Transitional Cell Carcinoma in a Bladder Diverticulum

Cheryl Ann Sadow, MD - Case Coordinator
Donnella S Green, MD - Radiology Discussion
Marc Barry, MD - Pathology Discussion
Pablo Ros, MD - Attending Radiologist
Steven E Seltzer, MD, FACR - Attending Radiologist

March 11, 2002

Presentation

Imaging Findings

Axial CT through the pelvis demonstrates two communicating fluid-filled structures. The larger, more midline structure appears to be arising from the laterallly-displaced urinary bladder and is consistent with a bladder diverticulum. There are some high-attenuation foci within both structures.

Coronal and sagittal T2-weighted and coronal T1-weighted MR images demonstrate heterogeneous signal within the bladder and diverticulum. This appearance is consistent win an internal soft tissue mass. Based on the size distribution, this mass likely arises in the diverticulum and extends into the urinary bladder.

Transitional cell carcinoma (TCC) is the most common bladder carcinoma, but this appearance would be atypical. TCC is generally more homogeneous and infiltrative. Other more aggressive bladder malignancies such as squamous cell carcinoma or adenocarcinoma are more likely in this case.

Differential Diagnosis

Diagnosis

Discussion

A radical cystoprostatectomy was performed. An image of the specimen demonstrates trabeculation of bladder mucosa and a large mass laterally. An area of ulceration is visible within the bladder; the bladder lumen was filled with necrotic papillary fragments of tumor. The bladder wall opens into large (16 cm) diverticulum, which is filled with a necrotic, hemorrhagic, papillary tumor. Microscopic images demonstrate cancer cells in nests. Extensive vascular invasion is apparent. In the bladder, several foci of in situ transitional cell carcinoma were noted. The tumor was diagnosed as grade 3 transitional cell carcinoma.

Radiology Discussion

When imaging demonstrates bladder filling defects, the differential diagnosis should include malignant and benign neoplasms, blood clot, edema in the wall due to an adjacent stone, ureterocele, enlarged prostate, muscular wall hypertrophy, postoperative change, endometriosis, and fungus ball. Possible malignant neoplasms include primary bladder carcinoma and metastasis from a primary tumor of the prostate, cervix or colon. Possible benign neoplasms include fibroepithelial polyp, hemangioma, adenoma, leiomyoma, and pheochromocytoma.

Bladder carcinoma typically presents in the 5th to 7th decade and is three times more prevalent in men than in women. In 95% of cases, bladder carcinoma is epithelial in origin, while less than 5% are mesenchymal. Approximately 90% of epithelial bladder carcinomas are the transitional cell type. Squamous cell carcinoma accounts for approximately 5% of cases, and adenocarcinoma represents approximately 2%. Mesenchymal carcinomas include leiomyosarcoma, lymphoma, and rhabdomyosarcoma (in children). Approximately 2% of epithelial bladder carcinomas arise from a bladder diverticulum, as in this case. Although this process is not specific to a particular type of epithelial cell carcinoma, such tumors are slightly more likely to be the squamous type. The most common metastatic sites for bladder carcinoma are the lungs, mediastinum, liver and bone.

Risk factors specific to transitional cell carcinoma include industrial carcinogens, cigarettes, and analgesic abuse. Schistosomiasis, neurogenic bladder, chronic infection, and indwelling catheters can increase a person’s risk for developing squamous cell carcinoma, while urachal remnants and pelvic irradiation can increase the risk for adenocarcinoma.

CT is very useful for assessment of pelvic side wall, viscera, and lymphadenopathy. Its usefulness is limited, however, if the case calls for differentiation of postoperative or post-irradiation changes from tumor (75% accuracy). MR is considered to be better for staging than CT. T2 sequences are helpful in identifying the interface between urine and bladder, T1 is more useful for distinguishing bladder and perivesicular fat, and the use of gadolinium is helpful in distinguishing small tumors.

References

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