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Incidence of Neoplasm in Vesical Diverticula
0022-534 7/83/1294-0734$02.00/0 THE JOURNAL OF UROLOGY
Vol. 129, April
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
INCIDENCE OF NEOPLASM IN VESICAL DIVERTICULA SAVA MICIC*
AND
VLADETA ILIC
From the Urologic Clinic, Medical Faculty, Belgrade, Yugoslavia
ABSTRACT
Diverticulectomy and partial or total cystectomy were done in 13 patients with carcinoma arising in a vesical diverticulum. Early diagnosis and adequate treatment are indicated. The incidence of a neoplasm in a bladder diverticulum is between 2 and 10 per cent. 1- 4 Special diagnostic and therapeutic problems exist in patients with tumors in.a vesical diverticulum. The accepted treatment is diverticulectomy. We herein report on 13 patients with primary neoplasms arising in a vesical diverticulum.
in 4 (table 2). Two patients with recurrent tumor are alive for > 1 year, while the remaining 3 died of the disease within 10 months. The patients with squamous cell carcinoma and adenocarcinoma died of disseminated disease within 6 to 17 months postoperatively. No recurrence was noted in 4 patients: 2 are well 3 years postoperatively and 2 died within 18 months of metastatic disease.
MATERIALS AND METHODS
We analyzed 96 men between 58 and 78 years old with vesical diverticula seen between 1961 and 1980. Of these patients 13 had primary tumors in the diverticulum. Patients with concomitant tumors elsewhere in the bladder were excluded. RESULTS
Symptoms included hematuria in 9 patients (69 per cent), urinary tract infection with pyuria in 10 (77 per cent), urinary obstruction in 10 (77 per cent) and fever in 2 (15 per cent). In the patients with obstructive symptoms cystoscopy revealed the neoplasm to be within a vesical diverticulum. Excretory urography was done in all patients and a filling defect in a vesical diverticulum was detected in 7. Histopathologic examination revealed transitional cell carcinoma in 9 patients (2 grade I, 3 grade II and 4 grade III), squamous cell carcinoma in 2 and adenocarcinoma in 2. Diverticulectomy was done in 7 patients and partial or total cystectomy was done in 4. Histopathologic examination revealed invasion of the muscle wall of the diverticulum in 11 patients, invasion of the superficial muscle in 5 and infiltration of deep muscle or perivesical tissues in 6 (table 1). In only 2 patients was there invasion of but not beyond the lamina propria. Recurrent tumor was evident in 5 patients with transitional cell carcinoma and was of higher stage than the primary tumor Accepted for publication April 30, 1982. * Requests for reprints: Urologic Clinic, Generala Zdanova 51, 11000 Belgrade, Yugoslavia. y
TABLE
REFERENCES
1. Petkovic, S.: Tumors in vesical diverticula. Urol. Cutan. Rev., 54:
1. Histopathologic stage and type of operation Histopathologic Stage Total No. Pts. Pl P2 P3 P4
Diverticulectomy Partial cystectomy Radical cystectomy
2
4
1
152, 1950. 2. Knappenberger, S. T., Uson, A. C. and Melicow, M. M.: Primary neoplasms occurring in vesical diverticula: a report of 18 cases. J. Urol., 83: 153, 1960. 3. Kelalis, P. P. and McLean, P.: The treatment of diverticulum of the bladder. J. Urol., 98: 349, 1967. 4. Faysal, M. H. and Freiha, F. S.: Primary neoplasm in vesical
7 4
3 2
2
TABLE
DISCUSSION
The most common cause of vesical diverticula is obstruction secondary to prostatic disease or bladder neck contracture. A vesical diverticulum causes residual urine after voiding, which predisposes to infection. Only 16 per cent ofresected diverticula were without any disease and chronic inflammation was detected in 81 per cent. 5 This chronic inflammation may be accompanied by metaplasia and may lead to carcinoma within the diverticulum. The thinness of the diverticular wall, which is without muscular fibers, facilitates earlier penetration of carcinoma and aggravates the prognosis of these patients. The poor prognosis also is advanced by frequent delay in diagnosis. Patients with vesical diverticula with or without hematuria should undergo complete investigation, including cystoscopy. Our findings, which include the propensity of chronic inflammation within vesical diverticula, the high incidence of squamous metaplasia, and the association of carcinoma and diverticula, indicate that careful and periodic examination of all patients with vesical diverticula should be emphasized, and support the statement that all vesical diverticula should be regarded as potential sources of hidden carcinoma. 5• 6 The treatment of tumors within bladder diverticula ranged from transurethral resection to total cystectomy and did not seem to affect the poor survival rate in these patients. The primary consideration for excision of the diverticulum should be the possibility of malignant changes within the diverticulum, with a critical appraisal of the mortality and morbidity of this operation.
2. Survival of patients with recurrent tumors
Primary Neoplasm
Recurrence
Pt.
Followup Stage
LK SM TN
KF JL
Tl T2 T2 T3 T2
Grade
I II II
III II
Operation
Interval (mos.)
Stage
Grade
Diverticulectomy Diverticulectomy Diverticulectomy Partial cystectomy Partial cystectomy
8 3
T2 T2 T3 T4 T3
II II Ill Ill II
7 6 11
734
Alive, 18 mos. Alive, 14 mos. Dead Dead Dead
11:JCIDENCE OF NEOPLASJ\1 :E~ VESICAL DIVER,TICULA
diverticula. A repcrt of 12 cases. Brit. J. Urol., 53: 141, 1981. 5. Petersoni L. J.; Paulson, D. F. and Glenn, J. F.: The histopathology of vesical diverticula. J. Urol., 110: 62, 1973. 6. Montague, D. K. and Boltuch, R. L.: Primary neoplasms in vesical diverticula: report of 10 cases. J. Urol., 116: 41, 1976. EDITORIAL COMMENT This documentation of the potential aggressiveness of transitional cell cancers found within bladder diverticula re-emphasizes the intrinsic behavior of tumors that may already have penetrated the vasculature or perivesical structures at the time of diagnosis. Surgery, in and of itself, clearly is inadequate since in these instances metastatic disease usually is already present, even if still subclinical.
735
It is clear that careful attention to the evaluation of any diverticula that are encountered may permit detection of superficial disease, at which point it would behoove the clinician to remove the diverticulum. Although it is tempting to suggest surgical removal of any diverticulum when it is discovered, because of the possibility of rapid progression of cancer if it occurs in such a diverticulum, the situation usually is al.ready decided at the time of discovery if a tumor is present. If not, careful and continued surveillance would seem appropriate.
Michael J. Droller Brady Urological Institute The Johns Hopkins Hospital Baltimore, Maryland
Vol. 129, April
Copyright© 1983 by The Williams & Wilkins Co.
Printed in U.S.A.
INCIDENCE OF NEOPLASM IN VESICAL DIVERTICULA SAVA MICIC*
AND
VLADETA ILIC
From the Urologic Clinic, Medical Faculty, Belgrade, Yugoslavia
ABSTRACT
Diverticulectomy and partial or total cystectomy were done in 13 patients with carcinoma arising in a vesical diverticulum. Early diagnosis and adequate treatment are indicated. The incidence of a neoplasm in a bladder diverticulum is between 2 and 10 per cent. 1- 4 Special diagnostic and therapeutic problems exist in patients with tumors in.a vesical diverticulum. The accepted treatment is diverticulectomy. We herein report on 13 patients with primary neoplasms arising in a vesical diverticulum.
in 4 (table 2). Two patients with recurrent tumor are alive for > 1 year, while the remaining 3 died of the disease within 10 months. The patients with squamous cell carcinoma and adenocarcinoma died of disseminated disease within 6 to 17 months postoperatively. No recurrence was noted in 4 patients: 2 are well 3 years postoperatively and 2 died within 18 months of metastatic disease.
MATERIALS AND METHODS
We analyzed 96 men between 58 and 78 years old with vesical diverticula seen between 1961 and 1980. Of these patients 13 had primary tumors in the diverticulum. Patients with concomitant tumors elsewhere in the bladder were excluded. RESULTS
Symptoms included hematuria in 9 patients (69 per cent), urinary tract infection with pyuria in 10 (77 per cent), urinary obstruction in 10 (77 per cent) and fever in 2 (15 per cent). In the patients with obstructive symptoms cystoscopy revealed the neoplasm to be within a vesical diverticulum. Excretory urography was done in all patients and a filling defect in a vesical diverticulum was detected in 7. Histopathologic examination revealed transitional cell carcinoma in 9 patients (2 grade I, 3 grade II and 4 grade III), squamous cell carcinoma in 2 and adenocarcinoma in 2. Diverticulectomy was done in 7 patients and partial or total cystectomy was done in 4. Histopathologic examination revealed invasion of the muscle wall of the diverticulum in 11 patients, invasion of the superficial muscle in 5 and infiltration of deep muscle or perivesical tissues in 6 (table 1). In only 2 patients was there invasion of but not beyond the lamina propria. Recurrent tumor was evident in 5 patients with transitional cell carcinoma and was of higher stage than the primary tumor Accepted for publication April 30, 1982. * Requests for reprints: Urologic Clinic, Generala Zdanova 51, 11000 Belgrade, Yugoslavia. y
TABLE
REFERENCES
1. Petkovic, S.: Tumors in vesical diverticula. Urol. Cutan. Rev., 54:
1. Histopathologic stage and type of operation Histopathologic Stage Total No. Pts. Pl P2 P3 P4
Diverticulectomy Partial cystectomy Radical cystectomy
2
4
1
152, 1950. 2. Knappenberger, S. T., Uson, A. C. and Melicow, M. M.: Primary neoplasms occurring in vesical diverticula: a report of 18 cases. J. Urol., 83: 153, 1960. 3. Kelalis, P. P. and McLean, P.: The treatment of diverticulum of the bladder. J. Urol., 98: 349, 1967. 4. Faysal, M. H. and Freiha, F. S.: Primary neoplasm in vesical
7 4
3 2
2
TABLE
DISCUSSION
The most common cause of vesical diverticula is obstruction secondary to prostatic disease or bladder neck contracture. A vesical diverticulum causes residual urine after voiding, which predisposes to infection. Only 16 per cent ofresected diverticula were without any disease and chronic inflammation was detected in 81 per cent. 5 This chronic inflammation may be accompanied by metaplasia and may lead to carcinoma within the diverticulum. The thinness of the diverticular wall, which is without muscular fibers, facilitates earlier penetration of carcinoma and aggravates the prognosis of these patients. The poor prognosis also is advanced by frequent delay in diagnosis. Patients with vesical diverticula with or without hematuria should undergo complete investigation, including cystoscopy. Our findings, which include the propensity of chronic inflammation within vesical diverticula, the high incidence of squamous metaplasia, and the association of carcinoma and diverticula, indicate that careful and periodic examination of all patients with vesical diverticula should be emphasized, and support the statement that all vesical diverticula should be regarded as potential sources of hidden carcinoma. 5• 6 The treatment of tumors within bladder diverticula ranged from transurethral resection to total cystectomy and did not seem to affect the poor survival rate in these patients. The primary consideration for excision of the diverticulum should be the possibility of malignant changes within the diverticulum, with a critical appraisal of the mortality and morbidity of this operation.
2. Survival of patients with recurrent tumors
Primary Neoplasm
Recurrence
Pt.
Followup Stage
LK SM TN
KF JL
Tl T2 T2 T3 T2
Grade
I II II
III II
Operation
Interval (mos.)
Stage
Grade
Diverticulectomy Diverticulectomy Diverticulectomy Partial cystectomy Partial cystectomy
8 3
T2 T2 T3 T4 T3
II II Ill Ill II
7 6 11
734
Alive, 18 mos. Alive, 14 mos. Dead Dead Dead
11:JCIDENCE OF NEOPLASJ\1 :E~ VESICAL DIVER,TICULA
diverticula. A repcrt of 12 cases. Brit. J. Urol., 53: 141, 1981. 5. Petersoni L. J.; Paulson, D. F. and Glenn, J. F.: The histopathology of vesical diverticula. J. Urol., 110: 62, 1973. 6. Montague, D. K. and Boltuch, R. L.: Primary neoplasms in vesical diverticula: report of 10 cases. J. Urol., 116: 41, 1976. EDITORIAL COMMENT This documentation of the potential aggressiveness of transitional cell cancers found within bladder diverticula re-emphasizes the intrinsic behavior of tumors that may already have penetrated the vasculature or perivesical structures at the time of diagnosis. Surgery, in and of itself, clearly is inadequate since in these instances metastatic disease usually is already present, even if still subclinical.
735
It is clear that careful attention to the evaluation of any diverticula that are encountered may permit detection of superficial disease, at which point it would behoove the clinician to remove the diverticulum. Although it is tempting to suggest surgical removal of any diverticulum when it is discovered, because of the possibility of rapid progression of cancer if it occurs in such a diverticulum, the situation usually is al.ready decided at the time of discovery if a tumor is present. If not, careful and continued surveillance would seem appropriate.
Michael J. Droller Brady Urological Institute The Johns Hopkins Hospital Baltimore, Maryland