Figure 1
Axial (A) and sagittal (B) contrast-enhanced CT images in the portal venous phase show a large exophytic soft tissue mass with multiple peripheric calcifications at the dome of the bladder
Sarcomatoid variant of urothelial carcinoma of the bladder with osseous and condroid metaplasia
SectionUroradiology & genital male imaging
Case TypeClinical Cases
Authors
Clara Casanova1, Vitor Sousa2, Ruben Gaio1, Pedro Almeida1, Nuno Pereira da Silva1, Inês Abreu1
Connected authors
76 years, male
Clinical History
A 76-year-old male patient with no relevant past medical history was referred to the urology department for intermittent macroscopic hematuria. Physical examination was unremarkable. Urine dipstick was positive for blood.
Imaging Findings
A cystoscopy showed an exophytic lesion in the left lateral wall measuring 25 mm. Biopsy was performed, and histology revealed a moderately differentiated high-grade urothelial carcinoma invading the lamina propria, but non-muscle invasive. A transurethral resection of the lesion was performed, and the patient underwent intravesical BCG immunotherapy.
Follow-up flexible cystoscopy and urine cytology at 2 and 4 months showed no signs of recurrence. Nevertheless, 6 months after the resection, follow-up cystoscopy showed evidence of a plane lesion in the bladder dome measuring 5 cm. Urine cytology was positive for neoplastic cells. A CT urography was ordered for further characterization.
CT showed a large exophytic soft tissue mass at the dome of the bladder with a prominent extravesical component with multiple peripheric calcifications, measuring 7,8 cm (Figure 1).
Discussion
The patient underwent a radical cystoprostatectomy with bilateral lymph node dissection.
Histology showed evidence of a poorly differentiated high-grade sarcomatoid variant of urothelial carcinoma with heterologous elements of osteosarcoma and chondrosarcoma, invading through the muscle and into the peripheral fatty tissue (T3b). Resected lymph nodes showed no evidence of metastatic disease.
Sarcomatoid variant of urothelial carcinoma is a rare histologic variant that exhibits morphologic and/or immunohistochemical evidence of epithelial and mesenchymal differentiation. It is found in 0.1% to 0.3% of all urothelial carcinomas of the bladder.[1]
The most frequent presenting symptoms are haematuria, dysuria, nocturia, acute retention of urine, and lower abdominal pain.
They usually present as a polypoidal or large broad-based mass in the lateral walls of the bladder. [2] This variant is associated with more advanced disease and inferior survival outcomes. Radiation and cyclophosphamide exposure are known risk factors.[3,4] Because of its rarity and lack of randomized controlled trials, there is no consensus on standard treatment. However, radical cystoprostatectomy with or without radiotherapy and/or chemotherapy are the mainstay of treatment.
Differential Diagnosis List
Sarcomatoid variant of urothelial carcinoma of the bladder with osseous and condroid metaplasia
Urachal adenocarcinoma
Sarcomatoid variant of urothelial carcinoma of the bladder
Final Diagnosis
Sarcomatoid variant of urothelial carcinoma of the bladder with osseous and condroid metaplasia
References
[1] Wright JL, Black PC, Brown GA, Porter MP, Kamat AM, Dinney CP, et al. Differences in survival among patients with sarcomatoid carcinoma, carcinosarcoma and urothelial carcinoma of the bladder. J Urol. 2007;178(6):2302–6. doi: 10.1016/j.juro.2007.08.038.
[2] Sanchez JEH, Figueira YR, Gonzalez RT, Lopez RM, Tejeda LMG. Sarcomatoid carcinoma of the urinary bladder: a case report and review of the literature. J Med Cases. 2014;5(2):116–119.
[3] Gu, L., Ai, Q., Cheng, Q. et al. Sarcomatoid variant urothelial carcinoma of the bladder: a systematic review and meta-analysis of the clinicopathological features and survival outcomes. Cancer Cell Int 20, 550 (2020). https://doi.org/10.1186/s12935-020-01626-9
[4] Lopez-Beltran A, Pacelli A, Rothenberg HJ, et al. Carcinosarcoma and sarcomatoid carcinoma of the bladder: clinicopathological study of 41 cases. J Urol. 1998;159(5):1497-1503. doi:10.1097/00005392-199805000-00023
Case information
| URL: | https://www.eurorad.org/case/17964 |
| DOI: | 10.35100/eurorad/case.17964 |
| ISSN: | 1563-4086 |
License
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Figure 2
Cystoprostatectomy specimen
Opened bladder (red arrow) with a large exophytic yellowish mass (green circle) with multiple calcifications (black arrows) invading the muscle and the layer of fatty tissue at the dome of the bladder
Figure 3
Histopathological findings
Neoplasm composed of trabeculae and small nests of neoplastic epithelial cells arranged in a desmoplastic stroma. There is a central area of heterologous differentiation of osteoid. HE, 100x. B – A sarcomatoid differentiated area with osteoid and spindle cells organized in clusters. HE, 200x. C- An area of sarcomatoid differentiation with osteoid (left) and a area composed of nests of epithelial cells with eosinophilic cytoplasm and large nuclei with moderated pleomorfism and proeminent nucleoli (right). HE, 200x. D- Nested pattern of urothelial carcinoma with epithelial cells organized in small, rounded groups of cells. HE, 200x
Axial (A) and sagittal (B) contrast-enhanced CT images in the portal venous phase show a large exophytic soft tissue mass with multiple peripheric calcifications at the dome of the bladder
Centro Hospitalar e Universitário de Coimbra, Portugal
Centro Hospitalar e Universitário de Coimbra, Portugal
Cystoprostatectomy specimen
Opened bladder (red arrow) with a large exophytic yellowish mass (green circle) with multiple calcifications (black arrows) invading the muscle and the layer of fatty tissue at the dome of the bladder
Centro Hospitalar e Universitário de Coimbra, Portugal
Centro Hospitalar e Universitário de Coimbra, Portugal
Histopathological findings
Neoplasm composed of trabeculae and small nests of neoplastic epithelial cells arranged in a desmoplastic stroma. There is a central area of heterologous differentiation of osteoid. HE, 100x. B – A sarcomatoid differentiated area with osteoid and spindle cells organized in clusters. HE, 200x. C- An area of sarcomatoid differentiation with osteoid (left) and a area composed of nests of epithelial cells with eosinophilic cytoplasm and large nuclei with moderated pleomorfism and proeminent nucleoli (right). HE, 200x. D- Nested pattern of urothelial carcinoma with epithelial cells organized in small, rounded groups of cells. HE, 200x
Centro Hospitalar e Universitário de Coimbra, Portugal
Centro Hospitalar e Universitário de Coimbra, Portugal