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Bladder

Other Carcinomas

Adenocarcinoma


Reviewer: Rugvedita Parakh, M.D., HCG Oncology (see Reviewers page)
Revised: 21 April 2011, last major update April 2011
Copyright: (c) 2003-2011, PathologyOutlines.com, Inc.

See also urachal adenocarcinoma

Definition
=========================================================================

● Defined as malignant glandular tumor differentiated towards colonic mucosa
● Restrict diagnosis to pure adenocarcinomas and avoid the terminology if associated with squamous or urothelial carcinoma component
● Epicenter is mucosa, not muscularis propria (which is found in urachal adenocarcinoma)

Epidemiology
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● Less than 2% of all bladder malignancies
● 2/3 occur in men; mean age 68 years

Sites
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● Usually lateral wall or trigone of bladder

Etiology
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● Some cases may be due to progression of extensive intestinal metaplasia (cystitis glandularis); these cases arise at trigone and are usually enteric
● Exstrophy (diffuse intestinalization; 7% develop adenocarcinoma, even after repair)
● Diverticula (usually develop urothelial carcinoma, occasionally adenocarcinoma)
● Also endometriosis, pelvic lipomatosis, Schistosoma haematobium
● Chronic irritation of bladder including nonfunctioning bladder

Clinical features
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● Usually present with hematuria, rarely with mucousuria, dysuria
● Patients are older and mucusuria is more common than in urachal adenocarcinomas
● 5 year survival is 20-40%

Prognostic features
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● Stage is most important prognostic feature
● Compared to urothelial carcinoma, patients present at more advanced stage, but have similar prognosis (Urology 2010;75:376)

Case reports
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● 42 year old woman with tumor developing at vesicocutaneous edge of vesicostomy 40 years after creation in patient with cadaveric renal transplant (Arch Pathol Lab Med 2004;128:e58)
● 77 year old woman with colloid carcinoma after long term cyclophosphamide for Waldenstrom’s macroglobulinemia (Am J Surg Pathol 1996;20:500)
● 86 year old man with moderately differentiated adenocarcinoma of bladder, prostatic low grade neuroendocrine carcinoma and Gleason 3+3 prostatic adenocarcinoma (Arch Pathol Lab Med 2004;128:e166)

Treatment
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● Radical cystectomy
● Adjuvant therapy may be given in some cases

Clinical images
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With complete bladder eversion and prolapse

Gross description
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● 2/3 are solitary
● Tumor surface is covered by gelatinous material

Gross images
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Mucinous adenocarcinoma


Large mass partially covered by everted and thickened bladder wall

Adenocarcinoma of urinary bladder

Micro description
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● Glandular component predominates, usually resembles colonic carcinoma
● Often produces mucin, usually deeply invades muscularis propria
● Almost all are considered high grade at diagnosis
● Other patterns include mucinous, signet ring, hepatoid (described in detail later), mixed
● Associated with in-situ component
● Intestinal metaplasia may be seen

Micro images
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Arising in base


Well differentiated mucinous tumor


Moderately differentiated tumor

       
Mucinous tumors (right: mucicarmine stain)


With villous adenoma


Arising from nephrogenic adenoma


Metastatic colon adenocarcinoma (fig 1A-1C) versus primary bladder adenocarcinoma (fig 2A-2B)

       
Secondary colorectal adenocarcinoma versus primary bladder adenocarcinoma (CDX2, villin, AMACR)


Metastatic colon adenocarcinoma (fig 3A-3B) versus primary bladder adenocarcinoma (fig 5)

Other images: PSA stains metastatic prostatic adenocarcinoma; PSAP stains metastatic prostatic adenocarcinoma

Cytology description
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● High grade, but often lacks features of glandular differentiation
● Rarely is well differentiated and benign appearing

Cytology images
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Metastasis to penile nodule

Positive stains
=========================================================================

● CK7 (variable), CK20 (variable), CEA, EMA, villin
● Variable CDX2 (Am J Surg Pathol 2003;27:303, Mod Pathol 2005;18:1217)
● Membranous staining for beta-catenin

Negative stains
=========================================================================

● PSA (Hum Pathol 1986;17:939), vimentin
● Variable PAP, CA-125
● Nuclear beta-catenin
● Uroplakin-3

Differential diagnosis
=========================================================================

Local extension of prostatic adenocarcinoma: most prostatic adenocarcinomas are PSA+ and PAP+, negative for p63, high molecular weight cytokeratin and thrombomodulin, but bladder adenocarcinomas are opposite
Local extension of colonic cancer: no urothelial carcinoma in situ, positive nuclear staining for beta-catenin in 81%, CK20+ in 94%, CK7 negative in 100%, thrombomodulin negative in 100%, vs. bladder adenocarcinoma which has negative nuclear staining for beta-catenin in 100%, CK20+ in only 53%, CK7+ in 65%, thrombomodulin+ in 59% (Am J Surg Pathol 2001;25:1380, Am J Surg Pathol 1993;17:171)
Metastatic disease: usually associated with known disseminated disease (Am J Surg Pathol 1990;14:877), submucosal centered, extensive vascular invasion
Colonic metaplasia: may mimic well differentiated adenocarcinoma due to widespread involvement with dissecting mucin pools; however minimal atypia, no mitoses, no signet ring cells, usually non-infiltrative, minimal/no muscle invasion (Hum Pathol 1997;28:1152)
Urothelial carcinoma with glandular features: doesn’t differentiate towards colonic mucosa, usually minimal mucin and goblet cells, “glands” are surrounded by urothelial-type cells
Florid cystitis glandularis: no nuclear anaplasia, rarely invades muscularis propria
Mullerinosis
Urachal adenocarcinoma: location is a clue

End of Bladder > Other Carcinomas > Adenocarcinoma


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