A c t a P a t h . J a p . 29(4) : 623-633, 1979

NONPAPILLARY CARCINOMA IN SITU OF THE URINARY BLADDER A Histopathologic Study and Mapping of the Urothelial Lesions

Hiroshi IWASAKI,* Munetomo ENJOJI**, and Motonori KANO*** * Department of Pathology, Fukuoku University School of Medicine, Fukuoku

** Department of Pathology, and *** Department of Urology, Faculty of Medicine, Kyuahu University, Fukuoka

(Received on Oct. 26, 1978)

Three cases of primary nonpapillary carcinoma of the urinary bladder diagnosed by urinary cytology and multiple biopsies were reported. Bladder specimens of two of the patients were totally embedded for step-sections that were mapped after histopathologic study. Atypical hyperplasia and carcinoma in situ with foci of microscopic invasion affected the bladder mucosa and extended continuously to the distal ureters as well as prostatic urethra. Multicentric distribution of the abnormal epithelium was deflnite in one case, and the bladder mucosa was extensively denuded in the other case. Metastasis to one of the regional lymph nodes was noted in the remaining one case. The origin of Pagetoid cells occurring in two of the cases is obscure, but we presume that these cells may represent transformed tumor cells showing differentiation toward the surface umbrella cells, or they are deriv- ed from Brunn’s nests where the cells may gain potential to differentiate to glandular epithelium. ACTA PATH. JAP. 29: 623- 633, 1979.

Zntroduction

Primary nonpapillary carcinoma in situ constitutes a rare but definite entity pre- senting a characteristic syndrome of intractable, antibiotic-resistent abacterial cystitis with presence of abnormal cells in the fresh urine.2 In spite of a number of excellent reports on in situ carcinoma of the bladder, the natural history of the lesion remains

Recently we had an opportunity to study in detail three cases of primary carcinoma in situ of the bladder diagnosed by urinary cytology and multiple biopsies. In two cases, complete mapping of epithelial lesions was performed to study the distribution of abnormal epithelium, and to demonstrate the presence or absence of microscopic invasion. We will discuss the origin of Pagetoid cells and aggressive nature of this lesion from our experience.

~0ntr0~e~sial.l-7,9-12,1*,15,17,18

Materials and Methods From July 1974 to September 1977, three patients with carcinoma in situ of the urinary

Clinical bladder were treated surgically a t the Urological Clinic of Kyushu University Hospital.

$36 4, &%e% 3% ;baB %f4& Reprint requests to Dr. H. IWASAKI, Department of Pathology, Fukuoka University School of Medicine, 34 Nanakuma, Nishi-ku, Fukuoka 814, Japan.

623

624 CARCINOMA IN SITU OF BLADDER Acta Path. Jap.

Table 1. Summary of Clinical Data of

Duration of Known Case No. Sex Age,* yr. Occupation Disease, mo. Symptoms

1 M 53 Office clerk 17 Urinary frequency, Suprapubic & urethral pain

2 M 65 Office clerk 3 Hematuria, & urinary

3 M 66 Merchant 17 Urinary frequency, frequency

nocturia, hematuria, & pain during urination

~ ___ ~~ ~~~~ ~

* Age at operation

data are summarized in Table 1. All patients have had no histories of exposure to carcinogenic agents except for smoking. The cystoscopic appearances were nonspecific ; there were mucosal edema, velvety reddening and yellowish granular lesions suggesting inflammation, while the mucosa sometimes appeared normal at the site involved. In each case urinary cytology revealed relatively small malignant cells with striking nuclear abnormalities, and multiple biopsies from the bladder mucosa demonstrated carcinoma in situ without invasion. Two patients were treated with radical cystoprostatourethrectomy and the other one was treated with radical cystectomy.

The freshly removed bladders of the former two patients were opened by a n anterior incision, spread stretched, pinned down on a piece of stiff card board and fixed in 10% f o r m a h (Koss et al., 1974). Following a 48-hour fixation, the entire bladder was cut into tissue blocks measuring about 3 x 0.3 cm and about 0.8 cm in thickness. Approximately 100 blocks were required to process the bladder in toto. Additional sections were taken from the ureters and penile urethra. Schematic diagrams were adopted to show the distribution of the lesions. I n addition to examina- tion of sections stained with hematoxylin and eosin, selected blocks were recut and sections were stained with elcian blue, PAS, silver impregnation for reticulin, and Masson’s trichrome.

Results

Macroscopic Findings

No gross tumors were present in each bladder. The bladder mucosa N-as strongly edematous and hyperemic. The mucosal surface were replaced in parts by numerous granular lesions measuring 0.3 mm to 1.0 mm in the greatest diameter. These granular areas were pooly circumscribed and alternated with the normal-appearing smooth mucosa. In Case 1, the granular lesions were densely packed on the lateral and anterior walls presenting a velvety appearance, while in Case 2 the mucosal surface was rather smooth and the granular lesions were restricted only to small portions. In Case 3, besides the granular lesions of the bladder mucosa, a small plaque-like lesion measuring 6 x 5 x 2 mm was found to obliterate the left ureteral orifice, but the right orifice appeared normal. There were small fresh ulcers a t the sites of biopsy in each bladder. Macroscopically, it was unable to predict the extent of in situ carcinoma in any case.

Microscopic Findings

A wide variety of abnormalities ranging from simple hyperplasia to atypical epithelium and in situ carcinoma was present in each bladder, while the normal

The proportion of the granular area to the smooth mucosa was varying.

29(4): 1979 H. IWASAKI, m. ENJOJI, AND M. KANO 626

Three Patiente with Carcinoma in Situ ~- -~ ~ ~-

Urinary Treatment Cystoscopic Findings Cytology

~. ~ ~

Velvety reddening, Malignant cells Radical cystopro- & yellowish granular Rtatourethrectomy lesions

Congestion, & edema Malignant cells Radical cystectomy

Erythematous Malignant cells Radical cystopro- granular zones statourethrectomy

epithelium remained only in small portion of the bladder mucosa (Figs. la, b and c). Carcinoma in situ showing a moderate to severe degree of cellular anaplasia, Grade 3 to 4 on Broder’s scale, involved a single, large geographic area as well as small isolated foci separated by non-neoplastic epithelium (Fig. 5a). In Case 1, small islands of in situ carcinoma were scattered in the bladder mucosa extensively denuded (Fig. 5b).

Small foci of microscopic invasion of the subepithelial stroma were found in all three cases. In these portions, the silver impregnation for reticulin revealed focal destruction of the basement membrane by malignant cells forming small nests or aggregates. Carcinoma in situ extended continuously from the bladder mucosa to the prostatic urethra, prostatic ducts and distal ureters (Cases 1 and 3). In situ carcinoma generally formed no papillary lesions, but one patient (Case 3) had micro- scopic papillary lesions in some parts of the bladder mucosa and in the left ureteral orifice (Fig. 4).

Two types of tumor cells morphologically different were noted: small cells and large Pagetoid cells. The small cells having a scanty cytoplasm and disproportionately large nucleus constituted a main proportion of the neoplasm (Figs. l b and 2a). The cells were crowded together, exhibiting a disorderly pattern of growth. Mitoses, normal and abnormal, were found to be scattered throughout the affected epithelium. The thickness of the abnormal epithelium was quite variable. Carcinoma in situ was usually composed of 5 to 20 or more cell layers, but i t was not rare to see the abnormal epithelium composed of only a single layer of malignant cells. The transition from normal epithelium to carcinoma in situ was usually sudden and so abrupt as to leave a demarcation line; the malignant cells extended along the basement membrane beneath the adjacent intact mucosa, lifting this mucosa to slough off and to be replaced by carcinoma in situ (Fig. 2a).

The Pagetoid cells which possessed abundant clear cytoplasm were found in two of the three cases (Cases 1 and 3). They affected the Brunn’s nests (Fig. 2c) and prostatic ducts as well as the surface epithelium. At the junction between the normal epithelium and in situ carcinoma, the Pagetoid cells were standing out prominently against the background of the smaller intact cells (Fig. 2b). Only a small amount of mucoid

--

FOIIOW-UP ~.

No recurrence, 1 yr

Died from intestinal bleeding, 2 yrs

No recurrence, 2 yrs

026 CARCINOMA I N SITU OF BLADDER Acta Path. Jap

29(4): 1979 H. IWASAKI, M. ENJOJI, AND M. KANO 627

substance was demonstrated in the sections stained with alcian blue, but PAS reaction was negative in these cells.

Varying degrees of epithelial alteration, such as simple hyperplasia and atypical epithelium with or without hyperplasia, were noted in all cases (Fig. 3). These alterations were most frequent in the areas adjacent to carcinoma in situ, but some- times were present independently. The atypical epithelium was often closely admixed with carcinoma in situ and the degree of cellular atypia was pronounced about the border of carcinoma in situ. The differentiation between atypical epithelium and carcinoma in situ was often difficult, because zones of continuous gradation of a dysplastic change were noted between these two conditions.

The mucosa affected by carcinoma in situ and atypical epithelium was often denuded extensively (Fig. 6a and b), producing a feature of “denuding cystitis”2 in result. Even in the areas where surface epithelium was completely denuded, many Brunn’s epithelial nests were preserved but involved frequently by carcinoma in situ. When the carcinoma in situinvolved the Brunn’s nests or prostatic ducts, the tumor cells tended to be more larger than those of the surface epithelium and transformed frequently into Pagetoid cells (Fig. 2c).

The subepithelial stroma was generally edematous, and contained a mild t o moderate inflammatory infiltrate consisting mainly of lymphocytes and plasma cells. Occasional lymphoid follicles with or without germinal centers were noted beneath the in situ carcinoma (Fig. la). The small blood vessels in the stroma were congested and lined by swollen endothelial cells.

The macroscopic granular lesions did not present a constant microscopic feature ; some were the spots of the residual mucosa which might be either normal or affected by carcinoma in situ within the irregularly denuded areas (Fig. lb), while others represented the Brunn’s nests with or without tumor cells (Fig. 2c). Microscopic papillary lesions, which were present in some parts of the bladder mucosa of Case 3, also contributed to the macroscopic granular lesions.

In one patient (Case 2) metastasis was found in one of the common iliac lymph nodes, but the other two patients showed no metastatic lesions.

Discussion

Complete mapping of epithelial lesions described by MELAMED et al. (1966) and Koss et al. (1974) is one of the most useful methods for studying the morphogenesis of bladder neoplasm. In the present study mapping was performed in two of the three cases, disclosing the characteristic distribution of the epithelial lesions. In one

~~~~ - ~~-~ -

Fig. 1. (Case 3). a (Top): Nonpapillary carcinoma in situ involving the mucosal layer. Kote exfoliation of the in situ carcinoma from the basement membrane. The subepithelial stroma contains lymph follicles. H&E, x 38. b (Center): Carcinoma in situ showing denudation. The subepithelial stroma is moderately inflamed. H&E, x 114. c (Bottom): Junction between normal epithelium and in situ carcinoma showing a distinct border. The in situ carcinoma on the right shows striking cellular abnormalities and a disorderly pattern of growth. H&E, x 250.

628 CARCINOMA IN SITU OF BLADDER A d a Path. Jap .

Fig. 2. a (Top): In s i tu carcinoma spreads along the basement membrane and lifts the intact mucosa to slough off (Case 3). b (Center): Pagetoid cells having abundant clear cytoplasm (Case 3) are standing out prominently against the background of the intact small cells. H&E, x 250. c (Bottom): Brunn’s nest on the left involved by in situ carcinoma contains many Pagetoid cells (Case 1). The surface epithelium is completely denuded. The Brunn’s nest on the right appears non-neoplastic. HCE, x 114.

H&E, x 250.

29(4): 1979 H. IWASAKI, M . ENJOJI, AND M. KANO 629

Fig. 3. The mucom is replaced by abnormal cells showing varying degrees of atypia (Case 2). The superficial rells show a slight maturation. H$E. x 260.

Fig. 4. Distal ureter in Case 3 affected by in situ carcinoma forming a papillary tumor. H&E, x 29.

630 CARCINOMA IN SITU OF BLADDER Acla Palh. Jup.

29(4): 1979 H. IWASARI, M. ENJOJI, AND M. KANO 63 1

patient carcinoma in situ occurred both in small isolated foci and in a single large geographic area separated by non-neoplastic mucosa and often intermingled with atypical epithelium (case 3). This finding seems to support the multicentric origin of carcinoma in s i td3 and to indicate its intimate relationship to atypical epithelium.

The bladder mucosa affected by in situ carcinoma exfoliates so easily to produce wide areas of denudation (denuding cystitis) because of diminished intercellular cohesiveness.2J0 This phenomenon seems to result in high frequency of abnormal cells in voided urine and to be followed by chronic inflammation in the subepithelial stroma causing chronic cystitis-like symptoms. Even in the denuded areas the Brunn’s nests were well preserved and often contained in situ carcinoma.

Carcinoma in situ seems different from papillary transitional cell carcinoma in the nature of tumor cells as well as in the growth pattern. The tumor cells of carcinoma in situ, which are less differentiated than those of papillary carcinoma, seem to possess little ability to induce proliferation of stromal cells. Absence of stromal induction by tumor cells explains why the in situ carcinoma spreads superficially to form flat lesions, but fails to produce visible papillary tumors.

There are two types of cells in carcinoma in situ: small cells and large Pagetoid cell^.^^^^ The Pagetoid cells appearing unique and characteristic of this bladder lesion occurred most frequently in the Brunn’s nests and in the developing margin of the in situ carcinoma. The true nature of the Pagetoid cells is obscure, but there seems to be three possibilities as to the origin of the cells. Firstly these cells might be resulted from a degenerative process of the usual small tumor cells, but this conception may seem unacceptable, because the Pagetoid cells show occasional mitotic figures and their nuclei appear not necessarily pyknotic but often vesicular. Secondly the Pagetoid cells may reflect differentiation from the usual small tumor cells toward the surface umbrella cells that are the largest cells in the normal urothelium and possess abundant clear cytoplasm. Thirdly these cells may be derived from the Brunn’s nests involved by carcinoma in situ. In Paget’s disease of the nipple, i t is likely that the initial lesion is an intraductal carcinoma arising in mammary ducts,8 and this primary ductal carcinoma extends upward into the epidermis where it causes the cutaneous lesion. The cells of the Brunn’s nests have a property to differentiate into the glandular epithelium as in cystitis cystica and glandularis. Therefore, when the in situ carcinoma affects the Brunn’s nests, the tumor cells may gain potential to differentiate into glandular epithelium and may be transformed into Pagetoid cells which infiltrate upward into the surface mucosa.

The natural history of carcinoma in situ of the bladder is a subject of controversy. Many authors pointed out a high risk of the progression of the in situ epithelial lesion to invasive carcinoma within a short period.5-7,12,14,17J8 Koss et al. (1977) estimated that in a t leat 70 per cent of patients invasive carcinoma of the bladder would develop within five years. On the contrary, FARROW et al. (1976) suggested that the natural evolution to invasive cancer might span a much longer period than had been reported previously. FARROW el al. (1977) also considered if differences in observed behavior of in situ bladder

632 CARCINOMA IN SITU OF BLADDER Aeta Path. Jap .

carcinoma were real, they could be explained by differences either in host resistance or in tumor potential. In our cases, although duration of symptoms was rather short, microscopic invasions were present in all cases and metastasis to the regional lymph node was found in one case. Besides, involvements of ureters, prostatic urethra and prostatic ducts were detected in two cases in which mapping was performed. WOLINSKA et al. (1977) reported a high probability of urethral carcinoma in patients who had had cystectomy for carcinoma of the urinary bladder, and their survival was poor when the disease was sufficiently advanced to be symptomatic or tumor was visible endoscopically. Therefore, it is reasonable to consider that radical cystopro- statourethrectomy is the treatment of choice for carcinoma in situ of the bladder.

1.

2.

3 .

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

References

BARLEBO, H., S~RENSEN, B.L., and OHLSEN, A.S.: Carcinoma in situ of the urinary bladder. Flat intra-epithelial neoplesia. ELLIOT, G.B., MOLONEY, P.J., and ANDERSON, G.H.: “Denuding cystitis” and in situ urothelial carcinoma. FARROW, G.M., UTZ, D.C., and RIFE, C.C.: Morphological and clinical observations of patients with early bladder cancer treated with total cystectomy. Cancer Res. 36: 2495- 2501, 1976. FARROW, G.M., UTZ, D.C., RIFE, C.C., and CREENE, L.F.: Clinical observations on sixty- nine cases of in situ carcinoma of the urinary bladder. Koss, L.G.: Tumors of the Urinary Bladder. Fascicle 11, 2nd Series, Atlas of Tumor Pathology. Koss, L.G., NAKANISHI, I., and FREED, S.Z.: Nonpepillary carcinoma in situ and atypical hyperplasia in cancerous bladders. Further studies of surgically removed bladders by mapp- ing. Urology 9: 442455, 1977. Koss, L.G., TIAMSON, E.M., and ROBBINS, M.A. : Mapping cancerous and precancerous bladder changes. A study of the urothelium in ten surgically removed bladders. J.A.M.A.

LEVER, W.F., and SCHUMBURO-LEVER, G. : Philadephia, J.B. Lippincott Company, 1975. MELAMED. M.R.. GRABSTALD. H.. and WHITMORE. W.F.. Jr.: Carcinoma in situ of bladdder:

Scand. J. Urol. Nephrol. 6 : 213-223, 1972.

Arch. Pathol. 96: 91-94, 1973.

Cancer Res. 37: 2794-2798, 1977.

Washington, D.C., Armed Forces Institute of Pathology, 1975.

227: 281-286, 1074. Histopathology of the Skin, 5th ed.

, . clinicopathologic study of case with a suggested approach to detection. 1966.

J. Urol. 96: 466471,

MELAMED, M.R., VOUTSA, N.G., and GRABSTALD, H.: Natural history and clinical behavior of in situ carcinoma of the human urinary bladder. Cancer 17: 1533-1545, 1064. MELIOOW, M.M. and HOLLOWELL, J.W. : Intra-urothelial cancer: carcinoma in situ, Bowen’s disease of the urinary system: discussion of thirty cams. J. Urol. 68: 763-772, 1952. SKINNER, D.G., RICHIE, J.P., COOPER, P.H., WAISMAN, J., and KAUFMAN, J.J.: The clinical significance of carcinoma in situ of the bladder and it8 association with overt carcinoma. J. Urol. 112: 68-71, 1974. SOTO, E.A., FRIEDELL, G.H., and TILTMAN, A.J.: Bladder cancer as seen in giant histologic sections. Cancer 39: 447455, 1977. UTZ, D.C., HANASH, K.A., and FARROW, G.M.: The plight of the patient with carcinoma in situ of the bladder. J. Urol. 103: 16&1f34, 1970. VOUTSA, N.G. and MELAMED, M.R.: Cytology of in situ carcinoma of the human urinary bladder. Cancer 16: 1307-1316, 1963. WOLINSRA, W.H., MELAMED, M.R., SCHELLHAMMER, P.F., and WHITMORE, W.F., JR.: Urethral cytology following cystectomy for bladder carcinoma. Am. J. Surg. Pathol. 1 :

YAMADA, T., YOKOGAWA, M., MITANI, G., INADA, T., OHWADA, F., and FUKUI, I.: Two 225-234, 1977.

29(4): 197.9 H. IWASAKI, M. ENJOJI, AND M . KANO 633

different types of cancer development in the urothelium of the human urinary bladder with different prognosis. Jpn. J. Clin. Oncol. 5: 77-90, 1975.

18. YATES-BELL, A.J.: Carcinoma in situ of the bladder. Br. J. Surg. 58: 359-364, 1971.