JOHN N. EBLE* AND ROBERT
YOUNG
From the Department of Pathology and Laboratory for Experimental Oncology, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, and Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
ABSTRACT
Osseous metaplasia of the stroma of carcinomas of the bladder is a rare finding that must be distinguished from osteosarcoma and carcinosarcoma. We report a case of multifocal osseous metaplasia in a high grade urothelial carcinoma with extensive glandular differentiation, arising in the base of the bladder of an 84-year-old man. Reports of 11 other cases of stromal osseous metaplasia in primary bladder carcinomas and of 5 cases of stromal osseous metaplasia in metastases of bladder carcinoma are reviewed. KEY WORDS:
bladder neoplasms, osteosarcoma, carcinosarcoma, metaplasia
Bone may be found in several types of cancers arising in the bladder. In osteosarcomas and carcinosarcomas the osteoid and calcified bone are the products of the malignant cells and they malignant have the morphology typical of bone produced neoplasms. 1 More rarely, bone is produced a process of benign OSlJeOUS metaplasia in the stroma in primary bladder tumors 2-8 and 5 with only 11 cases in metastatic deposits from bladder primaries. 9-11 We report a case of high grade urothelial carcinoma with extensive glandular differentiation, and multiple foci of stromal osteoid and calcific osseous metaplasia. Tumors of this type must be distinguished from carcinosarcoma and osteosarcoma of the bladder. CASE REPORT
An 84-year-old man presented in October 1989 with hematuria. examination disclosed a large exophytic tumor at the bladder neck. The tumor was resected transurehad a 5-year ofurothelial carcinoma thrally. The and infection of the bladder. In March 1985 he had undergone and segmental cystectomy for prosretropubic tatic and a large grade 2 bladder carcinoma. Subtransurethral resections of 2 bladder carcino6-week mas were done October 1985 and March 1986. the of 1986. course of intravesical was recurrences were resected in D..!'nlh. ....." ve,i-TT
ex~lm:lna.tlon
was on 26 tragmenl:S that varied the tumor from soft and gelatinous to firm. was high grade, focally urothelial carcinoma (fig. 1, with extensive glandular differentiation (fig. 1, and had foci with a spindle cell morphology. The muscle of the bladder neck was extensively infiltrated tumor. Scattered foci of osteoid were present within the stroma (fig. 2, A), which were often surrounded by flattened cells with small nuclei resembling osteoblasts. Within the osteoid the lacunae contained similar cells resembling osteoblasts (fig. 2, B). The pattern of deposition of the osteoid was visible in some of the foci (fig. 2, B). Although most of the foci were not calcified, a few were densely calcified (fig. 2, A). UV.L ... 'V'.L.JRJl.V .........
Accepted for publication September 19,1990. *Requests for reprints: Laboratory Service (113), Roudebush Veterans Administration Medical Center, 1481 W. Tenth St., Indianapolis, Indiana 46202-2884. 823
824
EBLE AND YOUNG
FIG. 1. A, papillary urothelial carcinoma with moderate nuclear atypia. B, high grade urothelial carcinoma with glandular differentiation. H & E, reduced from x40.
FIG. 2. A, multifocal stromal osseous metaplasia with focally dense calcification. H & E, reduced from x25. B, osteoid with prominent collagen fibers and numerous osteocytes in lacunae. H & E, reduced from x100. 1. Stromal osseous metaplasia in bladder carcinomas
TABLE
Reference Pang
2
3
Friedman and Ash Collins and Curran 4 Delides5
Yushita et a16 Toma et aF Nakachi et alB Present case
TABLE
Pt. Age-Sex
Histological Type
Grade
Outcome
60-F 50-M 68-M 68-M 60-M 65-M 56-M 65-M 64-M 66-M 85-F 84-M
Papillary urothelial Ca Papillary urothelial Ca Squamous cell Ca Papillary urothelial Ca Undifferentiated Ca Urothelial Ca Urothelial Ca Adenoca. Urothelial Ca Urothelial Ca Urothelial Ca Urothelial Ca with glandular differentiation
2 1 3 2 3 2 2
Not available No evidence of disease 5 yrs. Not available Not available Not available Died Not available Alive 3 yrs. Not available Not available Not available Alive with disease 7 mos.
2. Stromal osseous metaplasia in metastatic bladder carcinoma
Reference Cornes et a19 Chinn et apo Evison et aP!
Age-Sex Histological Type 54-M 65-M 54-M 74-F 64-F
Urothelial Ca U rothelial Ca U rothelial Ca U rothelial Ca U rothelial Ca
Grade
Outcome
1
Not available Alive 8 mos. Not available Not available Not available
3 Not available Not available Not available
4.
5. 6.
lesions from stromal osseous metaplasia, osteosarcoma and carcinosarcoma. Drs. J. Squires and W. Peele, Kokomo, Indiana, provided the clinical history of this patient.
7.
REFERENCES
8.
1. Young, R. H: and Rosenberg, A. E.: Osteosarcoma of the urinary
bladder. Report of a case and review of the literature. Cancer, 59: 174, 1987. 2. Pang, L. S. C.: Bony and cartilaginous tumors of the urinary bladder. J. Path. Bact., 76: 357, 1958. 3. Friedman, N. B. and Ash, J. E. Tumors of the urinary bladder. In:
9.
10.
3 2 3 3
Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 31a, p. 25, 1959. Collins, D. H. and Curran, R. C.: Pathological ossification and osseous metaplasia in man. In: Modern Trends in Pathology. Edited by D. H. Collins. London: Butterworth & Co., Ltd., pp. 321-323, 1959. Delides, G. S.: Bone and cartilage in malignant tumours of the urinary bladder. Brit. J. Urol., 44: 571, 1972. Yushita, Y., Suzu, H., Imamura, A., Zyodai, A., Shimomae, H., Kiyohara, T., Minami, Y., Yura, M., Morishita, N., Kusaba, Y., Kanetake, H., Matsuo, E., Shindo, K. and Saito, Y.: A case of primary vesical undifferentiated carcinoma with heterotopic ossification. Acta Urol. Jap., 28: 1419, 1982. Toma, H., Yamashita, N., Nakazawa, H. and Yamaguchi, Y.: Transitional cell carcinoma with osteoid metaplasia. Urology, 27: 174, 1986. Nakachi, K., Miyamoto, 1., Kuroda, J. and Kohro, T.: A case of transitional cell carcinoma of the bladder with heterotopic bone formation. Hinyokika Kiyo, 34: 1651, 1988. Cornes, J. S., Sussman, T. and Dawson, 1. M. P.: Bone formation in metastasis from carcinoma of urinary bladder: report of a case with review of the literature. Brit. J. Urol., 32: 290, 1960. Chinn, D., Genant, H. K., Quivey, J. M. and Carlsson, A.-M.:
-Cf~ II carcinoma 881, 1976. Bone Joint and .t(ovlamCle. J.: Bone formation associated Pizey, 11. carcinoma. Clin. Rad., osseous metastases from 303, 1981. 12. Young, Carcinosarcoma of the urinary bladder. Cancer, 1333,1987. 13. Huggins, C. B.: The formation of bone under the influence of T.l on :1 Ii
Humoral nature of osteogenic eprthellUln. Nature, 698, 1962. Calcification of bladder tumor. Urology,
656,
. The incidence of Uf()gr'aphlC findings in tumours of the bladder. Brit. J. 625, 1961. 17. Ferris, E. J. and O'Connor, S. J.: in urinary bladder tumors. AJR, 447,1965.
YOUNG
From the Department of Pathology and Laboratory for Experimental Oncology, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana, and Department of Pathology, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts
ABSTRACT
Osseous metaplasia of the stroma of carcinomas of the bladder is a rare finding that must be distinguished from osteosarcoma and carcinosarcoma. We report a case of multifocal osseous metaplasia in a high grade urothelial carcinoma with extensive glandular differentiation, arising in the base of the bladder of an 84-year-old man. Reports of 11 other cases of stromal osseous metaplasia in primary bladder carcinomas and of 5 cases of stromal osseous metaplasia in metastases of bladder carcinoma are reviewed. KEY WORDS:
bladder neoplasms, osteosarcoma, carcinosarcoma, metaplasia
Bone may be found in several types of cancers arising in the bladder. In osteosarcomas and carcinosarcomas the osteoid and calcified bone are the products of the malignant cells and they malignant have the morphology typical of bone produced neoplasms. 1 More rarely, bone is produced a process of benign OSlJeOUS metaplasia in the stroma in primary bladder tumors 2-8 and 5 with only 11 cases in metastatic deposits from bladder primaries. 9-11 We report a case of high grade urothelial carcinoma with extensive glandular differentiation, and multiple foci of stromal osteoid and calcific osseous metaplasia. Tumors of this type must be distinguished from carcinosarcoma and osteosarcoma of the bladder. CASE REPORT
An 84-year-old man presented in October 1989 with hematuria. examination disclosed a large exophytic tumor at the bladder neck. The tumor was resected transurehad a 5-year ofurothelial carcinoma thrally. The and infection of the bladder. In March 1985 he had undergone and segmental cystectomy for prosretropubic tatic and a large grade 2 bladder carcinoma. Subtransurethral resections of 2 bladder carcino6-week mas were done October 1985 and March 1986. the of 1986. course of intravesical was recurrences were resected in D..!'nlh. ....." ve,i-TT
ex~lm:lna.tlon
was on 26 tragmenl:S that varied the tumor from soft and gelatinous to firm. was high grade, focally urothelial carcinoma (fig. 1, with extensive glandular differentiation (fig. 1, and had foci with a spindle cell morphology. The muscle of the bladder neck was extensively infiltrated tumor. Scattered foci of osteoid were present within the stroma (fig. 2, A), which were often surrounded by flattened cells with small nuclei resembling osteoblasts. Within the osteoid the lacunae contained similar cells resembling osteoblasts (fig. 2, B). The pattern of deposition of the osteoid was visible in some of the foci (fig. 2, B). Although most of the foci were not calcified, a few were densely calcified (fig. 2, A). UV.L ... 'V'.L.JRJl.V .........
Accepted for publication September 19,1990. *Requests for reprints: Laboratory Service (113), Roudebush Veterans Administration Medical Center, 1481 W. Tenth St., Indianapolis, Indiana 46202-2884. 823
824
EBLE AND YOUNG
FIG. 1. A, papillary urothelial carcinoma with moderate nuclear atypia. B, high grade urothelial carcinoma with glandular differentiation. H & E, reduced from x40.
FIG. 2. A, multifocal stromal osseous metaplasia with focally dense calcification. H & E, reduced from x25. B, osteoid with prominent collagen fibers and numerous osteocytes in lacunae. H & E, reduced from x100. 1. Stromal osseous metaplasia in bladder carcinomas
TABLE
Reference Pang
2
3
Friedman and Ash Collins and Curran 4 Delides5
Yushita et a16 Toma et aF Nakachi et alB Present case
TABLE
Pt. Age-Sex
Histological Type
Grade
Outcome
60-F 50-M 68-M 68-M 60-M 65-M 56-M 65-M 64-M 66-M 85-F 84-M
Papillary urothelial Ca Papillary urothelial Ca Squamous cell Ca Papillary urothelial Ca Undifferentiated Ca Urothelial Ca Urothelial Ca Adenoca. Urothelial Ca Urothelial Ca Urothelial Ca Urothelial Ca with glandular differentiation
2 1 3 2 3 2 2
Not available No evidence of disease 5 yrs. Not available Not available Not available Died Not available Alive 3 yrs. Not available Not available Not available Alive with disease 7 mos.
2. Stromal osseous metaplasia in metastatic bladder carcinoma
Reference Cornes et a19 Chinn et apo Evison et aP!
Age-Sex Histological Type 54-M 65-M 54-M 74-F 64-F
Urothelial Ca U rothelial Ca U rothelial Ca U rothelial Ca U rothelial Ca
Grade
Outcome
1
Not available Alive 8 mos. Not available Not available Not available
3 Not available Not available Not available
4.
5. 6.
lesions from stromal osseous metaplasia, osteosarcoma and carcinosarcoma. Drs. J. Squires and W. Peele, Kokomo, Indiana, provided the clinical history of this patient.
7.
REFERENCES
8.
1. Young, R. H: and Rosenberg, A. E.: Osteosarcoma of the urinary
bladder. Report of a case and review of the literature. Cancer, 59: 174, 1987. 2. Pang, L. S. C.: Bony and cartilaginous tumors of the urinary bladder. J. Path. Bact., 76: 357, 1958. 3. Friedman, N. B. and Ash, J. E. Tumors of the urinary bladder. In:
9.
10.
3 2 3 3
Atlas of Tumor Pathology. Washington, D. C.: Armed Forces Institute of Pathology, sect. VIII, fasc. 31a, p. 25, 1959. Collins, D. H. and Curran, R. C.: Pathological ossification and osseous metaplasia in man. In: Modern Trends in Pathology. Edited by D. H. Collins. London: Butterworth & Co., Ltd., pp. 321-323, 1959. Delides, G. S.: Bone and cartilage in malignant tumours of the urinary bladder. Brit. J. Urol., 44: 571, 1972. Yushita, Y., Suzu, H., Imamura, A., Zyodai, A., Shimomae, H., Kiyohara, T., Minami, Y., Yura, M., Morishita, N., Kusaba, Y., Kanetake, H., Matsuo, E., Shindo, K. and Saito, Y.: A case of primary vesical undifferentiated carcinoma with heterotopic ossification. Acta Urol. Jap., 28: 1419, 1982. Toma, H., Yamashita, N., Nakazawa, H. and Yamaguchi, Y.: Transitional cell carcinoma with osteoid metaplasia. Urology, 27: 174, 1986. Nakachi, K., Miyamoto, 1., Kuroda, J. and Kohro, T.: A case of transitional cell carcinoma of the bladder with heterotopic bone formation. Hinyokika Kiyo, 34: 1651, 1988. Cornes, J. S., Sussman, T. and Dawson, 1. M. P.: Bone formation in metastasis from carcinoma of urinary bladder: report of a case with review of the literature. Brit. J. Urol., 32: 290, 1960. Chinn, D., Genant, H. K., Quivey, J. M. and Carlsson, A.-M.:
-Cf~ II carcinoma 881, 1976. Bone Joint and .t(ovlamCle. J.: Bone formation associated Pizey, 11. carcinoma. Clin. Rad., osseous metastases from 303, 1981. 12. Young, Carcinosarcoma of the urinary bladder. Cancer, 1333,1987. 13. Huggins, C. B.: The formation of bone under the influence of T.l on :1 Ii
Humoral nature of osteogenic eprthellUln. Nature, 698, 1962. Calcification of bladder tumor. Urology,
656,
. The incidence of Uf()gr'aphlC findings in tumours of the bladder. Brit. J. 625, 1961. 17. Ferris, E. J. and O'Connor, S. J.: in urinary bladder tumors. AJR, 447,1965.
