Urinary Bladder Adenocarcinoma Metastatic to the Abdominal Wall: Report of a Case with Cytohistologic Correlation

Abstract

We report a case of adenocarcinoma metastatic to the abdominal wall in a 71-year-old man with a history of primary bladder adenocarcinoma. CT-guided core biopsy was performed; imprints and histologic sections showed malignant glands lined by tumor cells with hyperchromatic nuclei and prominent nucleoli, infiltrating through skeletal muscle. Immunohistochemistry revealed positivity for CK7, membranous/cytoplasmic β-catenin, caudal-type homeobox transcription factor 2 (CDX2), and α-methylacyl coenzyme A racemase and negativity for CK20, p63, prostate-specific antigen (PSA), and prostate-specific acid phosphatase (PSAP). These findings were interpreted as metastatic adenocarcinoma, consistent with bladder primary. Primary bladder adenocarcinoma is a rare malignancy arising within glandular metaplasia and is associated with cystitis cystica and cystitis glandularis. Predisposing factors include bladder exstrophy, schistosomiasis, and other causes of chronic bladder irritation. This tumor is divided into intestinal, clear cell, and signet ring cell subtypes. Treatment involves radical cystectomy with pelvic lymph node dissection, and prognosis is unfavorable. Primary bladder adenocarcinoma should be differentiated from urachal adenocarcinoma, which arises from urachal remnants near the bladder dome, and secondary adenocarcinoma, or vesical involvement by adenocarcinoma from a different primary. CK7, CK20, CDX2, thrombomodulin, and β-catenin can help distinguish primary bladder adenocarcinoma from colonic adenocarcinoma; PSA and PSAP can help distinguish primary bladder adenocarcinoma from prostate adenocarcinoma.

Primary Signet-Ring Cell Carcinoma of the Urinary Bladder Successfully Managed with Radical Cystectomy in a Young Patient

“…Another rare presentation in the literature is mucinuria which is reported in 3–12% of the patients [5]. Our patient had history of one-year intermittent painless hematuria with clot as the presenting symptom.…”

“…This glandular metaplasia may also occur without urothelial invagination, resulting in a variable cystoscopic appearance: sessile, papillary, nodular, or ulcerated. The intestinal, clear cell, and signet-ring cell subtypes are the best known subtypes in the literature [ 5 ]. In our case presentation, the mass was sessile and in pathology evaluation it was signet-ring type.…”

“…Interstitial part is the most frequent place for mucus deposition. In seldom cases, mucin is passed through the lumen in acini and its excess changes the nuclei to peripheral crescent and makes a signet-ring shape [ 5 ].…”

“…Clinical presentation of PSRCC of the bladder is similar to other bladder malignancies and hematuria is the most common presenting symptom. Another rare presentation in the literature is mucinuria which is reported in 3–12% of the patients [ 5 ]. Our patient had history of one-year intermittent painless hematuria with clot as the presenting symptom.…”

“…One of the main problems in cases of PSRCC of the bladder is to exclude metastatic adenocarcinoma from other sites of the body. As secondary adenocarcinoma is more common than primary adenocarcinoma and differentiating the two in cytologic preparations can be difficult [ 5 ], we evaluated the other possible secondary origin of this tumor in our patient at a young age by gastroduodenoscopy and rectosigmoidoscopy. Another tumor that can invade the bladder by local extension and mimic primary bladder adenocarcinoma is prostate adenocarcinoma [ 6 ] which was ruled out by transrectal needle biopsy of prostate.…”