. from the bifurcation of the aorta and pheochromocytoma was the final diagnosis. Although it is not evident that the bladder tumor had been gran-
ular cell myoblastoma or pheochromocytoma, it cannot be denied that it was of neural origin. Although the facts cited intensify the histogenesis of neural origin, definite proof is lacking. These myoblastomas are believed to be benign. 11 11 Paskin, D. L., Hull, J. D. and Cookson, P. J.: Granular cell myoblastoma: a comprehensive review of 15-years experience. Ann. Surg., 175: 501, 1972.
GRANULAR CELL MYOBLASTOJ'!IA OF BLADDER
However, 4 of 7 granular cell myoblastomas were malignant when associated with the bladder. 2 Moreover, areas of the tumor surface are ulcerated and covered with vascular granulation in most of the cases reported to be involved with the bladder. Treatment of the tumor might include local excision with wide cuff and postoperative irradiation.
SUMMARY
A case of granular cell myoblastoma of the bladder without recurrence 5 years postoperatively is reported. Although the preponderance of neurogenic origin as histogenesis is prevailing, proof is indefinite. Dr. Kohji Watanabe made the diagnosis in this case.