Synchronous signet ring cell carcinoma and squamous cell carcinoma arising in an augmented ileocystoplasty. Case report and review of the literature

The impact of signet-ring cell carcinoma histology on bladder cancer outcome

BACKGROUND

Signet-ring cell carcinoma (SRCC) of the urinary bladder is a rare entity. No previous studies have directly compared the cancer-specific survival of patients with SRCC to patients with urothelial carcinoma (UC) of the urinary bladder.

MATERIALS AND METHODS

Patients with diagnosis of urinary bladder SRCC and UC were identified in the Surveillance, epidemiology, and end results program (SEER) (2001-2004). Demographic of patients and clinical characteristics at diagnosis were compared. Differences in cancer-specific survival were compared using univariate and multivariate analysis.

RESULTS

A total of 103 patients with SRCC and 14,648 patients with UC were indentified. Patients with SRCC were younger (P < 0.001), more commonly presented with higher-grade histology (P < 0.001) and advanced stage disease (P < 0.001), in comparison with patients with UC. The 3-year cancer-specific survival rate was 67.0% for patients with UC and 33.2% for SRCC. On multivariate analysis, there was an increased mortality risk in patients with SRCC versus UC (HR 1.49, 95% CI 1.11-2.00, P < 0.01).

CONCLUSIONS

Even after adjusting for demographic, surgical, and pathological factors, cancer-specific survival rate was significantly worse in patients with SRCC compared to UC. Further research into the biology of this rare tumor is required to explain these results.

Clinical characteristics and outcomes of patients with primary signet-ring cell carcinoma of the urinary bladder

OBJECTIVE

The aim of this study was to examine the epidemiology, natural history, treatment pattern and predictors of long-term survival of patients with signet-ring cell carcinoma (SRCC) of the urinary bladder based on the analysis of the national Surveillance, Epidemiology, and End Results (SEER) database.

METHODS AND RESULTS

In total, 230 patients with pathologically confirmed SRCC of the urinary bladder were identified between 1973 and 2004. The mean age was 65 ± 13 years. Overall, 75.7% of the patients had a poorly differentiated or undifferentiated histology grade, 26.5% presented with metastatic disease, 59 (25.7%) underwent transurethral resection for bladder tumor only and 107 (46.5%) had partial or radical cystectomy. The 1-, 3- and 10-year cancer-specific survival rates were 66.8, 40.6 and 25.8%, respectively. Using multivariable Cox proportional hazard model, age (HR 1.024; p = 0.004), stage (distant vs. local, HR 6.2; p < 0.001) and cystectomy (HR 0.53; p = 0.002) were identified as independent predictors for cancer-specific survival.

CONCLUSIONS

Receipt of cystectomy was strongly associated with improved survival in the patients with SRCC of urinary bladder. However, many patients with localized tumors did not receive potentially curative cystectomy. Further studies to address the barriers to the delivery of appropriate care to these patients are warranted.

Transplantation of Preserved Human Amniotic Membrane for Bladder Augmentation in Rats

Although gastrointestinal segments have been widely used for bladder reconstruction, they are not ideal because of the possible complications. Searches have therefore continued for an alternative material for augmentation. Here, we performed bladder augmentation in rats using human amniotic membrane (hAM). Morphologically, the hAM-augmented bladder revealed regeneration of urothelium, detrusor smooth muscle, and nerve fibers within 3 months post-operatively. In our functional evaluation of bladder strips, we compared hAM-augmented bladders with bladders augmented using small intestinal submucosa (SIS). For example, at 6 months post-operatively, contractions of the following size (as a percentage of the responses in the control-bladder group) were obtained in response to high potassium, carbachol, and electrical field stimulation, respectively: hAM 22% vs SIS 15%, hAM 15% vs SIS 7%, hAM 5.3% vs SIS 1.3% (no significant differences, hAM vs SIS). Both hAM- and SIS-augmented bladders displayed adequate capacity and compliance. The present results indicate that, for bladder augmentation, hAM can be used as a scaffold and is comparable in this respect with SIS. hAM can be more easily obtained than SIS and requires little preparation, and its use raises few ethical questions. Hence, hAM may represent a new therapeutic alternative for urological reconstructions.

SECONDARY MALIGNANCIES IN DIFFERENT FORMS OF URINARY DIVERSION USING ISOLATED GUT

PURPOSE

Tumor development following ureterosigmoidostomy is a worldwide accepted late complication. In contrast, tumor risk in other forms of urinary diversion with the separation of urine and feces is still unclear. We present a complete and detailed analysis of all reported tumors following urinary diversions using isolated gut segments in the literature. We estimated the tumor risk in comparison to ureterosigmoidostomies and to the general population.

MATERIALS AND METHODS

We reviewed the world literature up to April 2003 via MEDLINE for secondary tumors in urinary diversions using isolated intestinal segments.

RESULTS

We found 81 tumor case reports following urinary diversion using isolated intestinal segments. Tumors developed in 18 conduits, 45 cystoplasties, 5 rectal bladders, 3 neobladders, 6 colonic pouches and 4 ileal ureter replacements.

CONCLUSIONS

All urinary diversions using bowel with or without separation of urine and feces carry a significantly higher tumor risk for intestinal tumor development compared to the general population. The tumor spectrum and tumor location in isolated gut segments are different than tumors following ureterosigmoidostomies but the total tumor risk is probably similar. The latency period depends on the initial diagnosis with malignant diseases leading to a shorter induction time. Concerning etiology, many theories exist but the exact mechanism remains unclear. Regular endoscopic control beginning with postoperative year 3 for early detection of secondary malignancies is mandatory.

[Carcinomatous degeneration on augmentation ileocystoplasty for tuberculous bladder]

The development of cancer on the ileal graft after augmentation ileocystoplasty for benign bladder disease is a little known complication. The authors report a case of squamous cell carcinoma in the ileal bladder occurring 37 years after augmentation ileocystoplasty for tuberculous bladder, in a 68-year old patient. Carcinomatous degeneration is usually occurs more than ten years after cystoplasty. Patients treated by this operation must be submitted to annual cystoscopy combined with guided biopsies at the slightest doubt. This surveillance should be started between the 5th and the 10th postoperative year.

Effect of antibiotics on enterocystoplasty urinary nitrosamine levels

OBJECTIVES

To evaluate the microbiologic characteristics of enterocystoplasty urine and assess the influence of bacteria type and effect of prophylactic and therapeutic antibiotic administration on the urinary nitrosamine levels of patients with enterocystoplasty. Nitrosamines have been implicated in the development of cancer in patients with an enterocystoplasty. Urinary tract infection (UTI) is associated with elevated nitrosamine levels.

METHODS

Urine samples were collected to determine the urinary nitrosamine levels and for microscopy, culture, and sensitivity from 42 patients with an enterocystoplasty and 6 normal controls. A subgroup of 5 enterocystoplasty patients with proven UTI was also evaluated by measuring the urinary nitrosamine levels before and after a therapeutic course of antibiotics.

RESULTS

Of the 42 cystoplasty patients, 22 had a proven UTI; none of the controls had one. Sixteen of the cystoplasty patients were taking prophylactic antibiotics and had mean N-nitrosamine levels equivalent to the control levels. The mean nitrosamine levels were highest in patients with a UTI (1.9 micromol/L). Escherichia coli was the most common infecting organism (11 patients) and resulted in the highest mean nitrosamine levels (2.1 micromol/L). The nitrosamine levels fell with UTI treatment to within the control range.

CONCLUSIONS

UTI occurs in 51% of enterocystoplasty patients and is associated with elevated mean urinary nitrosamine levels. E. coli is the infecting organism in 50% of cases. Antibiotic prophylaxis reduces the nitrosamine levels to those of the controls. UTI treatment results in a rapid reduction of elevated nitrosamine levels to control levels.

Enterocystoplasty

Despite the problems of augmentation cystoplasty, on balance it has been a much better form of management of the lower urinary tract in patients with bladder neuropathy or high pressure detrusor contractions than the alternatives of rectal diversion, indwelling catheter or external urinary diversion. The metabolic consequences do not seem to interfere with general health in the medium term. The risk of perforation appears to be present with other forms of augmentation cystoplasty or bladder replacement. However, the results are far from perfect and the ideal technique will be one that: removes the need for intraperitoneal surgery and prevents the risk of intestinal adhesions; stops the development of intestinal mucus and stone formation; prevents the metabolic complications and potential bony complications during adolescence; at the same time improves the patient's resistance to UTI; maintains the same degree of long-term, good, low-pressure urine storage and the consequent improvement and stability of the upper urinary tract.

Factors causing variation in urinary N-nitrosamine levels in enterocystoplasties

OBJECTIVE

To establish the presence or absence of any diurnal or long-term variation in N-nitrosamine levels (which might be important in the development of cancer in enterocystoplasties) in enterocystoplasty urine, and to assess other factors that might alter enterocystoplasty N-nitrosamine levels. Patients, subjects and methods Thirty-six patients with enterocystoplasties and six normal controls were assessed. Urine samples were collected every 4 h over a 24-h period and N-nitrosamine levels determined using a modification of the Pignatelli

METHOD

An additional urine sample was assessed by microscopy, culture and sensitivity. In a subgroup of 16 patients with an enterocystoplasty, the urinary N-nitrosamine levels were re-measured at 3-monthly intervals.

RESULTS

No diurnal or long-term variation in urinary N-nitrosamine levels was identified. The mean N-nitrosamine levels were significantly higher in the cystoplasty group than in the controls (1.7 vs 1.0 micromol/L; P = 0.008). Mean N-nitrosamine levels were also significantly higher in enterocystoplasty patients with sterile pyuria than in those with no pyuria (P = 0.01). Those taking prophylactic antibiotics had significantly lower mean N-nitrosamine levels than those not doing so (P = 0.05). Individuals with infected urine and those needing to intermittently catheterize had higher N-nitrosamine levels than their counterparts, but this difference was not significant. Conclusion There were no diurnal or long-term variations in urinary N-nitrosamine levels. Levels were consistently higher in patients with inflamed or infected cystoplasties, those using intermittent self-catheterization and those not taking antibiotic prophylaxis.

Oliguria, an unusual presentation of primary signet ring-cell adenocarcinoma of the urinary bladder: a case report and review of the literature

Adenocarcinomas represent approximately 2% of primary bladder epithelial malignancies. Of these, the signet ring-cell variant is the rarest form. We report such a case, with the unusual presentation of oliguria, including radiologic and histopathologic findings. The current literature is reviewed.