AJR 2003; 180:779-784
© American Roentgen Ray Society
MR Imaging Features of Non-Transitional Cell Carcinoma of the Urinary Bladder with Pathologic Correlation
Aylin Tekes1,
Ihab R. Kamel1,
Theresa Y. Chan2,
Mark P. Schoenberg3 and
David A. Bluemke1
1 Russell H. Morgan Department of Radiology and Radiological Sciences, Johns
Hopkins Hospital, Rm. 100, 600 N. Wolfe St., Baltimore, MD 21287.
2 Department of Pathology, Weinberg Bldg., Johns Hopkins Hospital, Baltimore, MD
21231.
3 James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions,
Marburg 150, Baltimore, MD 21287-2101.
Received March 7, 2002;
accepted after revision August 6, 2002.
Presented at the annual meeting of the American Roentgen Ray Society,
Atlanta, April-May 2002.
Address correspondence to I. R. Kamel.
Introduction
Carcinoma of the urinary bladder, after prostate cancer, is the most common
malignant tumor of the urinary tract in men and women and accounts for 2% of
all malignancies [1].
Approximately 5-10% of malignant bladder tumors are nontransitional and
consist of squamous cell carcinomas, adenocarcinomas, small cell carcinomas,
and, rarely, sarcomas [1].
Presently, MR imaging is the modality of choice in imaging urinary bladder
neoplasms. Multiplanar imaging with magnetic resonance allows better
visualization of the bladder dome, trigone, and adjacent prostate and seminal
vesicles. The accuracy of MR imaging in staging bladder cancer ranges from 73%
to 96%. These values are 10-33% higher than those obtained on CT. Staging on
MR imaging is necessary to choose the best treatment option and follow-up
[2].
To our knowledge, MR imaging features of nontransitional carcinomas have
not been specifically described. We present MR imaging features of different
histologic types of non—transitional cell carcinomas with pathologic
correlation.
Technique
Patients were scanned using a 1.5-T MR scanner (Signa; General Electric
Medical Systems, Milwaukee, WI) with a phased array pelvic coil. Conventional
T1-weighted spin-echo images (TR/TE, 550/9; matrix, 512 x 192; field of
view, 20 cm; section thickness, 6 mm; intersection gap, 2 mm; signals
acquired, 4) and T2-weighted fast spin-echo images (TR range/TE range,
4000-5500/80-120; matrix, 256 x 256; field of view, 24 cm; section
thickness, 6 mm; interscan gap, 2 mm; signals acquired, 4) with fat
suppression were obtained. Subsequently, fast multiplanar spoiled
gradient-echo images (200-300/1.7-4.2; flip angle, 70°; matrix, 512
x 192; slice thickness, 6 mm; intersection gap, 2 mm; signals acquired,
2) with fat suppression were obtained in the axial plane before, at 20 sec
(arterial phase), and at 70 sec (venous phase) after injection of
gadopentetate dimeglumine (0.1 mmol/kg). Sagittal and coronal
gadolinium-enhanced images were added if the tumor was located in the base or
the dome of the bladder. All patients subsequently underwent radical
cystectomy. For each patient, histologic sections were obtained from
cystectomy specimens and correlated with the MR imaging findings. Tumors were
evaluated according to the TNM staging system
[3].
Squamous Cell Carcinoma
Squamous cell carcinoma is the most common non—transitional cell
bladder tumor, accounting for 3-7% of all bladder tumors in the United States.
Approximately 80% of squamous cell carcinomas in Egypt are associated with
chronic infection caused by schistosomiasis (bilharziasis)
[4]. The disease is relatively
more common in women, unlike transitional cell carcinoma, which is more common
in men. The reported female-to-male ratio varies from 1.25:1 to 1.8:1
[5]. Nonbilharzial squamous
cell carcinomas occur in association with chronic irritation from urinary
calculi, long-term indwelling catheters, or chronically infected bladder
diverticula [4].
Most patients are 60-70 years old, and the most common clinical sign is
gross hematuria. In contrast to transitional cell carcinomas, squamous cell
carcinomas are often widespread and involve areas other than the base of the
bladder [6] (Fig.
1A,1B,1C,1D).
Most squamous cell carcinomas are solitary and large at the time of detection,
with invasion of the muscular wall reported in more than 80% of patients.
Metastases have been identified in at least 10% of patients at the time of
diagnosis. Interestingly, metastases from squamous cell carcinomas of the
urinary bladder often occur at sites other than the regional lymph nodes.
Common metastatic sites include bone, lung, and bowel
[6] (Fig.
2A,2B,2C).
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Fig. 1A. —66-year-old woman with stage T2b squamous cell carcinoma.
Axial T2-weighted fast spin-echo MR image shows central portion of mass
(arrow) to be almost uniform and low in signal intensity.
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Fig. 1B. —66-year-old woman with stage T2b squamous cell carcinoma.
Sagittal T1-weighted unenhanced fast spoiled gradient-echo MR image (TR/TE,
295/4.2) shows broad-based mass (arrow) arising from dome of bladder.
Signal intensity is isointense to muscle and homogeneous.
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Fig. 1C. —66-year-old woman with stage T2b squamous cell carcinoma.
Sagittal arterial phase fast spoiled gradient-echo MR image (295/4.2) obtained
after gadolinium administration is helpful in showing tumor extent in
relationship to bladder wall. Peripheral component of mass (arrow)
does not enhance, probably because of adherent thrombus.
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Fig. 1D. —66-year-old woman with stage T2b squamous cell carcinoma.
Photomicrograph of cystectomy specimen shows squamous cell carcinoma with
formation of keratin pearls (arrows). (H and E, x200)
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Fig. 2A. —54-year-old woman with stage T4b squamous cell carcinoma of
bladder. Axial T2-weighted MR image (TR/TE, 4000/120) reveals marked, nearly
circumferential wall thickening of bladder with relative sparing of anterior
left aspect of bladder. Note bilateral hydroureters (arrows).
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Fig. 2B. —54-year-old woman with stage T4b squamous cell carcinoma of
bladder. Axial T1-weighted MR image (500/8) reveals areas of bright signal
intensity (arrow) in bladder lumen. Patient had gross hematuria at
time of MR imaging, and bright T1 signal area is probably due to
hemorrhage.
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Fig. 2C. —54-year-old woman with stage T4b squamous cell carcinoma of
bladder. Axial T2-weighted MR image (4000/120) obtained at slightly higher
level than A reveals mass (arrows) arising from dome of
bladder and invading small-bowel loops (arrowheads).
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Adenocarcinoma
Adenocarcinoma of the urinary bladder is uncommon, accounting for 0.5-2% of
all bladder malignancies [7].
The tumor arises in two common sites: the base of the bladder, including the
trigone, and the dome of the bladder. Adenocarcinomas are classified into
three groups: primary, urachal, and metastatic
[4]. Like squamous cell
carcinomas, many adenocarcinomas probably occur in reaction to long-term
mucosal irritation. Cystitis glandularis, bladder exstrophy, and urachal
remnants are also associated with adenocarcinoma of the bladder. Cystitis
glandularis has been observed in approximately 50% of adenocarcinoma cases
located at the bladder base
[2,3,4,5,6];
however, most authors do not accept this entity as a predisposing factor for
urothelial adenocarcinoma. Adenocarcinoma is observed in fewer than 10% of
patients with bladder exstrophy, and more than 80% of urachal neoplasms are
adenocarcinomas. Hematuria occurs in approximately 90% of patients, regardless
of the primary site of the tumor
[6].
Adenocarcinomas may be papillary or solid (Fig.
3A,3B,3C).
These tumors are mucin-producing, indistinguishable from adenocarcinoma of the
gastrointestinal tract. Signet cell adenocarcinomas characteristically produce
linitis plastica of the bladder
[8] (Fig.
4A,4B,4C,4D).
Signet ring cell cancers are usually diffusely infiltrating and are of
advanced stage at the time of diagnosis. Deep muscle invasion is the rule
[6].
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Fig. 3A. —42-year-old man with stage T3b adenocarcinoma of bladder with
transitional and small cell components. Axial T2-weighted MR image (TR/TE,
5466/120) reveals extensive papillary projections of broad-based mass
(arrows) arising from left lateral wall and extending to bladder
base.
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Fig. 3B. —42-year-old man with stage T3b adenocarcinoma of bladder with
transitional and small cell components. Axial venous phase contrast-enhanced
fast spoiled gradient-echo MR image (300/3) shows heterogeneous enhancement of
tumor. Stranding in perivesical fat (arrow) is noted, which
corresponds to perivesical fat invasion by tumor at histopathologic
examination (not shown).
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Fig. 3C. —42-year-old man with stage T3b adenocarcinoma of bladder with
transitional and small cell components. Photomicrograph of cystectomy specimen
shows infiltrating high-grade urothelial carcinoma consisting of
adenocarcinoma and small cell carcinoma. Adenocarcinoma component shows glands
with more abundant cytoplasm and more open chromatin (arrows). Small
cell component shows cells with hyperchromatic nuclei, little cytoplasm, and
nuclear molding (curved arrows). (H and E, x100)
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Fig. 4A. —73-year-old man with stage T4a adenocarcinoma of urinary
bladder. Axial T2-weighted MR image (TR/TE, 4000/100) of tumor shows marked
circumferential thickening of bladder wall (arrows). Adenocarcinoma
with signet cell features results in linitis plastica appearance of urinary
bladder.
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Fig. 4B. —73-year-old man with stage T4a adenocarcinoma of urinary
bladder. Axial arterial phase contrast-enhanced fast spoiled gradient-echo MR
image (200/2.2) reveals thickened bladder wall (arrow) with prominent
mucosal enhancement. Perivesical stranding (arrowhead) corresponds to
tumor at histopathologic examination (not shown).
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Fig. 4C. —73-year-old man with stage T4a adenocarcinoma of urinary
bladder. Axial arterial phase contrast-enhanced fast spoiled gradient-echo MR
image (200/2.2) of bladder base shows extension of tumor to prostate
(straight arrow) and perivesical fat (curved arrow).
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Fig. 4D. —73-year-old man with stage T4a adenocarcinoma of urinary
bladder. Photomicrograph of adenocarcinoma obtained from cystectomy specimen
at high magnification shows cancer cells with signet ring cell features
(arrows). (H and E, x400)
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Small Cell Carcinoma
Small cell carcinoma of the bladder has also been called undifferentiated
and poorly differentiated carcinoma. Most small cell carcinomas occur as a
component of mixed carcinomas. Pure small cell carcinomas are rare, accounting
for fewer than 1% of all urothelial neoplasms. Age, sex, and symptoms are
comparable to those of transitional cell carcinomas
[6] (Fig.
5A,5B,5C).
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Fig. 5A. —74-year-old man with stage T4a small cell carcinoma of
urinary bladder. Axial T2-weighted MR image (TR/TE, 4400/120) shows left
posterolateral nodular mass of slightly higher signal intensity to muscle
(arrow) with associated wall thickening of anterior and right lateral
wall, causing left hydroureter (arrowhead).
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Fig. 5B. —74-year-old man with stage T4a small cell carcinoma of
urinary bladder. Axial venous phase contrast-enhanced fast spoiled
gradient-echo MR image (266/4.2) shows poorly enhancing mass with minimal
peripheral enhancement (curved arrow) because of necrosis. Poor
enhancement of this small cell tumor is distinct from typical transitional
cell carcinomas that show marked early, strong enhancement. Note same signal
intensity in perivesical fat (straight arrow), which corresponds to
tumor extension in histopathologic examination (not shown).
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Fig. 5C. —74-year-old man with stage T4a small cell carcinoma of
urinary bladder. Photomicrograph of cystectomy specimen shows small cell
carcinoma with sheet of hyperchromatic cells, abundant mitoses, and apoptosis.
(H and E, x400)
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Cystoscopically, small cell carcinomas tend to be polypoid or nodular and
often appear as ulcerated masses that cannot be distinguished from other
high-grade bladder cancers. Small cell carcinomas can arise from various
locations and are not predominantly localized to the base of the bladder.
Metastatic spread occurs rapidly, and the most frequent sites are the regional
lymph nodes, bones, and peritoneal cavity
[6].
Carcinosarcoma (Malignant Mixed Mesodermal Tumors)
Carcinosarcoma of the urinary bladder is a rare neoplasm; approximately 70
cases have been reported. They are most frequently observed in the female
genital tract [9]. Neither the
etiology nor the pathogenesis of carcinosarcomas is currently known. Bladder
carcinosarcomas predominate in men, with a ratio of 3:1. Most patients
complain of hematuria, but clinical symptoms are nonspecific. The tumors are
most common at the base of the bladder and are polypoid masses
[6]. Carcinosarcomas are
usually deeply infiltrative at the time of clinical detection. Most deaths
result from complications of local growth rather than distant metastasis
[6]. Histologically, the most
common epithelial component is transitional cell carcinoma, although
glandular, squamous, and even small cell carcinomas have been reported. The
sarcomatous component is most commonly poorly differentiated and spindled, but
cartilaginous, osseous, and muscle differentiation are also seen
[6] (Fig.
6A,6B,6C).
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Fig. 6A. —83-year-old man with stage T3b carcinosarcoma of urinary
bladder. Axial T2-weighted MR image (TR/TE, 4000/100) shows large intraluminal
bladder mass. Note extensive size of mass that completely fills urinary
bladder and marked heterogeneous signal intensity (arrow).
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Fig. 6B. —83-year-old man with stage T3b carcinosarcoma of urinary
bladder. Axial arterial phase contrast-enhanced fast spoiled gradient-echo MR
image (220/2.2) obtained slightly higher than A shows large polypoid
fungating mass arising from left lateral wall and protruding into lumen with
heterogeneous enhancement. Note peripheral nonenhancing portion of tumor due
to probable adherent thrombus (arrows).
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Fig. 6C. —83-year-old man with stage T3b carcinosarcoma of urinary
bladder. Photomicrograph of cystectomy specimen shows that this mass lesion
includes rhabdosarcoma, transitional cell carcinoma, and adenocarcinoma
components. High magnification of rhabdomyosarcoma component (curved
arrow) of tumor shows cells, spindled to round, with abundant
eosinophilic cytoplasm. Strap cell with striations (straight arrows)
can be seen in center of field. (H and E, x400)
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Plasmacytoma
Plasmacytomas arising in the urinary bladder are rare, and all information
concerning these neoplasms is derived from case reports
[6]. The few reported cases
have occurred in men and women ranging in age from 39 to 89 years. Signs and
symptoms are nonspecific [6].
Like plasmacytomas in other extramedullary sites, these lesions look and act
more like solid tumors than lymphoproliferative neoplasms. Plasmacytomas may
present as single or multiple masses in the bladder wall (Fig.
7A,7B,7C).
IgA and IgG, as well as both kappa and lambda light chains, have been
documented in individual cases
[6].
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Fig. 7A. —72-year-old man with stage T2b plasmacytoma of bladder. Axial
T2-weighted MR image (TR/TE, 4400/80) shows broad-based large mass lesion of
same signal intensity as bladder wall occupying almost one third of bladder on
right side (arrows).
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Fig. 7B. —72-year-old man with stage T2b plasmacytoma of bladder. Axial
arterial phase contrast-enhanced fast spoiled gradient-echo MR image (245/4.2)
shows homogeneous enhancement of organ-confined mass (arrows).
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Fig. 7C. —72-year-old man with stage T2b plasmacytoma of bladder.
Photomicrograph of cystectomy specimen shows plasmacytoma consisting of sheet
of discohesive cells with prominent nucleolus and eccentric eosinophilic
cytoplasm. (H and E, x400)
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Conclusion
Non—transitional cell carcinomas are aggressive tumors that usually
extend beyond the bladder wall at the time of initial diagnosis. They tend to
cause marked bladder wall thickening and tend to be larger than transitional
cell carcinomas. Clinical staging, including transurethral resection, is not
accurate for detection of extravesical spread. MR imaging readily identifies
spread of extravesical tumor that will lead to cystectomy, palliative
radiation, or chemotherapy.
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