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Presented by Jonathan Epstein, M.D. and prepared by Rui Zheng, M.D., Ph.D.
Case 2: A 40 year old female was diagnosed several months ago with uterine cervical cancer.
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1. Question
Week 452: Case 2
A 40 year old female was diagnosed several months ago with uterine cervical cancer. Several months later she was noted to have hematuria and a bladder mass was biopsied.images/1alex/09272010case2image1.jpg
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images/1alex/09272010case2image5.jpgCorrect
Answer: Polypoid cystitis with cervical cancer extending into the bladder
Histology: The fragments of bladder show classic features of polypoid cystitis. There is marked lamina propria edema where the urothelium is thrown into broad bulbous projections. The urothelium lining the edematous projections is normal in terms of thickness and cytology. These findings are typical of polypoid cystitis. In addition, there are separate fragments of squamous epithelium with marked hyperkeratosis. The squamous epithelium shows pleomorphic nuclei and irregular nests of squamous epithelium within the connective tissue.
Discussion: The most common carcinomas to secondarily involve the bladder are those of the prostate, rectosigmoid, and uterine cervix. Distinction of squamous cell carcinoma primary in the uterine cervix from a urothelial or squamous carcinoma of the bladder cannot be accomplished on routine morphology. In some cases one can appreciate that the bulk of the tumor is involving the deeper aspects of the bladder rather than the mucosa suggesting secondary involvement of the bladder. In the current case the knowledge of a well established prior uterine cervical cancer also should raise the possibility of secondary involvement of the bladder by a carcinoma involving a contiguous organ. In situ hybridization for HPV16 and 18 may be useful as with rare exception urothelial and squamous carcinomas of the bladder are not related to HPV. Immunohistochemistry for P16 is not useful diagnostically as there is expression in both uterine cervical cancer as well as bladder urothelial and squamous cell carcinoma. In the current case, stains for high risk HPV were performed which were positive helping to verify that the fragments of squamous carcinoma in the bladder resulted from spread from the patient’s uterine cervical primary. Although one can see reactive squamous metaplasia overlying polypoid cystitis the degree of cytologic atypia in the fragments of squamous epithelium in the current case is not that seen with reactive atypia and is diagnostic of malignancy.
Incorrect
Answer: Polypoid cystitis with cervical cancer extending into the bladder
Histology: The fragments of bladder show classic features of polypoid cystitis. There is marked lamina propria edema where the urothelium is thrown into broad bulbous projections. The urothelium lining the edematous projections is normal in terms of thickness and cytology. These findings are typical of polypoid cystitis. In addition, there are separate fragments of squamous epithelium with marked hyperkeratosis. The squamous epithelium shows pleomorphic nuclei and irregular nests of squamous epithelium within the connective tissue.
Discussion: The most common carcinomas to secondarily involve the bladder are those of the prostate, rectosigmoid, and uterine cervix. Distinction of squamous cell carcinoma primary in the uterine cervix from a urothelial or squamous carcinoma of the bladder cannot be accomplished on routine morphology. In some cases one can appreciate that the bulk of the tumor is involving the deeper aspects of the bladder rather than the mucosa suggesting secondary involvement of the bladder. In the current case the knowledge of a well established prior uterine cervical cancer also should raise the possibility of secondary involvement of the bladder by a carcinoma involving a contiguous organ. In situ hybridization for HPV16 and 18 may be useful as with rare exception urothelial and squamous carcinomas of the bladder are not related to HPV. Immunohistochemistry for P16 is not useful diagnostically as there is expression in both uterine cervical cancer as well as bladder urothelial and squamous cell carcinoma. In the current case, stains for high risk HPV were performed which were positive helping to verify that the fragments of squamous carcinoma in the bladder resulted from spread from the patient’s uterine cervical primary. Although one can see reactive squamous metaplasia overlying polypoid cystitis the degree of cytologic atypia in the fragments of squamous epithelium in the current case is not that seen with reactive atypia and is diagnostic of malignancy.
