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Mucinous Carcinoma of the Urachus Invading the Bladder
THE JouRKAL OF UROLOGY
Vol. 67, No. 4, April 1952 Ptinlcd in V.S.1L
l\1-UCINOUS CARCIKOMA OF THE URACHUS INVADING THE
BLADDER J\1.
s.
A. R KURITZ, R A. BURGER
AND
G. W. REAGAX
A total of 4G cases, besides our own, of mucinous carcinoma of the urnchus invading the bladder haye been described in the liternture. The majority were men in the fourth and fifth decades. The youngest reported case 1rns in a man 26 years of age, REPORT OF CASE
H, a 52 year old ,vas admitted to the Veterans Administration Hospital, North Little Arkansas, on June 3, 1949, ,vith a diagnosis of psychosis, manic deprec;si\·e, mixed type, On .June 9, 1949, he began to haYe frequency, nocturia and hematuria. Repeated urine examinations showed 30 to 35 red blood cells per high pmrnr field. Cystoscopic examination on June 14, 1949, showed a small, firm tumor with a hard base at the dome of the bladder. A diagnosis of malignancy ,vas made, Because of the flatness of the mass, a sati:ofactory biopsy was not obtained, On June 29, 1949, cystoscopy was The tumor mass appeared about the same size as previously noted. satisfactory biopsy ,ms not obtained because of the flatness of the lesion, Suprnpubic cystotomy and radium seed implantation into the tumor were recommended, On July a midline incision ,ms made and the bladder ,ms exposed extraperitoneally, A mass about 3½ inches in diameter ,ms noted intimately attached to the bladder in the midline, The tumor was smooth and circumscribed and not adherent to the peritoneum nor attached to the umbilicus. It ,Ya8 surrounded by loose areolar tissue. There were no palpable lymph nodes. The upper one-third of the bladder together with the tumor mass was resected. Cut sections of the tumor mass showed it to contain a gelatinous material. H \ms not loculated or lobulated. The interior of the bladder showed a circular, sessile tumor, about 2½ cm. in diameter, cauliflower in appearance, very hard and raised aboye the bladder mucosa about 1 cm, This tumor mass in the Yault of the bladder ,vas continuous ,Yith the above described cystic mass, The entire specimen was hourglass in shape and measured 9 by G by :5 crrL (fig. 1). The larger portion ,ms oval and encapsulated, The ,rnll here a ,-eragecl less than 1 mm. in thickness and was very fibrous. The contents of this large cystic mass ,rnre gelatinous and yellow gray; the material \\"as tenacious and adherent to the cyst walL There ,ms direct continuity beh,·een the cystic mass and the portion of tumor involving the wall of the urinary blacldeL The intraYesical neoplasm ,ms not encapsulated and extended into the vesical mu::;cnlature. It measured -1 cm. in diameter and \rns 2 cm. thick, This mass ,ms irregular, fungating and reddish grny. This tissue on cut section ,ms firm and gray ,vith areas of red brown softening. Reviewed in the Veterans Administration and published with the approval of the Chief JVIedical Director. The staternents and conclusions published by the authors are the result of their own study and clo not necessarily reflect the opinion or policy of the "Veterans Administration,
523
524
"\VESSELL, K"GRITZ, BURGER AND REAGAN
Sections from the cystic mass showed a thin fibrous wall with no recognizable lining epithelium. At the junction with the solid mass there were many bizarre shaped glands lined by tall columnar epithelium with considerable mucus pres-
C
Fm. 1. Gross specimen. A, intravesical portion of carcinoma; B, extravesical portion; C, cyst wall opened; and D, gelatinous contents of cyst.
Fm. 2. Section of bladder showing: A, transitional epithelium of mucosa; B, invading adenocarcinoma.
ent. The glandular epithelium "Yrns moderately pleomorphic with many of the cells shmYing hyperchromatic nuclei. Invasion of the muscular layer of the urinary bladder was present and the neoplasm extended up to immediately beneath the transitional epithelium of the bladder. Small groups of anaplastic cells ·were seen in endothelial lined channels in one area. Vascularity was moderate.
MUCINO-GS C:\ RCINOiVH OF URACHUS INVADING BLADDEH
525
The neoplasm is considered a mucinous adenocarcinoma of the urachus with invasion of the urinary bladder (fig. 2). Suprapubic and prevesical drainage was carried out. All draius including the suprapubic drain were removed on Augm;t 5, 1949. On August 12, l949, the suprapubic drain wound was healed and the patient was passing urine by urethra. The postoperative course ,Yas uneventful. The patient has been follm1·ed monthly since operation and up to this time (6 m011ths' postoperative) has been symptom free without local recurrence or clern.onstrable metastasis . DISCUSSION
These lesions ar8 mmally first seen by the urologist through the cystoscope. They may appear a:;; ulcerated or papillomatous grmYths at the vault of the bladder. The syrnptomatology of this tumor is similar to other malignant tumor;, of the bladder. Often the first symptom is hematuria with frequency. Inflammatory phenomena may maclk the hematuria since, as in all cases of cancer of the bladder, infection is likely to occur early. If infection is pronounced voiding is usualiy associated ,rith pain. A l01,-, tender, palpable mass in the suprapubic area and the voiding of mucilaginous material have been described in the literatun,. When a lesion is Yisualized, it is important that the character of the tumor be determined from a pathological standpoint,. Proper treatment is directly dependent upon a correct diagnosis. This type of tumor rarely metastasizes before operation, but it has been noted that metastases are relatively frequent after operation. The consensus of all who have encountered this tumor is that radical surgical excision of the tumor is the only method of any value. Some han~ advocated removal of the peritoneum over the bladder together with the umbilicus. The accepted therapy of papillary tumors of the bladder such as fulguration or radium t>eed ixnplantation is valueless in urachal tumor;:;. The latter conten-tion is based on the fact that the lesion visible through the cystoscope is no criterion of the actual size of the uraehal neoplasm since the bulk of the growth is intra-abdominal and erosion through the bladder is a late rnanifestation. In the ease presented satisfactory biopsy vrns not obtained and bec:au:-;e of this fact, the true nature of the tumor was not suspected until operation. This case again emphasizes the importance of thorough examination in all cases of hernaturia. SUMMARY
A case of carcinoma of the uraehus invading the bladder has been presented. The clinical, diagnostic and therapeutic features of this tumor haYe beeu reviewed, Veterans Administration Hospital, North Little Rock, Ark. (A. B. K.) REFERENCES B.e:GG, lL C.: J. Anat., 64: 170, HJ30. BEGG, R. C.: B1·it . J thug., 18: 422, 1930-31. BEGG, R. C .. Brit ..J. Surg., 27: 769, 1936. RAPPOPORT, A. AND l\1xos, C .. Arch. Path., 41: 388, 1946. HAYES, J. J. AND SEo.u, A. D.: J. UroL, 53: 659, 1945. HuGHES, 1'. B. AND LATOIVSKY, L. W.: Am. J. Surg., 58: 422, 1()42.
.l
. .I.,'
Vol. 67, No. 4, April 1952 Ptinlcd in V.S.1L
l\1-UCINOUS CARCIKOMA OF THE URACHUS INVADING THE
BLADDER J\1.
s.
A. R KURITZ, R A. BURGER
AND
G. W. REAGAX
A total of 4G cases, besides our own, of mucinous carcinoma of the urnchus invading the bladder haye been described in the liternture. The majority were men in the fourth and fifth decades. The youngest reported case 1rns in a man 26 years of age, REPORT OF CASE
H, a 52 year old ,vas admitted to the Veterans Administration Hospital, North Little Arkansas, on June 3, 1949, ,vith a diagnosis of psychosis, manic deprec;si\·e, mixed type, On .June 9, 1949, he began to haYe frequency, nocturia and hematuria. Repeated urine examinations showed 30 to 35 red blood cells per high pmrnr field. Cystoscopic examination on June 14, 1949, showed a small, firm tumor with a hard base at the dome of the bladder. A diagnosis of malignancy ,vas made, Because of the flatness of the mass, a sati:ofactory biopsy was not obtained, On June 29, 1949, cystoscopy was The tumor mass appeared about the same size as previously noted. satisfactory biopsy ,ms not obtained because of the flatness of the lesion, Suprnpubic cystotomy and radium seed implantation into the tumor were recommended, On July a midline incision ,ms made and the bladder ,ms exposed extraperitoneally, A mass about 3½ inches in diameter ,ms noted intimately attached to the bladder in the midline, The tumor was smooth and circumscribed and not adherent to the peritoneum nor attached to the umbilicus. It ,Ya8 surrounded by loose areolar tissue. There were no palpable lymph nodes. The upper one-third of the bladder together with the tumor mass was resected. Cut sections of the tumor mass showed it to contain a gelatinous material. H \ms not loculated or lobulated. The interior of the bladder showed a circular, sessile tumor, about 2½ cm. in diameter, cauliflower in appearance, very hard and raised aboye the bladder mucosa about 1 cm, This tumor mass in the Yault of the bladder ,vas continuous ,Yith the above described cystic mass, The entire specimen was hourglass in shape and measured 9 by G by :5 crrL (fig. 1). The larger portion ,ms oval and encapsulated, The ,rnll here a ,-eragecl less than 1 mm. in thickness and was very fibrous. The contents of this large cystic mass ,rnre gelatinous and yellow gray; the material \\"as tenacious and adherent to the cyst walL There ,ms direct continuity beh,·een the cystic mass and the portion of tumor involving the wall of the urinary blacldeL The intraYesical neoplasm ,ms not encapsulated and extended into the vesical mu::;cnlature. It measured -1 cm. in diameter and \rns 2 cm. thick, This mass ,ms irregular, fungating and reddish grny. This tissue on cut section ,ms firm and gray ,vith areas of red brown softening. Reviewed in the Veterans Administration and published with the approval of the Chief JVIedical Director. The staternents and conclusions published by the authors are the result of their own study and clo not necessarily reflect the opinion or policy of the "Veterans Administration,
523
524
"\VESSELL, K"GRITZ, BURGER AND REAGAN
Sections from the cystic mass showed a thin fibrous wall with no recognizable lining epithelium. At the junction with the solid mass there were many bizarre shaped glands lined by tall columnar epithelium with considerable mucus pres-
C
Fm. 1. Gross specimen. A, intravesical portion of carcinoma; B, extravesical portion; C, cyst wall opened; and D, gelatinous contents of cyst.
Fm. 2. Section of bladder showing: A, transitional epithelium of mucosa; B, invading adenocarcinoma.
ent. The glandular epithelium "Yrns moderately pleomorphic with many of the cells shmYing hyperchromatic nuclei. Invasion of the muscular layer of the urinary bladder was present and the neoplasm extended up to immediately beneath the transitional epithelium of the bladder. Small groups of anaplastic cells ·were seen in endothelial lined channels in one area. Vascularity was moderate.
MUCINO-GS C:\ RCINOiVH OF URACHUS INVADING BLADDEH
525
The neoplasm is considered a mucinous adenocarcinoma of the urachus with invasion of the urinary bladder (fig. 2). Suprapubic and prevesical drainage was carried out. All draius including the suprapubic drain were removed on Augm;t 5, 1949. On August 12, l949, the suprapubic drain wound was healed and the patient was passing urine by urethra. The postoperative course ,Yas uneventful. The patient has been follm1·ed monthly since operation and up to this time (6 m011ths' postoperative) has been symptom free without local recurrence or clern.onstrable metastasis . DISCUSSION
These lesions ar8 mmally first seen by the urologist through the cystoscope. They may appear a:;; ulcerated or papillomatous grmYths at the vault of the bladder. The syrnptomatology of this tumor is similar to other malignant tumor;, of the bladder. Often the first symptom is hematuria with frequency. Inflammatory phenomena may maclk the hematuria since, as in all cases of cancer of the bladder, infection is likely to occur early. If infection is pronounced voiding is usualiy associated ,rith pain. A l01,-, tender, palpable mass in the suprapubic area and the voiding of mucilaginous material have been described in the literatun,. When a lesion is Yisualized, it is important that the character of the tumor be determined from a pathological standpoint,. Proper treatment is directly dependent upon a correct diagnosis. This type of tumor rarely metastasizes before operation, but it has been noted that metastases are relatively frequent after operation. The consensus of all who have encountered this tumor is that radical surgical excision of the tumor is the only method of any value. Some han~ advocated removal of the peritoneum over the bladder together with the umbilicus. The accepted therapy of papillary tumors of the bladder such as fulguration or radium t>eed ixnplantation is valueless in urachal tumor;:;. The latter conten-tion is based on the fact that the lesion visible through the cystoscope is no criterion of the actual size of the uraehal neoplasm since the bulk of the growth is intra-abdominal and erosion through the bladder is a late rnanifestation. In the ease presented satisfactory biopsy vrns not obtained and bec:au:-;e of this fact, the true nature of the tumor was not suspected until operation. This case again emphasizes the importance of thorough examination in all cases of hernaturia. SUMMARY
A case of carcinoma of the uraehus invading the bladder has been presented. The clinical, diagnostic and therapeutic features of this tumor haYe beeu reviewed, Veterans Administration Hospital, North Little Rock, Ark. (A. B. K.) REFERENCES B.e:GG, lL C.: J. Anat., 64: 170, HJ30. BEGG, R. C.: B1·it . J thug., 18: 422, 1930-31. BEGG, R. C .. Brit ..J. Surg., 27: 769, 1936. RAPPOPORT, A. AND l\1xos, C .. Arch. Path., 41: 388, 1946. HAYES, J. J. AND SEo.u, A. D.: J. UroL, 53: 659, 1945. HuGHES, 1'. B. AND LATOIVSKY, L. W.: Am. J. Surg., 58: 422, 1()42.
.l
. .I.,'