|
PATHOLOGY
Pseudocarcinomatous
epithelial hyperplasia in the bladder unassociated with prior irradiation
or chemotherapy
Lane Z, Epstein JI
Department of Pathology, The Johns Hopkins Hospital, Baltimore, MD 21231,
USA
Am J Surg Pathol. 2008; 32: 92-7
- Pseudocarcinomatous
epithelial hyperplasia in the bladder is a little known phenomenon,
recognized to be associated with prior irradiation and/or chemotherapy.
Whether this process can occur outside of this setting has not been
studied. We identified 8 of these cases mimicking invasive urothelial
carcinoma from our consultation files from 07/04 to 07/06 with no prior
history of radiation or chemotherapy. The mean age at diagnosis was
65 years (range, 42 to 81 y), with 5 of the 8 males. Seven patients
had a potential etiology for these changes that could either have resulted
in localized ischemia or injury to the urothelium. These included case
1: atrial fibrillation, hypertension, congestive heart failure, gastrointestinal
bleeding, and coronary artery vascular disease; case 2: coronary angioplasty,
atrial fibrillation, hyperlipidemia, and amputation of arm for ischemia;
case 3: hypertension, uncontrolled diabetes, hyperlipidemia, and atrial
fibrillation; case 4: underlying arteriovenous malformation of the bladder;
cases 5 to 6: history of indwelling Foley catheter; and case 7: history
of radical prostatectomy for prostate cancer but no radiation. One patient
had no potential contributing factors. All 8 patients presented with
gross hematuria. At cystoscopy, 7 patients had polypoid lesions with
1 appearing nonpolypoid. Histologically, all cases showed epithelial
proliferation of urothelium with cells having prominent eosinophilic
cytoplasm. This process that mimicked invasive cancer within the lamina
propria was marked in 3 cases (38%). Moderate nuclear pleomorphism was
seen in 6 cases (75%). Only 1 case revealed mitotic figures. Ulceration
was seen in 1 case. All cases showed some degree of hemorrhage with
hemosiderin deposition identified in 3 cases (38%). Fibrin deposition
was present in 1 case within the stroma, 3 cases in the vessels, and
4 cases in both. Five cases show stromal fibrosis. Edema and vascular
congestion were common features (90% and 100%, respectively). Six out
of 8 cases were accompanied by moderate to marked acute and chronic
inflammation. The original diagnosis included nested variant urothelial
carcinoma (1 case), atypical suspicious for invasive carcinoma (5 cases),
hemangioma (1 case), and eosinophilic cystitis (1 case). Patients were
followed for a mean of 16.5 months (range, 10 to 34 mo), and none developed
bladder cancer. As a rare response to ischemia and chronic irritation,
pseudocarcinomatous epithelial proliferations in the bladder may be
confused with invasive urothelial carcinoma. Pathologists must be aware
of the histologic changes mimicking cancer, and recognize that it can
occur outside of the setting of prior irradiation or chemotherapy.
- Editorial
Comment
Irradiation and/or chemotherapy induce well known lesions in the urinary
bladder. They include: acute cystitis with desquamation of the urothelial
cells, hyperemia, edema in the lamina propria, atypical epithelial and/or
stromal cells, hyalinization and thrombosis of the vessels, and prominent
telangiectatic vessels that explain the hematuria that often occurs.
Late complications of radiation injury include ulcers, marked contraction
of the bladder because of fibrosis, and ureteral strictures that may
lead to severe pyelonephritisd and death (1).
A pitfall for the pathologist in radiation cystitis is pseudocarcinomatous
proliferation of the urothelium simulating invasive urothelial carcinoma.
In 2000, Baker and Young (2) reported 4 cases with this lesion. It is
a reactive process and the authors point out some clues for the correct
diagnosis: absence of mitotic figures, preservation or decrease of the
nuclear-to-cytoplasmic ratio, prominent vacuolar change, and squamoid
appearance of the epithelium.
The report of Lane and Epstein’s is very important because it
adds to pseudocarcinomatous epithelial hyperplasia in the bladder causes
unassociated with prior irradiation or chemotherapy that must be known
by the pathologist. One patient had no potential contributing factor,
but 7 patients had ischemia and/or chronic irritation as possible causes
for this reactive lesion mimicking invasive urothelial carcinoma. We
had the opportunity to see in our Institution a biopsy of the urinary
bladder of a 44-year-old male showing pseudocarcinomatous hyperplasia
unassociated with prior irradiation or chemotherapy. This reactive lesion
was associated to chronic cystitis due to a rectalvesical fistula secondary
to diverticulitis.
References
1. Young RH: Non-neoplastic Epithelial Abnormalities and Tumorlike Lesions.
In: Young RH (ed.), Pathology of the Urinary Bladder. New York, Churchill
Livingstone, 1989; pp. 1-63.
2. Baker PM, Young RH: Radiation-induced pseudocarcinomatous proliferations
of the urinary bladder: a report of 4 cases. Hum Pathol. 2000; 31: 678-83.
Dr.
Athanase Billis
Full-Professor of Pathology
State University of Campinas, Unicamp
Campinas, São Paulo, Brazil |