Kumud

Gugliada,

MD

#{149} Peter

M. Nardi,

Inflammatory of the Bladder’

alone.

Only

pathologic

I

1991;

pseudosarcoma of is a rare entity and, to has not been described literature. Tumors

the bladder our knowledge, in the radiologic have

occurred

at various

in

ages.

patients

Some

of

both

patients

sexes

report

having undergone bladder surgery. Radiologically and cystoscopically, inflammatory pseudosarcoma is indistin-

guishable

from

a malignant

mesenchy-

mal bladder tumor. Only pathologic examination can enable a definitive diagnosis. Bladder pseudosarcomas are benign and no recurrences have been reported. A relationship to nodular fasciitis has been suggested on the basis of

similar nation The scribe sarcoma

appearance

at pathologic

(1,2). purpose of this the appearance at

computed

report of this

examiis to depseudo-

tomographic

(CT)

examination and its clinical and pathologic manifestations. We present two cases and a review of the literature. To our knowledge, nine articles have been published in the English oncology, pa-

thology,

and

urology

none

has

appeared

in

CASE

B. Tomno,

MD

the

radiology

lit-

REPORTS

literature,

55-year-old woman was adto the hospital because of a 2-

Case i-A

mitted month

history

pain

and

of intermittent

urinary

suprapubic

frequency.

Urinalysis

revealed microscopic hematunia. was no history of bladder surgery. month

prior

to admission,

been

treated

with

tract

infection.

vealed

no

the

Physical

examination

but

Mallinckrodt,

St Louis)

8-cm-diameter

enhancing

in the anterior

wall

rectus

the

of the tumor pathologic

examination

infiltration small bowel went partial

of the tumor loops. The cystectomy

with

rectus examination

cells

coma. reported matory

abdo-

with

the

previously admitted

one

pack

At the

healthy 27-yearto the hospital be-

tient

had

severe

tated

the

transfusion

Physical

time

that

of 2 units

examination

tributory

per

revealed

for

the

pa-

necessi-

obtained

cm-diameter,

with

agent,

enhancing,

endophytic

mass

the bladder. tissue changes

in

There in

a 2-3-

predominantly

the

anterior

wall

of

fat

soft(Fig

were nonspecific the penivesical

2a). This

patient

resection nation gestive

of the

underwent

of

transurethral

tumor.

demonstrated pseudosarcoma

Pathologic an

(Fig

sug2b).

In

The

this

that

the

by

time,

patients)

in report-

cases

This

(in-

been

in these Table.

the

Roth

1 1 cases

have

findings in

of

reported

are

tumor

tab-

can

oc-

cur in both sexes and at various ages, but the youngest reported patient was 16 years of age. Predisposing factors have

been

reported

cystitis

(3)

(4,5). no history

lesions

seem

common

so

and

symptom

hematunia; in

three

transfusion.

nihilo.

was cases

to

two

suprapubic

pain.

tures

were

invariably

negative.

gone

in

may

the bladder; has

not

been

was

necessitate

patients

mild

Pseudosarcoma

the The

severe

enced

site

patients

in all patients

Only

re-

instead,

ex

bleeding

enough

are bladder

most

of either; to arise

far

prior

However,

have

exami-

appearance

our

surgery

use of an in-

revealed

first

(3). Since

1980

current

con-

pseudosarcoma

was

cluding

that

of blood. no

Inflammatory

ulated

factors. contrast

re-

DISCUSSION

ed.

day

of admission,

hematunia

laser

of biopsies were with a pseudosar-

our knowledge, this is the only case of recurrence of an inflampseudosarcoma of the bladder.

bladder

stroma.

of cigarettes

10 years.

and

in

To

in

mitocells

cause of a 5-7-month history of occasional suprapubic pain and gross hematuria. The patient gave a history of having smoked

resection

times under-

eosino-

nucleoli

stroma. Few inflammatory

within

transurethral

fulguration. Results ported as compatible

enteroenterostomy

myxoid Chronic

Case 2.-A man was

went

into adjacent patient underand small bowel

of prominent

interspersed

patient the tumor recurred four 1’/ years; each time the patient

demonstrated

primary

cytoplasm

tissues

In addition,

of the involved Microscopic

an edematous ses were seen.

old

1). examination

muscle.

spindle-shaped

philic

shows an ennecrosis on the The pseudosarabdominal wall.

at CT of extension

the

were

(Fig

findings

Figure 1. Axial CT image hancing tumor with central anterior wall of the bladder. coma invades the anterior

of the

to infiltrate adjacent

the

pathologic

abdominis

CT images,

I From the Departments of Radiology (KG., P.M.N., M.S.B.) and Pathology (R.B.T.), The Long Island College Hospital, 340 Henry St. Brooklyn, NY 11201. Received May 31, 1990; revision requested July 17; revision received October 1; accepted November 29. Address reprint requests to P.M.N. ,. RSNA, 1991

of the fundus

rectus

showed

a 7mass

into the penivesical

and resection minis muscle.

60%;

necrotic

and

excision

(Conray

demonstrated

muscle

at gross

confirmed

re-

GE Medical Syswith use of an

mass appeared tissues and

abdominis

Results

had

for a urinary

factors.

(GE 9800;

bladder. This the penivesical

There One

patient

antibiotics

contributory

travenous

66

#{149} Roosevelt

(Pseudotumor)

tems, Milwaukee) obtained intravenous contrast agent

179:66-68

NFLAMMATORY

MD

erature.

CT images

terms: Bladder neoplasms. 83.3, #{149} Bladder neoplasms, CT, 83.1211

Radiology

S. Borenstein,

exami-

nation can enable a definitive diagnosis. The authors report two cases of these benign tumors in patients with no history of bladder disease or trauma; the tumors were large, demonstrated invasion into local tissues, and recurred in one case after incomplete transurethral resection. Index 83.891

#{149} Mark

Pseudosarcoma

Inflammatory pseudosarcoma of the bladder is a rare benign entity that cannot be differentiated from malignant tumor at radiologic examination

MD

be

expeniUrine

found

however, involved

culat any

the tnin

the

cases

b. Figure original

2.

Age,

(a) Contrast-enhanced magnification, X400)

Sex, Location,

CT image demonstrates shows a spindle cell lesion

P redisposin Age

Reference Roth (3) Proppe et al (4) Nochomovitz and Orenstein (1) Ro et al (6) Young and Scully Stark et al (2) Present

*

study

Transurethral

reported

so

varied

in size

eter.

(5)

far

To date,

(y)/ Sex

Penivesical

extension

of our cases one. In the

but was previously penivesical

have

in diam-

patients,

in diameter At cystoscopy, mass suggests a findings, reportcases (1,2), have mass, which the bladder wall perivesical tissues. noted

involvement

in

both

in only CT dewas

not present in two patients; in one patient there was questionable penivesical disease that was not confirmed at surgery or pathologic examination. No cases have been reported to involve the

small

bowel

or anterior

abdominal

wall; however, in our first case, the pseudosarcoma infiltrated both. Optimal management of inflammatory pseudosarcoma of the bladder is

Volume

179

#{149} Number

1

None after None after None after None after No follow-up None after None after None after Recurrence

uncertain because of the small number of patients identified. In the cases reported, six patients underwent partial

sarcoma

at pathologic

examination.

though

no recurrences

cystectomy

complete

surgery*

5 3-5 2 4 2 2 3 8 4.5

3 3 2 1

y mo y y

2 y 17 mo 3 mo

cell carcinoma.

cm

was

Partial cystectomy Transurethral resection Partial cystectomy Transurethral resection Transurethral resection Partial cystectomy Partial cystectomy Partial cystectomy Transurethral resection

Posterior bladder wall Lateral bladder wall Fundus Posterior lateral wall Not specified Fundus Posterior bladder wall Fundus Fundus

confirmed reported

Recurrence No follow-up None after 3 y

Not

1 .5 specified

Treatment Partial cystectomy Transurethral resection

None None None None Cancer None None None None

our

(hematoxylin-eosin stain; (inflammatory pseudosarcoma).

C ases of Pseudosarcoma

Diameter of Tumor (cm)

Location of Tumor

22/M 73/F 56/F 52/F 59/M i9/M 16/F 55/F 27/M

tumors

mass. (b) Photomicrography cells and blood vessels

in All Reported

Res ults of Follow-up

Posterior fundus Not specified

1.5 to 8 cm

excluding

bladder wall inflammatory

Recurrent cystitis Cancer surgery*

(2).

The

with

32/F 29/M

for transitional

from

and

Predisposing Factors

resection

tumors larger than 5 have not been reported. the appearance of the malignant tumor. CT ed in only three other revealed a broad-based was either limited to or extended into the

scriptions,

g Factors,

endophytic admixed

urethral mors

tions tients;

seven

3 years.

and

three

underwent

ported

trans-

resection of the tumor. The tudid not recur. Follow-up examinawere not performed in two pafollow-up

patients

One

in

ranged

patient

the

remaining

from

underwent

3 months

to

trans-

urethral resection to remove a documented transmural lesion (2); the pseudosarcoma did not recur even though the resection was incomplete. In our patients, the first underwent a partial cystectomy with no recurrence seen at follow-up examination 3 months after the surgery. The second patient was diagnosed as having inflammatory pseudosarcoma and underwent transurethral resection in 1987. Since then, he has had four recurrences in the same region, all of which were resected transurethrally. All the tissue specimens were

reported

as

inflammatory

pseudo-

by

other

authors,

resection,

recurrences

be the result

have

in

we our

second

of incomplete

Al-

been

even

re-

after

believe

in-

that

patient

the may

removal

of

the transmural lesion at transurethral resection. It is possible that partial cystectomy might have prevented these recurrences.

Therefore,

complete

exci-

sion may be necessary for a complete cure. No cases showed evidence of metastatic disease. The relationship between inflammatory pseudosarcoma and nodular fasci-

itis has been postulated by Nochomovitz and Orenstein, Stark et al, and Ro et al (1,2,6). Nodular fasciitis was at first

described

only

in nonvisceral

sites,

most commonly in the forearm (7,8). However, cases have now been reported in the urethra, vulva, prostate and so on (5,9-il). As is true of pseudosarcoma of the bladder, nodular fasciitis found in both sexes at all ages. Some

Radiology

is

#{149} 67

patients with nodular fasciitis have meported a history of nonsurgical trauma. The size of the lesions of nodular fasciitis has varied from 2 to 5 cm in diameten. No recurrences have been reported. Pathologically, there are many similarities between the two entities: Both are characterized by the presence of spindle-shaped cells, prominent capillaries, chronic inflammatory cells, and infiltration rather than destruction of sunrounding tissue. At microscopic examination, inflammatony pseudosancoma may be confused with sarcomatous lesions (leiomyosarcoma on rhabdomyosarcoma). However,

the

presence

of edematous

stroma with relatively the absence of nuclear tism and pleomorphism tive

of a benign

lesion.

tions on Z bands are mom cells demonstnate istics of myofibmoblasts.

few mitoses and hypenchromaare all indicaNo cnoss-striadetected. The ha-

the character-

68

conclude

that

and

clinical

#{149} Radiology

has

not

been

widely

3.

recognized,

but it should be included in the differential diagnosis of all enhancing bladden tumors. Pseudosarcomas (pseudotumors) are probably more common than is realized because earlier pathologic reports may have documented such lesions as sarcomas. Awareness of the differences

between

lignant

tumors

avoid

the

benign

can help

radical

treatment

and

of a benign

demonstrate

that

the

appearance

examination of the

final

6.

can endiagno-

8.

9.

10.

U

References

2.

7.

of lo-

the

1.

5.

le-

cal invasion and large size of the tumor at nadiologic examination does not pnedude the diagnosis of pseudosarcoma. Only pathologic able determination

4.

ma-

physicians

sion. Our two cases demonstrate that mecurrence of inflammatory pseudosarcoma of the bladder can occur if tumors are not completely resected. In addition, and most important, our cases

sis.

madiologic apmanifestations of pseudosancoma of the bladder are nonspecific, and differentiation from a malignant tumor on the basis of results at madiologic or physical examination is impossible. Pathologic examination is the definitive diagnostic modality. Inflammatory pseudosancoma of the bladWe

peanance

den

Nochomovitz LE, Orenstein JM. Inflammatory pseudotumor of the urinary bladder: possible relationship to nodular fasciitis. Am J Sung Pathol 1985; 9:366-373. Stark CL, Feddenson R, Lowe BA, Benson CT, Black W, Borden TA. Inflammatory pseudotumor (pseudosarcoma) of the bladder. J Urol 1989; 141:610-612.

1 1.

Roth JA. Reactive pseudosarcomatous response in the urinary bladder. Urology 1980; 16:635-637. Proppe KH, Scully RE, Rosai J. Postoperative spindle cell nodules of the genitourinary tract resembling sarcomas. Am Sung Pathol 1984; 8:101-108. Young RH, Scully RE. Pseudosarcomatous lesions of the urinary bladder, prostate gland, and urethra. Arch Pathol Lab Med 1987; 111:354-358. Ro JY, Ayala AG, Ordonez NC, Swanson DA, Babain RJ. Pseudosarcomatous fibromyxoid tumor of the urinary bladder. Am J Clin Pathol 1986; 86:583-590.

Bernstein

KE, Lattes

R.

Nodular

(pseudo-

sarcomatous) fasciitis: a nonnecunrent lesion. Cancer 1982; 49:1668-1678. Konwaler BE, Keasbey L, Kaplan L. Subcutaneous pseudosarcomatous fibromatosis (fasciitis). Am J Clin Pathol 1955; 25:241-252. Gaffney EF, Majmudan B, Bryan JA. Nodular fasciitis (pseudosancomatous fasciitis) of the vulva. Int J Gynecol Pathol 1982; 1:307-312. Roberts W, Daly JW. Pseudosarcomatous fasciitis of the vulva. Gynecol Oncol 1981; 11:383-386. Hafiz MA, Token C, Sutula M. An atypical fibromyxoid tumor of the prostate. Cancer 1984; 54:2500-2504.

April

1991