Bladder, ureter & renal pelvis

Glandular neoplasms

Adenocarcinoma



Topic Completed: 12 August 2021

Minor changes: 20 October 2021

Copyright: 2003-2021, PathologyOutlines.com, Inc.

PubMed Search: Adenocarcinoma of the bladder[TI] full text[SB]

See Also: Urachal adenocarcinoma

Chunlai Zuo, M.D., M.S.
Huihui Ye, M.D., M.S.
Page views in 2020: 6,936
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Cite this page: Zuo C, Ye H. Adenocarcinoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderadeno.html. Accessed December 8th, 2021.
Definition / general
  • Carcinoma derived from the urothelium and showing pure glandular differentiation
  • Not including urachal adenocarcinoma or urothelial carcinoma with glandular differentiation
Essential features
  • Rare, derived from the urothelium of the bladder with pure glandular differentiation
  • Histology: intestinal (enteric) type, mucinous type, signet ring cell type, NOS and mixed
  • Immunohistochemistry: often CK7+ and CK20+ or CK7- and CK20+, no nuclear staining for beta catenin
  • Diagnosis made after excluding secondary adenocarcinoma either by metastasis or by direct extension
Terminology
  • Primary adenocarcinoma of the bladder
  • Primary adenocarcinoma of the ureter
  • Primary adenocarcinoma of the renal pelvis
ICD coding
  • ICD-10:
    • C65 - malignant neoplasm of renal pelvis
    • C66 - malignant neoplasm of ureter
    • C67 - malignant neoplasm of bladder
Epidemiology
Sites
  • Usually lateral, posterior wall or trigone of bladder (if dome, should consider urachal adenocarcinoma by default)
  • Second most common site in urethra; rare in ureters and renal pelvis
Etiology
  • Some cases may be due to progression of extensive intestinal metaplasia (cystitis glandularis) or villous adenoma; these cases arise at trigone and are usually enteric
  • Exstrophy: diffuse intestinalization; 4 - 7% risk of developing adenocarcinoma, even after repair (J Urol 1970;104:699)
  • Diverticula: usually develop urothelial carcinoma, occasionally adenocarcinoma
  • Also Schistosoma haematobium (Urol Oncol 2006;24:13)
  • Chronic irritation of bladder, including nonfunctioning bladder or obstruction (Urol Oncol 2006;24:13)
  • Urethral adenocarcinomas may arise from metaplastic surface mucosa or from periurethral glands secondary to chronic inflammation, stricture, diverticula, fistula and infections
Clinical features
  • Usually presents with hematuria, rarely with mucusuria, dysuria (Cancer 1991;67:2165)
  • Patients are older and mucusuria is more common than in urachal adenocarcinoma
  • 5 year disease free survival rate is 40 - 50% (Urol Oncol 2006;24:13)
Diagnosis
  • Screen test: urine cytology
  • Imaging modalities include ultrasound, computerized tomography (CT) urogram, retrograde pyelogram or magnetic resonance imaging (MRI) urogram
  • Cystoscopic examination of the entire urethra and bladder, with diagnostic specimens collected by either biopsy or transurethral resection of bladder tumor (TURBT) (Eur Urol Focus 2021 [Epub ahead of print])
Radiology images

Contributed by Chunlai Zuo, M.D., M.S. and Huihui Ye, M.D., M.S.
Bladder wall mass by CT

Bladder wall mass by CT



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Bladder neck mass by ultrasound

Bladder neck mass by ultrasound

Prognostic factors
  • Stage is most important prognostic factor
  • Compared with urothelial carcinoma, patients with bladder adenocarcinoma have a worse prognosis, as they commonly present at a more advanced stage
  • It is controversial whether it is more aggressive if controlled for tumor stage
  • After adjusting pathologic stage, the presence of lymphovascular invasion and lymph node status, a study demonstrated that the primary adenocarcinoma has a worse prognosis than conventional urothelial carcinoma (J Urol 2006;175:2048)
Case reports
Treatment
  • Radical cystectomy and pelvic lymph node dissection
  • Adjuvant therapy (radiation or chemotherapy) may be given in some cases
Clinical images

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Bladder neck mass by ultrasound

Bladder neck tumor cystoscopy

Gross description
  • 67% are solitary lesions (while urothelial carcinoma tends to be multifocal)
  • Tumor surface may be covered by gelatinous material
  • Papillary, nodular, flat or ulcerated
Gross images

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Primary signet ring
cell carcinoma of
upper urinary tract

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Adenocarcinoma of urinary bladder

Microscopic (histologic) description
  • Intestinal type (or enteric type):
    • Resembles colonic adenocarcinoma (Cancer 1991;67:2165)
    • Neoplastic glands are lined by pleomorphic mucin producing pseudostratified columnar epithelium
    • Central dirty necrosis is commonly seen
  • Mucinous (colloid) type:
    • Nests of neoplastic cells floating in abundant extravasated mucin
    • Singly dispersed or groups of signet ring cells can be seen in the mucin pools
    • Mucin usually deeply invades muscularis propria
  • Signet ring cell type (diffuse poorly differentiated adenocarcinoma):
    • Discohesive round cells with large intracellular mucin vacuoles displacing nuclei to the periphery without extracellular mucin
    • Diffusely infiltrating stromal tissue
  • Association with in situ component is an important clue to differentiate primary adenocarcinoma of the bladder from secondary adenocarcinoma involving the bladder
  • Intestinal metaplasia or villous adenoma may be seen
Microscopic (histologic) images

Contributed by Chunlai Zuo, M.D., M.S. and Huihui Ye, M.D., M.S.
Villoglandular growth

Villoglandular growth

Cytologic atypia

Cytologic atypia

Desmoplastic reaction

Desmoplastic reaction

Intraluminal mucin

Intraluminal mucin

Muscularis propria invasion

Muscularis propria invasion


Signet ring cells

Signet ring cells

Mucin pool

Mucin pool

Malignant glandular epithelium

Malignant glandular epithelium

Intestinal / enteric type Intestinal / enteric type

Intestinal / enteric type

Virtual slides

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Mucinous adenocarcinoma of the bladder

Cytology description
  • Clusters of tumor cells, intracytoplasmic vacuoles, eccentrically located nuclei, hyperchromatic irregular nuclear contours, conspicuous to prominent nucleoli (Cancer 1998;84:335)
  • Tumor cells of signet ring cell carcinoma show large intracytoplasmic mucin vacuole, hyperchromatic crescent shaped nuclei
  • Background necrosis or mucin may be present, depending on the subtype
Cytology images

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Vacuolated cells

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Penile metastasis

Positive stains
Negative stains
Molecular / cytogenetics description
Molecular / cytogenetics images

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Abnormal FISH

Sample pathology report
  • Bladder and prostate, radical cystoprostatectomy:
    • Bladder, invasive adenocarcinoma, mixed mucinous type with signet ring cell component (see synoptic report)
    • Prostate, negative for carcinoma
Differential diagnosis
Board review style question #1

A bladder TURBT is shown. Which of the following immunohistochemistry stains is most helpful in distinguishing the metastatic colon cancer to the bladder from the primary adenocarcinoma of the bladder, intestinal type?

  1. Beta catenin
  2. CDX2
  3. CK7
  4. CK20
  5. STAB2
Board review style answer #1
A. Beta catenin. Up to 80% of metastatic colon cancers are positive for nuclear beta catenin (in addition to cytoplasmic stains), an indicator of WNT pathway activation. Primary adenocarcinoma of the bladder, intestinal type can express CK20, CDX2 and STAB2, however, lacks nuclear beta catenin staining.


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