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Plasmacytoid Urothelial Carcinoma of the Urinary Bladder
european urology 50 (2006) 1360–1362
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Previous Month’s Discussion and Answer
Plasmacytoid Urothelial Carcinoma of the Urinary Bladder Report of Seven New Cases: Part 2 Kien T. Mai a,*, Hossein M. Yazdi a, Eric Saltel b, Seyda Erdogan c, William A. Stinson d, Ilias Caggianos b, Christopher Morash b a Division of Anatomical Pathology, Department of Laboratory Medicine, The Ottawa Hospital and Department of Pathology and Laboratory Medicine, University of Ottawa, Ontario, Canada b Department of Urology, The Ottawa Hospital and University of Ottawa, Ontario, Canada c Pathology Departments of Cukurova University Medical Faculty, Turkey d Division of Anatomical Pathology, Department of Laboratory Medicine, Kelowna General Hospital, Kelowna, British Columbia, Canada
1.
Discussion
The study case represented the plasmacytoid variant of urothelial carcinoma (PUC). We excluded extramedullary plasmacytoma, which occurs in the urinary bladder [1] because of the positive reaction with Alcian blue in some tumor cells, positive immunostaining for cytokeratin, or epithelial membrane antigen and negative reactivity for kappa and lambda light chains. The positive expression of CD138 may also cause a diagnostic problem. CD138 is expressed on the surface of myeloma, lymphomas, and epithelial and non-epithelial tumors [2]. The other differential diagnoses are metastatic signet ring cell carcinoma from the stomach and other organs, metastatic lobular carcinoma of the breast in biopsy specimen without accompanying carcinoma in situ, and common type of urothelial carcinoma (CUC). Metastatic carcinoma can be excluded by the limited number of signet ring cells in PUC, the negative immunoreactivity for estrogen and progesterone receptors, and the absence of primary carcinoma in other organs.
Review of the medical literature revealed only two previously reported cases of PUC [3,4]. In the review of our retrospective cohort of 260 cases of invasive urothelial carcinoma in the seven-year period at our institution were seven cases, including this report case, an incidence of PUC to be 2.7% of invasive UC. These included (a) five cases with or without focal areas of CUC in less than 5% of the total tumor mass (cases 1, 2, 4, and 5) and (b) two cases of CUC associated with focal areas of PUC in 5% and 10% of the tumor mass, and associated with invasive CUC (cases 6 and 7). Table 1 tabulates the current seven cases and two reported cases in literature with the patients’ demographic features. Patients with diffuse PUC commonly presented with lower urinary tract symptoms (LUTS) with dysuria and abdominal pain. Hematuria occurred in only one patient. Radiological findings consistently showed thickened urinary bladder walls and hydronephrosis. No papillary tumor was seen with cystoscopy, but induration of the mucosal surface was noted. The cytological examination of the catheterized urine of patients with a predominant PUC component (cases 1 to 5) were negative in two cases or diagnosed as cytologic atypia because of the scant number of atypical
DOI of original article: 10.1016/j.eururo.2005.12.047 * Corresponding author. Anatomical Pathology, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9. Tel. +1 613 761 4344; Fax: +1 613 761 4846. E-mail address: [email protected] (K.T. Mai). 0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.03.034
1361
european urology 50 (2006) 1360–1362
Table 1 – Histochemical and immunohistichemical staining Case # 1 2 3 4 5 6 7
Alcian blue in signet ring cells
CD138
CK7
CK20
E-CAD
MIB1
0 + + 0 0 0 0
2 2 1 3 3 2 2
3 3 3 3 3 3 3
1 1 1 2 2 1 1
0 0 0 0 0 3 3
50 55 50 40 60 40 50
single cells in a background with tumor diathesis (three cases). The review of the gross descriptions of the urinary bladders removed by radical cystectomy (cases 3 to 5) indicated contracted bladders with extensive induration and thickened walls (cases 3 and 4) and focal induration (case 5). Microscopically and immunohistochically, PUC of the reviewed cases displayed similar features to the pilot case (Table 1, cases 1 to 5). Immunohistochemically, accompanying CUC was distinguished from PUC by the positive immunoreactivity for E-cadherin (Table 1, cases 6
and 7). Urothelial carcinoma in situ was not seen in any TURBT specimens, but was present in the contiguous mucosa in the radical cystectomy in two of the three CUC cases. There was no evidence of plasmacytoid differentiation of the carcinoma cells in the areas of carcinoma in situ. In cases of PUC associated with CUC, there were gradual transitional changes from CUC with nests of UC to PUC with discohesive cell infiltration pattern (Fig. 1). Awareness of PUC is important in the diagnosis. PUC frequently presents with advanced stage disease with extension into other pelvic organs, distant metastasis occurred only late in the disease. Since the malignant process involves predominantly the subepithelial tissue with an absence of exophytic mucosal lesions, LUTS appears to occur late in the disease. The absence or presence of hematuria and the negative cytology or cytological atypia in urine cytology associated with the indurated endoscopic appearance of the mucosal surface are characteristic.
EU-ACME question All of the following statements about plasmacytoid urothelial carcinoma are true EXCEPT: A. The carcinoma is a rare variant of urothelial carcinoma and is often associated with extensive locoregional disease. B. Hematuria occurs late in clinical presentation. C. Histopathologically, the carcinoma may mimic metastatic breast lobular carcinoma and gastric signet ring carcinoma. D. In biopsy material, plasmacytoid urothelial carcinoma is differentiated from plasmacytoma by using immunostaining for CD138 known to be a marker for plasmacytes.
Fig. 1 – PUC (upper half) associated with CUC (lower half) in the same focus of the tumor. Note some PUC cells displayed signet ring cell features.
Correct answer: D. In biopsy material, plasmacytoid urothelial carcinoma is differentiated from plasmacytoma by using immunostaining for CD138 known to be a marker for plasmacytes.
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european urology 50 (2006) 1360–1362
References [1] Lopez A, Mendez F, Puras-Baez A. Extramedullary plasmacytoma invading the bladder: case report and review of the literature. Urologic Oncology 2003;21:419–23. [2] O’Connell FP, Pinkus JL, Pinkus GS. CD138 (syndecan-1), a plasma cell marker immunohistochemical profile in hematopoietic and nonhematopoietic neoplasms. Am J Clin Pathol 2004;121:254–63.
[3] Sahin AA, Myhre M, Ro JY, Sneige N, et al. Plasmacytoid transitional cell carcinoma, report of a case with initial presentation mimicking multiple myeloma. Acta Cytol 1991;35:277–80. [4] Zhang X, Elhosseiny A, Melamed MR. Plasmacytoid urothelial carcinoma of the bladder, a case report and the first description of urinary cytology. Acta Cytol 2002; 46:412–6.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Previous Month’s Discussion and Answer
Plasmacytoid Urothelial Carcinoma of the Urinary Bladder Report of Seven New Cases: Part 2 Kien T. Mai a,*, Hossein M. Yazdi a, Eric Saltel b, Seyda Erdogan c, William A. Stinson d, Ilias Caggianos b, Christopher Morash b a Division of Anatomical Pathology, Department of Laboratory Medicine, The Ottawa Hospital and Department of Pathology and Laboratory Medicine, University of Ottawa, Ontario, Canada b Department of Urology, The Ottawa Hospital and University of Ottawa, Ontario, Canada c Pathology Departments of Cukurova University Medical Faculty, Turkey d Division of Anatomical Pathology, Department of Laboratory Medicine, Kelowna General Hospital, Kelowna, British Columbia, Canada
1.
Discussion
The study case represented the plasmacytoid variant of urothelial carcinoma (PUC). We excluded extramedullary plasmacytoma, which occurs in the urinary bladder [1] because of the positive reaction with Alcian blue in some tumor cells, positive immunostaining for cytokeratin, or epithelial membrane antigen and negative reactivity for kappa and lambda light chains. The positive expression of CD138 may also cause a diagnostic problem. CD138 is expressed on the surface of myeloma, lymphomas, and epithelial and non-epithelial tumors [2]. The other differential diagnoses are metastatic signet ring cell carcinoma from the stomach and other organs, metastatic lobular carcinoma of the breast in biopsy specimen without accompanying carcinoma in situ, and common type of urothelial carcinoma (CUC). Metastatic carcinoma can be excluded by the limited number of signet ring cells in PUC, the negative immunoreactivity for estrogen and progesterone receptors, and the absence of primary carcinoma in other organs.
Review of the medical literature revealed only two previously reported cases of PUC [3,4]. In the review of our retrospective cohort of 260 cases of invasive urothelial carcinoma in the seven-year period at our institution were seven cases, including this report case, an incidence of PUC to be 2.7% of invasive UC. These included (a) five cases with or without focal areas of CUC in less than 5% of the total tumor mass (cases 1, 2, 4, and 5) and (b) two cases of CUC associated with focal areas of PUC in 5% and 10% of the tumor mass, and associated with invasive CUC (cases 6 and 7). Table 1 tabulates the current seven cases and two reported cases in literature with the patients’ demographic features. Patients with diffuse PUC commonly presented with lower urinary tract symptoms (LUTS) with dysuria and abdominal pain. Hematuria occurred in only one patient. Radiological findings consistently showed thickened urinary bladder walls and hydronephrosis. No papillary tumor was seen with cystoscopy, but induration of the mucosal surface was noted. The cytological examination of the catheterized urine of patients with a predominant PUC component (cases 1 to 5) were negative in two cases or diagnosed as cytologic atypia because of the scant number of atypical
DOI of original article: 10.1016/j.eururo.2005.12.047 * Corresponding author. Anatomical Pathology, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, Canada, K1Y 4E9. Tel. +1 613 761 4344; Fax: +1 613 761 4846. E-mail address: [email protected] (K.T. Mai). 0302-2838/$ – see back matter # 2006 European Association of Urology. Published by Elsevier B.V. All rights reserved.
doi:10.1016/j.eururo.2006.03.034
1361
european urology 50 (2006) 1360–1362
Table 1 – Histochemical and immunohistichemical staining Case # 1 2 3 4 5 6 7
Alcian blue in signet ring cells
CD138
CK7
CK20
E-CAD
MIB1
0 + + 0 0 0 0
2 2 1 3 3 2 2
3 3 3 3 3 3 3
1 1 1 2 2 1 1
0 0 0 0 0 3 3
50 55 50 40 60 40 50
single cells in a background with tumor diathesis (three cases). The review of the gross descriptions of the urinary bladders removed by radical cystectomy (cases 3 to 5) indicated contracted bladders with extensive induration and thickened walls (cases 3 and 4) and focal induration (case 5). Microscopically and immunohistochically, PUC of the reviewed cases displayed similar features to the pilot case (Table 1, cases 1 to 5). Immunohistochemically, accompanying CUC was distinguished from PUC by the positive immunoreactivity for E-cadherin (Table 1, cases 6
and 7). Urothelial carcinoma in situ was not seen in any TURBT specimens, but was present in the contiguous mucosa in the radical cystectomy in two of the three CUC cases. There was no evidence of plasmacytoid differentiation of the carcinoma cells in the areas of carcinoma in situ. In cases of PUC associated with CUC, there were gradual transitional changes from CUC with nests of UC to PUC with discohesive cell infiltration pattern (Fig. 1). Awareness of PUC is important in the diagnosis. PUC frequently presents with advanced stage disease with extension into other pelvic organs, distant metastasis occurred only late in the disease. Since the malignant process involves predominantly the subepithelial tissue with an absence of exophytic mucosal lesions, LUTS appears to occur late in the disease. The absence or presence of hematuria and the negative cytology or cytological atypia in urine cytology associated with the indurated endoscopic appearance of the mucosal surface are characteristic.
EU-ACME question All of the following statements about plasmacytoid urothelial carcinoma are true EXCEPT: A. The carcinoma is a rare variant of urothelial carcinoma and is often associated with extensive locoregional disease. B. Hematuria occurs late in clinical presentation. C. Histopathologically, the carcinoma may mimic metastatic breast lobular carcinoma and gastric signet ring carcinoma. D. In biopsy material, plasmacytoid urothelial carcinoma is differentiated from plasmacytoma by using immunostaining for CD138 known to be a marker for plasmacytes.
Fig. 1 – PUC (upper half) associated with CUC (lower half) in the same focus of the tumor. Note some PUC cells displayed signet ring cell features.
Correct answer: D. In biopsy material, plasmacytoid urothelial carcinoma is differentiated from plasmacytoma by using immunostaining for CD138 known to be a marker for plasmacytes.
1362
european urology 50 (2006) 1360–1362
References [1] Lopez A, Mendez F, Puras-Baez A. Extramedullary plasmacytoma invading the bladder: case report and review of the literature. Urologic Oncology 2003;21:419–23. [2] O’Connell FP, Pinkus JL, Pinkus GS. CD138 (syndecan-1), a plasma cell marker immunohistochemical profile in hematopoietic and nonhematopoietic neoplasms. Am J Clin Pathol 2004;121:254–63.
[3] Sahin AA, Myhre M, Ro JY, Sneige N, et al. Plasmacytoid transitional cell carcinoma, report of a case with initial presentation mimicking multiple myeloma. Acta Cytol 1991;35:277–80. [4] Zhang X, Elhosseiny A, Melamed MR. Plasmacytoid urothelial carcinoma of the bladder, a case report and the first description of urinary cytology. Acta Cytol 2002; 46:412–6.