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Presented by Dr. Jonathan Epstein and prepared by Dr. Sintawat Wangsiricharoen
Clinical History. A 65 year old man underwent a TURB for a bladder mass.
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1. Question
Clinical History. A 65 year old man underwent a TURB for a bladder mass.
Correct
Answer: B.
Histology: The tumor consists of a signet ring cell adenocarcinoma. Focally, there are well-formed glands with a few goblet cells and areas with loss of goblet cells and high grade dysplasia.
Discussion. If one had only the signet ring cell adenocarcinoma on a TURB, typically one would have to state in the pathology report, that this could be primary in the bladder but could not rule out spread from a GI primary. The only stain that could possibly help would be GATA3 which is positive in a minority of signet ring cell adenocarcinomas arising in the bladder. Other markers of intestinal differentiation, such as CDX2 or STAB2 in addition to CK7 or CK20 can be seen in both bladder and GI adenocarcinomas and are not helpful in this differential diagnosis. However, in this case there are other features that allow us to determine that this tumor arose in the bladder. The finding of a precursor lesion of glands with intestinal metaplasia with high grade dysplasia indicates a bladder primary. Bladder adenocarcinomas arise from two pathways. One is, as in this case, from intestinal metaplasia that develops dysplasia. The other is adenocarcinomas that arise from villous adenomas of the bladder. The glandular tumors and their precursors in the bladder are entirely analogous to their GI counterparts in their morphology and immunophenotype.
Incorrect
Answer: B.
Histology: The tumor consists of a signet ring cell adenocarcinoma. Focally, there are well-formed glands with a few goblet cells and areas with loss of goblet cells and high grade dysplasia.
Discussion. If one had only the signet ring cell adenocarcinoma on a TURB, typically one would have to state in the pathology report, that this could be primary in the bladder but could not rule out spread from a GI primary. The only stain that could possibly help would be GATA3 which is positive in a minority of signet ring cell adenocarcinomas arising in the bladder. Other markers of intestinal differentiation, such as CDX2 or STAB2 in addition to CK7 or CK20 can be seen in both bladder and GI adenocarcinomas and are not helpful in this differential diagnosis. However, in this case there are other features that allow us to determine that this tumor arose in the bladder. The finding of a precursor lesion of glands with intestinal metaplasia with high grade dysplasia indicates a bladder primary. Bladder adenocarcinomas arise from two pathways. One is, as in this case, from intestinal metaplasia that develops dysplasia. The other is adenocarcinomas that arise from villous adenomas of the bladder. The glandular tumors and their precursors in the bladder are entirely analogous to their GI counterparts in their morphology and immunophenotype.
