Primary choriocarcinoma of the urinary bladder--a case report

Urothelial Carcinomas With Trophoblastic Differentiation, Including Choriocarcinoma: Clinicopathologic Series of 16 Cases

Trophoblastic differentiation (including choriocarcinoma) arising in urothelial carcinoma has been described in numerous case reports, but never in a single series. We present a series of these tumors, describing the morphologic spectrum, applying traditional and novel immunohistochemical stains, and characterizing clinical follow-up. We identified 16 cases, arising predominantly in the bladder (N=14), but also the ureter (N=1) and prostatic urethra (N=1). Six of our cases (38%) contained invasive urothelial carcinoma with admixed syncytiotrophoblasts, 8 cases (50%) consisted of invasive urothelial carcinoma with choriocarcinoma, 1 case (6%) showed urothelial carcinoma in situ with associated choriocarcinoma, and 1 case (6%) consisted of pure choriocarcinoma. Other subtypes of variant morphology were seen in 5 of our cases (31%) and included squamous, glandular, lipoid, chordoid/myxoid, and sarcomatoid features. Given the limited specificity of human chorionic gonadotropin immunohistochemistry, we also studied the expression of a novel specific trophoblastic marker, hydroxyl-δ-5-steroid dehydrogenase, as well as Sal-like protein 4. Human chorionic gonadotropin expression was seen in nearly all cases (93%) but was often not limited to the trophoblastic component, staining the urothelial component also in 85% of the cases. Expression of hydroxyl-δ-5-steroid dehydrogenase was more sensitive and more specific, staining 100% of the cases and limited to trophoblasts in all but 1 case. Sal-like protein 4 expression was variable, staining trophoblast in only 50% of cases and staining the urothelial carcinoma component in 43% of those positive cases. Most of our tumors presented at a high stage and were associated with poor clinical outcomes, with at least muscle-invasive disease (pT2) in 10 of the 14 bladder tumors (71%), periureteric fat invasion in the ureter tumor (pT3), distant metastases in 7 of 16 cases (44%) and death of disease in 3 of the 15 patients with follow-up (20%). Our study describes a series of urothelial carcinomas with trophoblastic differentiation, demonstrating the morphologic spectrum of this entity, its frequent association with other subtypes of variant morphology, its characteristic immunoprofile, and its aggressive clinical behavior.

Ectopic Non-gestational Pure Choriocarcinoma of the Urinary Bladder in a Young Nulliparous Female: A Diagnostic Challenge

Choriocarcinoma can occur at ectopic extragenital locations such as lungs, mediastinum, retroperitoneum, and even in the brain (nongestational choriocarcinoma). Choriocarcinoma arising in the urinary bladder is extremely uncommon with only a few cases reported worldwide. It is important to recognize and give comprehensive diagnosis of this entity, as it has poorer prognosis as compared to the conventional gestational choriocarcinoma and requires stepped-up chemotherapy. Here, we present such a case in a 19-year-old girl and the diagnostic conundrum associated with it.

GATA-3 expression in primary pure choriocarcinoma of the bladder

INTRODUCTION

Primary pure choriocarcinoma of the bladder is extremely rare and should be distinguished from urothelial carcinoma. GATA-3 is a zinc finger transcription factor and a known sensitive immunostaining marker for urothelial carcinoma. However, its accuracy in the detection of urothelial carcinoma is moderate and it is also an important factor in trophoblast differentiation.

CASE PRESENTATION

A 78-year-old man presented with asymptomatic gross hematuria for 6 months. Cystoscopy and clinical imaging revealed local bladder carcinoma. He underwent a radical cystectomy and histological diagnosis revealed pure choriocarcinoma (pT2aN0M0) with positive immunostaining, indicating GATA-3 was present. Systemic chemotherapy could not be applied due to his poor general condition, and he died 7 months after surgery.

CONCLUSION

We reported the first case of pure choriocarcinoma of the bladder, which showed positive immunostaining results indicating the presence of GATA-3.

[Specific types of bladder cancer]

Bladder cancer shows rare variants and special subtypes with diverse prognostic importance and therefore may necessitate different therapeutic approaches. For pathologists it is important to histologically diagnose and specify such variants. Nested variants of urothelial carcinoma with inconspicuous, well-formed tumor cell nests present with an aggressive course. The plasmacytoid variant, which morphologically resembles plasma cells is associated with a shorter survival time and a high frequency of peritoneal metastasis. Micropapillary urothelial carcinoma with small papillary tumor cell islands within artificial tissue retraction spaces and frequent lymphovascular invasion also has a poor prognosis. Other important rare differential variants listed in the World Health Organization (WHO) classification are microcystic, lymphoepithelioma-like, sarcomatoid, giant cell and undifferentiated urothelial carcinomas. Additionally, there are three special types of bladder cancer: squamous cell carcinoma, adenocarcinoma and small cell neuroendocrine carcinoma of the bladder. These tumors are characterized by pure squamous cell or glandular differentiation and are sometimes less responsive to adjuvant (chemo)therapy. Small cell carcinoma of the bladder mimics the neuroendocrine features of its pulmonary counterpart, shows an aggressive course but is sensitive to (neo-)adjuvant chemotherapy. The morphology and histology of the most important variants and special types are discussed in this review.

Primary Choriocarcinoma of the Bladder: A Case Report and Review of Literature

Primary choriocarcinoma of the urinary bladder is a rare entity, and should be distinguished from urothelial carcinoma with trophoblastic differentiation. The leading treatment modalities include surgical extirpation, chemotherapy, and radiation; however, survival remains poor. Herein we describe a rare case of choriocarcinoma of the bladder in a man who presented for evaluation with hematuria and subsequently underwent radical cystectomy with urinary diversion. Diagnosis of extragonadal germ cell tumor was confirmed using fluorescence in situ hybridization identification of isochromosome 12p.

Urothelial carcinoma of the bladder with choriocarcinomatous differentiation A report of two cases and review of the literature

Urothelial carcinoma with choriocarcinomatous differentiation is a rare morphologic variant of bladder cancer, and only a limited number of cases have been reported. We present two cases of bladder cancer with choriocarcinomatous features that had different outcomes. The clinical and pathologic features are reviewed to better understand the natural history of this malignant neoplasm. The histologic features of the tumor were compared between the two cases. Immunoperoxidase staining was performed on the tumor cells with polyclonal beta human chorionic gonadotropin (β-hCG) antibody. A comprehensive literature search revealed an additional 25 confirmed cases, which are summarized in this presentation. Of the 27 patients, only 3 patients were reported to be alive without evidence of disease after treatment. The majority presented with invasive tumors and had a mean survival of 12 months after diagnosis. Chemotherapy, radiation, or radical surgery in advanced stages did not improve survival. Choriocarcinoma in visceral organs usually occurs with high-grade carcinomas and we believe that it is best considered dedifferentiation of the tumor. Urothelial carcinoma with choriocarcinomatous differentiation is an extremely aggressive tumor, and in the rare patient with early stage disease and normal to moderately elevated serum β-hCG levels, long-term survival can be achieved with radical surgery.

Primary choriocarcinoma of the renal pelvis presenting as intracerebral hemorrhage: a case report and review of the literature

Introduction

A choriocarcinoma is a malignant neoplasm normally arising in the gestational trophoblast, gonads and, less frequently, the retroperitoneum, mediastinum and pineal gland. Primary choriocarcinomas of the renal pelvis are extremely rare.

Case presentation

We report a case of primary choriocarcinoma of the renal pelvis in a 38-year-old Greek woman of reproductive age, presenting with a sudden development of intracerebral hemorrhage due to metastatic lesions. The diagnosis was established with a renal biopsy, along with an elevated serum level of beta-human chorionic gonadotropin. An extensive diagnostic work up confirmed the origin of the choriocarcinoma to be the renal pelvis.

Conclusion

Extragonadal choriocarcinomas are rare neoplasms that require extensive laboratory and imaging studies to exclude a gonadal origin. Moreover, this is the first case of severe intracerebral hemorrhage as the initial presentation of primary choriocarcinoma of the renal pelvis. Nonetheless, choriocarcinomas should be considered in the differential diagnosis of women of reproductive age.

Autopsy case of primary choriocarcinoma of the urinary bladder

Choriocarcinomas usually develop in the uterus and ovaries in the female, being extremely rare in the extragenital organs in the male. Extragenital choriocarcinomas in the male usually develop in the mediastinum or retroperitoneum. The frequency of choriocarcinoma in the urinary bladder is extremely low. The purpose of the present paper was to report an autopsy case of choriocarcinoma in the urinary bladder in the male. An 81-year-old male patient with macrohematuria was first diagnosed with transitional cell carcinoma (TCC). At autopsy a hemorrhagic necrotic tumor, which was found in the urinary bladder with metastatic lesions in the lungs, was diagnosed as choriocarcinoma microscopically. There was no evidence for choriocarcinoma derived from any other organs than the urinary bladder, although there were metastatic lesions in both lungs and the direct invasion into the prostate. From these findings it is concluded that the tumor was a primary choriocarcinoma in the urinary bladder in a male patient. Choriocarcinoma of the urinary bladder is very rare, but the prognosis is extremely poor in comparison with TCC even in the urinary bladder. Therefore, it is essential to clearly discriminate between choriocarcinomas and TCC.