Carcinosarcoma of the urinary bladder--an aggressive tumor with diverse histogenesis. A clinicopathologic study of 4 cases and review of the literature

Clinical evolution of bladder carcinosarcoma: A case report and literature review

RATIONALE

Bladder carcinosarcoma (BC) is a malignant tumor composed of a mixture of malignant epithelial and stromal components. Carcinosarcoma mostly occurs in the upper respiratory tract and upper gastrointestinal tract and is less common in the urinary system. The incidence of malignant tumors of the urinary system is <3%. It rarely occurs in the bladder and accounts for approximately 0.31% of all malignant bladder tumors. A literature review and this report will help to further improve our understanding, diagnosis, and treatment of bladder carcinosarcoma (BC).

PATIENT CONCERN

We describe the case of an 80-year-old female patient who was admitted to the hospital with a history of intermittent hematuria for 3 years. Furthermore, total cystectomy was refused when a BC was diagnosed. Palliative resection surgery was necessary because of the recurrent hematuria and abdominal pain.

DIAGNOSES

Pathologically confirmed BC after surgery.

INTERVENTIONS

The patient's first transurethral resection of bladder tumor (TURBT) was diagnosed as BC. However, the patient refused a total cystectomy. Two months after intravesical treatment with epirubicin, bladder tumor recurrence was observed during follow-up cystoscopy. The patient underwent a second TURBT for hemostatic treatment due to persistent hematuria. Due to hematuria and abdominal pain, a third TURBT was performed to reduce tumor size and stop bleeding. Finally, tumor recurrence resulted in bilateral hydronephrosis, and the patient underwent bilateral renal catheter drainage guided by B-ultrasound.

OUTCOMES

Bladder carcinosarcoma caused uremia, electrolyte imbalance, and sepsis. Approximately 19 months after the discovery of the tumor, the patient died.

LESSONS

Radical bladder resection is recommended once a BC is diagnosed. By reporting the cases and reviewing the literature in the database, we will summarize the epidemiology, origin, etiology, clinical features, existing treatments, and prognostic factors of BC, and propose new prospects for BC therapy.

Case Report: Primary low-grade dedifferentiated liposarcoma of the urinary bladder with molecular confirmation

Liposarcomas originating in the urinary bladder are extremely rare. Only six cases of bladder liposarcoma have been reported, and all have been described as myxoid liposarcomas. Notably, none of the patients underwent molecular testing. Here, we report a dedifferentiated liposarcoma (DDL) that occurred in the urinary bladder, primarily in a 69-year-old Chinese woman, with infrequent low-grade dedifferentiation. Computed tomography (CT) revealed an ill-defined solid mass in the anterior bladder wall. The patient underwent a partial bladder resection. Histologically, the tumor cells with mild-to-moderate nuclear atypia were arranged in fascicular and storiform patterns, mimicking a low-grade fibroblastic tumor. In addition, scattered small foci of typical lipoma-like well-differentiated components were identified. Immunohistochemically, the tumor tested positivity for MDM2, CDK4, and p16. Fluorescence in situ hybridization revealed MDM2 gene amplification in the neoplastic cells. Whole-exome sequencing showed that this tumor also harbored CDK4, TSPAN31, and JUN amplification. At the latest follow-up (85 months after surgery), the patient was alive, with no evidence of disease. To the best of our knowledge, this is the first example of a molecularly confirmed primary bladder liposarcoma and the first case of DDL at this site.

A spontaneous thymic carcinosarcoma in a young Sprague Dawley rat

We encountered a case of spontaneous thymic carcinosarcoma in a young Crl:CD (Sprague Dawley) rat. Grossly, a white multinodular mass replaced the thymus in the thoracic cavity. Histologically, multiple nodules were separated by fibrous stroma, and each nodule included isolated regions that were composed of epithelial or non-epithelial tumor cells. The epithelial tumor cells were relatively large and round to polygonal cells with large nuclei and weakly eosinophilic cytoplasm. These cells were cytokeratin-positive and vimentin-negative. These cells infiltrated the lungs. The non-epithelial tumor cells were poorly differentiated, small, round to spindle-shaped cells with small nuclei and basophilic cytoplasm. These cells were vimentin-positive and mostly cytokeratin-negative. Many islands of cartilage were observed near non-epithelial cells. Based on these findings, the tumor was diagnosed as a primary thymic carcinosarcoma consisting of a malignant thymoma composed of epithelial tumor cells and a mesenchymal chondrosarcoma composed of non-epithelial tumor cells.

Sarcomatoid carcinoma of the urinary bladder: analysis of five cases and literature review

Sarcomatoid carcinomas of the bladder represent a tiny part of bladder tumors and are characterized by a high potential for malignancy. Very aggressive and affecting mainly men, these tumors present both a urothelial and sarcomatoid contingent. The treatment of these tumors is not well codified given the rarity of cases reported in the literature, however, it seems that the treatment is essentially based on radical cystectomy with extensive pelvic lymph node dissection. We report the experience of our departement in the management of this type of tumor in a series of five cases collected over a period of 8 years.

A Large Carcinosarcoma of the Gallbladder Accompanied by Pancreaticobiliary Maljunction: A Case with a Six-year Survival

Pancreatobiliary maljunction (PBM) is a rare congenital malformation, often associated with adenocarcinoma. However, PBM accompanying gallbladder carcinosarcoma has rarely been reported. A 72-year-old woman was referred to our hospital, complaining of abdominal pain. Computed tomography showed a polypoid mass in the gallbladder. Endoscopic retrograde cholangiopancreatography showed PBM, and aspirated bile demonstrated elevated levels of pancreatic-type amylase (26,780 U/L) and cancer cells. Extended cholecystectomy was performed. Histologically, the tumor had adenocarcinoma, squamous cell carcinoma and sarcoma components. Despite the large tumor size (84 mm) and intra-vessel cancer permeations, this patient has been healthy for 73 months since the surgery.

Urinary bladder carcinoma with divergent differentiation featuring small cell carcinoma, sarcomatoid carcinoma, and liposarcomatous component

Both small cell carcinoma and sarcomatoid carcinoma of the urinary bladder are highly aggressive tumors, and a concurrence of these tumors is extremely rare. We report a case of urinary bladder cancer with small cell carcinoma as a predominant component, accompanied by sarcomatoid carcinoma and conventional urothelial carcinoma (UC). Although the small cell carcinoma component had resolved on receiving chemoradiotherapy, rapid growth of the residual tumor led to a fatal outcome. A 47-year-old man presented with occasional bladder irritation and had a 2-year history of asymptomatic hematuria. Cystoscopy revealed a huge mass in the urinary bladder, and transurethral resection was performed. Microscopically, small cell carcinoma was detected as the major tumor component. Spindle-shaped sarcomatoid cells were also observed that were intermingled with small cell carcinoma and conventional UC. In addition, a sheet-like growth of the lipoblast-like neoplastic cells was observed focally. Initially, by providing chemoradiotherapy, we achieved a marked tumor regression; however, the tumor rapidly regrew after the completion of chemoradiotherapy, and the patient underwent radical cystectomy. Only conventional UC and sarcomatoid carcinoma were identified in the cystectomy specimen. The patient died of the disease 4 months after cystectomy. Urinary bladder cancer may include a combination of multiple aggressive histologies as in the present case. Because the variation in the tumor components may affect the efficacy of therapy, a correct diagnosis of every tumor component is necessary.

Canine Carcinosarcomas in the Head

Four cases of neoplasms in the heads of old dogs were studied. All the dogs showed both carcinomatous and sarcomatous malignant components in an admixed growing pattern. Histologic analysis of the tumors showed that the carcinomatous cells resembled squamous cell carcinoma in all dogs except one, where an adenoid arrangement of the neoplastic cells was also observed. The sarcomatous component showed osteoid matrix produced by pleomorphic poorly differentiated cells, which is regarded as a typical feature of osteosarcomas. Immunohistochemical analysis demonstrated that the components were positive only for cytokeratin (carcinomatous component) or vimentin (sarcomatous component). This observation led us to classify the neoplasms as true carcinosarcomas, thus providing evidence of a new preferential location for this unusual tumor in dog.

Bladder preserving approach for liposarcomatoid variant of transitional urothelial carcinoma

Urothelial carcinoma of the bladder with variant histologies is usually underdiagnosed and understaged. It is found in <25% of cases during transurethral resection of bladder tumours. The majority of cases carry a worse prognosis, with higher rates of recurrence and progression, and should be managed aggressively. Here, we report a rare case of liposarcomatoid variant of urothelial carcinoma managed by partial cystectomy and standard pelvic lymph node dissection.

Carcinosarcoma of the ureter with a small cell component: report of a rare pathologic entity and potential for diagnostic error on biopsy

Carcinosarcomas of the ureter are rare biphasic neoplasms, composed of both malignant epithelial (carcinomatous) and malignant mesenchymal (sarcomatous) components. Carcinosarcomas of the urinary tract are exceedingly rare. We report a unique case of a carcinosarcoma of the ureter with a chondrosarcoma and small cell tumor component arising in a 68-year-old male who presented with microscopic hematuria. CT intravenous pyelogram revealed right-sided hydroureter and hydronephrosis with thickening and narrowing of the right ureter. The patient underwent robot-assisted ureterectomy with bladder cuff excision and subsequent adjuvant chemotherapy. The patient is disease-free at 32 months after treatment. We provide a brief synoptic review of carcinosarcoma of the ureter and bladder with utilization of immunohistochemical (IHC) stains and potential diagnostic pitfalls.

Micropapillary bladder cancer: current treatment patterns and review of the literature

OBJECTIVES

No guidelines exist for the management of micropapillary bladder cancer (MPBC) and most reports of this variant of urothelial carcinoma are case series comprising small numbers of patients. We sought to determine current practice patterns for MPBC using a survey sent to the Society of Urologic Oncology (SUO) and to present those results in the setting of a comprehensive review of the existing literature.

MATERIALS AND METHODS

A survey developed by the Translational Science Working Group of the Bladder Cancer Advocacy Network-sponsored Think Tank meeting was distributed to members of the SUO. The results from 118 respondents were analyzed and presented with a literature review.

RESULTS

Most survey respondents were urologists, with 80% considering bladder cancer their primary area of interest. Although 78% of the respondents reported a dedicated genitourinary pathologist at their institution, there were discrepant opinions on how a pathologic diagnosis of MPBC is determined as well as variability on the proportion of MPBC that is clinically significant. Among them, 78% treat MPBC differently than conventional urothelial carcinoma, with 81% reporting that they would treat cT1 MPBC with upfront radical cystectomy. However, the respondents had split opinions regarding the sensitivity of MPBC to cisplatin-based chemotherapy, which affected utilization of neoadjuvant chemotherapy in muscle-invasive disease.

CONCLUSIONS

The management of MPBC is diverse among members of the SUO. Although most favors early cystectomy for cT1 MPBC, there is no consensus on the use of neoadjuvant chemotherapy for muscle-invasive MPBC.

Diagnosis and treatment of carcinosarcoma of the renal pelvis: A case report

Carcinosarcoma is a rare type of renal pelvis malignancy, the diagnosis of which requires the presence of malignant epithelial and mesenchymal components. The prognosis of this disease is extremely poor due to its rapid progression and widespread metastases. The present study describes a case of carcinosarcoma involving the right renal pelvis in a 73-year-old female who presented with intermittent hematuria and right-flank pain that had persisted for one month. Computed tomography revealed a 2.4×2.5 cm mass in the right renal pelvis, which was diagnosed as a right renal pelvic tumor. Laparoscopic radical resection of the right kidney and ureter was performed. Following surgery, immunohistochemical analysis showed positive reactions for epithelial and mesenchymal markers. Based on these findings, the patient was diagnosed with carcinosarcoma. Thus, immunohistochemical analysis is a critical method for the accurate diagnosis of carcinosarcoma.

Rhabdomyosarcoma with pseudolipoblasts arising in ovarian carcinosarcoma: a distinctive postchemotherapy morphologic variant mimicking pleomorphic liposarcoma

We describe a case of ovarian carcinosarcoma occurring in a 60-year-old female. The neoplasm was excised after neoadjuvant chemotherapy and contained a predominant heterologous pleomorphic rhabdomyosarcomatous component in which there were numerous multivacuolated rhabdomyoblasts that strongly mimicked lipoblasts. The clear cell variant of rhabdomyosarcoma is rarely documented, but this case shows a highly unusual finding in which the rhabdomyoblasts show the prominent multivacuolation with nuclear indentation characteristic of and indistinguishable from pleomorphic lipoblasts. This appears to represent a posttreatment phenomenon. As this finding might conceivably occur in other rhabdomyosarcomas after chemotherapy, we highlight the potential for diagnostic confusion with pleomorphic liposarcoma, which is usually diagnosed by morphology so that immunohistochemistry for muscle markers might not be performed.

Micropapillary variant of urothelial carcinoma

Micropapillary carcinoma (MPC) of urinary tract is an uncommon variant of urothelial carcinoma with significant diagnostic and prognostic implications. Though MPC shows characteristic microscopic features, there exists interobserver variability and also it needs to be differentiated from the metastasis from other organs. The prognosis is generally poor, depending on the proportion of the micropapillary component in some reports. Early cystectomy in cases with only lamina propria invasion may be indicated according to recent studies. This review outlines the general features of this entity and briefly comments on the controversies and the recent development.

A Case Report of Urinary Bladder Carcinosarcoma and Review of the Literature

Carcinosarcoma of the bladder is an unusual tumour characterized by a combination of malignant epithelial and soft tissue elements. Most of the reported cases have been case reports or small series. Optimal treatment is uncertain. We herein report our experience in such a case treated with transurethral resection followed by radiotherapy with adverse final outcome. Treatment of bladder carcinosarcomas should be aggressive and multimodal but optional treatment is still unknown. Radiotherapy alone is insufficient as a treatment option of these aggressive tumors.

Emerging concepts in micropapillary urothelial carcinoma

Micropapillary urothelial carcinoma is a relatively uncommon variant of urothelial carcinoma, but its recognition carries important prognostic and treatment implications. Micropapillary morphology occurs in neoplasms arising in many different organ systems and displays aggressive biologic behavior regardless of its site of origin. On account of this association, micropapillary features in urothelial carcinoma should be reported regardless of whether the pattern is focal or dominant. The overall prognosis for micropapillary urothelial carcinoma is poor and recent studies suggest that early treatment with cystectomy could improve outcome, as these tumors are unlikely to respond to chemotherapy when used as a secondary treatment modality. This review discusses the histologic features required for diagnosis and the clinical significance of rendering a diagnosis of micropapillary urothelial carcinoma.

Renal carcinosarcoma: case report and review of literature

Carcinosarcoma is a malignancy that occurs very rarely in the renal pelvis, and only a very limited number of cases has been documented. These tumors are composed of both malignant mesenchymal and epithelial elements. Unlike the cases described so far, this carcinosarcoma of the renal pelvis was characterized by quick recurrence, following complete surgical resection. Carcinosarcomas of the renal pelvis are known to be rapid in progression and associated with a poor prognosis. They usually metastasize soon after surgery, but very little information is available on the histologic types that characterize the recurrent tumors. We presented a histologically proven case of renal carcinosarcoma extending from renal pelvis. Convalescence was uneventful, and fifteen months after the operation, he is alive with no recurrence or metastasis. If a rapidly growing tumor is detected that seems to originate from the kidney with extension to ureter and bladder, carcinosarcoma should be included in the differential diagnosis.

Differences in survival among patients with sarcomatoid carcinoma, carcinosarcoma and urothelial carcinoma of the bladder

PURPOSE

Sarcomatoid carcinoma and carcinosarcoma of the bladder are rare tumors that contain epithelial and mesenchymal elements, and may portend a worse prognosis than conventional urothelial carcinoma. We investigated the survival of patients with the 2 tumor subtypes compared to survival in those with urothelial carcinoma.

MATERIALS AND METHODS

Cases of sarcomatoid carcinoma, carcinosarcoma and high grade urothelial carcinoma of the bladder were identified from the Surveillance, Epidemiology and End Results Program. Demographic and pathological characteristics were compared. Differences in survival based on histological subtype were estimated using Kaplan-Meier analysis and multivariate Cox proportional hazards regression.

RESULTS

Overall unadjusted survival rates for 46,515 patients with urothelial carcinoma, 135 with sarcomatoid carcinoma and 166 with carcinosarcoma were 77%, 54% and 48% at 1 year, and 47%, 37% and 17% at 5 years, respectively. Sarcomatoid carcinoma and carcinosarcoma presented at a similar age but at a higher T stage and with more frequent regional and distant metastases compared to urothelial carcinoma. On multivariate analysis patients with sarcomatoid carcinoma (HR 1.18, 95% CI 0.91-1.52) and carcinosarcoma (HR 2.00, 95% CI 1.65-2.41) were at higher risk for death compared to those with urothelial carcinoma. Overall mortality was worse with carcinosarcoma than with sarcomatoid carcinoma (HR 1.70, 95% CI 1.23-2.34).

CONCLUSIONS

Compared to patients with urothelial carcinoma those with sarcomatoid carcinoma and carcinosarcoma present at a more advanced stage and are at greater risk for death even after adjusting for stage at presentation. The survival rate of sarcomatoid carcinoma is better than that of carcinosarcoma, offering some justification for the continued differentiation of these tumor types for clinical prognostication.

Clinical and therapeutic significance of aberrant differentiation patterns in bladder cancer

Pure urothelial carcinoma makes up 90-95% of all bladder cancer. The remaining 5-10% represent urothelial carcinoma with aberrant differentiation patterns and nonurothelial carcinoma. Reviews on this topic often focus on the pathological features of these histologic subtypes. In this review we have summarized the clinical significance of each major histologic pattern and analyzed the response of each to standard treatment modalities. The main limitation to optimizing management is the inability to perform clinical trials owing to the rarity of these tumors. This can be circumvented to some degree by extrapolating knowledge acquired from more common similar tumors in other organ sites. Ultimately, however, multicenter clinical trials will need to be organized to address some key management issues.

Histologic Variants of Infiltrating Urothelial Carcinoma

Context.—The spectrum of urothelial carcinoma is broad, and variant morphologies are being reported continually. Many of these variants have been extensively documented and even established as subclasses of urothelial carcinoma.

Objective.—To review the established and more recently described variants of urothelial carcinoma. The significance of recognizing these variants is discussed.

Data Sources.—The literature is reviewed in conjunction with our experience pertaining to urothelial carcinomas of the bladder and ureters.

Conclusions.—Urothelial carcinoma displays many forms, and some of these variant morphologies may introduce diagnostic difficulties because of their similarity to other malignancies and/or benign lesions. Additionally, it is important to recognize variants that are associated with different outcomes from conventional urothelial carcinoma. For these reasons, familiarity with the diverse morphology of urothelial carcinoma is not simply an academic exercise but is important in providing quality care for patients affected by this disease.

Primary Cutaneous Metaplastic Carcinoma: Report of a Case Involving Angiosarcoma

Primary cutaneous metaplastic carcinoma is an uncommon cutaneous malignancy comprising a mixture of epithelial and mesenchymal components. The former is most frequently a squamous cell or basal cell carcinoma, and the latter is most typically a pleomorphic sarcoma or atypical fibroxanthoma. We describe the first primary cutaneous metaplastic carcinoma with angiosarcoma as the mesenchymal component arising on the scalp of a 90-year-old woman.

Lipoid-cell Variant of Urothelial Carcinoma: A Clinicopathologic and Immunohistochemical Study of Five Cases

Invasive urothelial carcinoma may present with many deceptive morphologic variants. We report the clinicopathologic and immunohistochemical features of 5 cases of the so-called lipid-cell variant of urothelial carcinoma. The tumors occurred in 4 men and 1 women aged from 56 to 80 years. Four cases were developed in the bladder and 1 case in the renal pelvis. All cases were revealed by a macroscopic hematuria. The tumors were composed of sheets and nests of large epithelial cells with an abundant clear multivacuolated cytoplasm mimicking lipoblasts. Nuclei were irregular, hyperchromatic, eccentric, and frequently indented by cytoplasmic vacuoles. Mucin stains (PAS, Alcian Blue) were negative. Tumor cells were strongly stained with cytokeratin 7, cytokeratin 20, and EMA but were negative with S-100 protein. In all cases, a usual high-grade urothelial carcinoma component was admixed with lipoid tumor cells. Two tumors infiltrated the bladder muscle, 2 cases invaded the bladder submucosa, and 1 case invaded the renal parenchyma. In the follow-up, despite appropriate surgical treatment, 4 patients died of the disease and 1 patient is alive without recurrence. Because of its rarity and the tumor cells' appearance, the lipoid-cell variant may be misdiagnosed and must be distinguished from liposarcoma or signet-ring cell carcinoma. In the present series, the lipoid-cell variant of urothelial carcinoma was associated with an aggressive behavior and a poor prognosis.

Histogenesis of sarcomatoid urothelial carcinoma of the urinary bladder: evidence for a common clonal origin with divergent differentiation

The histogenesis of sarcomatoid urothelial carcinoma, a rare neoplasm with bidirectional epithelial and mesenchymal differentiation, has been a matter of controversy. To clarify its origin, we analysed the status of X-chromosome inactivation in sarcomatoid urothelial carcinomas from 10 female patients and examined losses of heterozygosity (LOH) in these specimens and in additional 20 tumours from male patients. Six polymorphic microsatellite markers where genetic alterations occur frequently in early or advanced stages of urothelial carcinomas, including D3S3050, D8S261, IFNA, D9S177, D11S569 and TP53, were investigated in the current study. The identical pattern of non-random X-chromosome inactivation in both carcinomatous and sarcomatous components was identified in five of eight informative female patients, and the remaining three informative cases showed a random, but concordant, pattern of X-chromosome inactivation. The concordant X-chromosome inactivation results in all eight informative cases support the concept of a monoclonal origin of both components of this biphasic neoplasm. Among the tumours demonstrating loss of heterozygosity, high incidences of an identical pattern of allelic loss between carcinomatous and sarcomatous components were identified in genetic alterations associated with early carcinogenesis: 86% at D8S261, 78% at D11S569, 75% at D9S177 and 57% at IFNA. In contrast, concordant LOH patterns were less frequently observed for microsatellites related to advanced carcinogenesis: only 40% at D3S3050 and 40% at TP53. The significant overlap of loss of heterozygosity supports a monoclonal cell origin and suggests that clonal divergence may occur during tumour progression and differentiation. Divergent patterns of discordant allelic loss of microsatellite markers imply that heterogeneous pathogenetic pathways may exist in the evolution of this enigmatic neoplasm.

Lung carcinosarcoma with liposarcoma element: Autopsy case

Pulmonary carcinosarcoma, consisting of both carcinoma and sarcoma with a heterologous element, is a rare subtype, comprising approximately 0.3% of primary lung neoplasia. A 57-year-old man was admitted because of severe dyspnea. A tumor wholly occupying the right thorax was biopsied and diagnosed as pleomorphic sarcoma. The tumor did not respond to chemotherapy, and the patient died of respiratory failure and sepsis. At autopsy, pleomorphic sarcoma was histologically dominant and contained a liposarcoma element confirmed by histocytological and electron microscopic analysis. Adenocarcinoma component with papillary and tubular patterns was confined to the medial lesion of the right lower lobe (3x8 cm), which was found in the chest X-ray 3 years before admission, and had continuously merged with the sarcomatous lesion through the histological transition of both components. Aggressive and rapid growth of the sarcoma derived from the earlier adenocarcinoma became prevalent and contributed to the severe clinical outcome. This is the first documented case of primary lung carcinosarcoma with a liposarcoma element.

Invasive micropapillary carcinoma of the urinary bladder: An immunohistochemical study of neoplastic and stromal cells

A 66-year-old man complained of hematuria. A cystoscopy revealed a non-papillary tumor and radical cystectomy was performed. Macroscopically, an ulcerative lesion was observed. Microscopically, the neoplasm showed a mixture of urothelial carcinoma, squamous cell carcinoma and micropapillary carcinoma. Immunohistochemically, micropapillary carcinoma cells were positive for cytokeratins 7 and 20, carcinoembryonic antigen and CA125. Additionally, myofibroblasts were distributed in a chicken-wire pattern in the stroma of micropapillary carcinoma. Subsequently, the patient died of carcinoma 1 year after the onset of symptoms. Our results support the previous hypothesis that bladder micropapillary carcinoma runs an aggressive clinical course and suggest that micropapillary carcinoma may show the glandular differentiation of urothelial carcinoma and show the stromal reaction by myofibroblasts resembling that of carcinoma in other anatomic sites.

Gemcitabine and cisplatin following surgical treatment of urinary bladder carcinosarcoma

The clinical case of a 73-year-old man with a history of transitional cell carcinoma of the bladder, an ulcerated mass on the left hemitrigone and left hydronephrosis who underwent radical cystoprostatectomy and urinary diversion followed by cisplatin-gemcitabine chemotherapy is presented. Pathological examination revealed a biphasic mixed tumor characterized by an epithelial and a mesenchymal component. At 24 months of follow-up the patient is alive and free from recurrent disease, with good quality of life and preserved renal function. Carcinosarcoma is highly aggressive and often has a dismal outcome regardless of treatment. Among all the studied prognostic factors, pathological stage is the main predictor of survival. The outcome of our patient suggests that the relatively well tolerated gemcitabine-cisplatin regimen after surgical treatment of invasive carcinosarcoma of the bladder might improve the currently dismal prognosis of selected elderly patients.

Carcinoma micropapilar de vejiga: aportación de un caso y revisión de la bibliografía

Micropapillary carcinoma is an uncommon pathologic variant of bladder carcinoma with aggressive behavior. Its usual presentation is like a high grade and high stage carcinoma and associated with other histologic types in different proportion. It doesn't differ clinically from normal transitional cell carcinoma of the bladder. Studies of molecular markers are still contradictories. Treatment should be early and aggresive, based on surgical therapy as radiotherapy and chemotherapy have shown limited results. We report a 72 year old man suffering from low urinary tract symptoms for years and recently presented gross hematuria. He was diagnosed as high stage micropapillary carcinoma. One year after radical cystectomy and subsequent chemotherapy based on carboplatin and gemcitabine, progression of the disease was shown on CT and the patient died 14 months after the diagnosis.

[Carcinosarcoma of the bladder: report of our cases and review of the literature]

Carcinosarcomas of the bladder are rare. As a result, the natural history of them and the best methods of treatment remain uncertain. These tumors tend to be rapidly growing, invasive and recur locally. We reviewed our experience with four patients presenting between 1995 and 2002. Epidemiology findings, clinical aspects, histological features, diagnostic methods, treatment and survival are discussed in relation to literature.

Carcinosarcoma of the renal pelvis and urinary bladder: a case report

Carcinosarcomas are rare biphasic malignant neoplasms with an epithelial and a spindle cell component. We present a 62-year-old man with a history of noticeably abdominal distension, proved by surgery to be caused by carcinosarcoma of the renal pelvis and urinary bladder, occupying the entire left abdominal flank. We also illustrate the appearance of this rare entity on sonography and computed tomography.

Carcinosarcoma with a large cell neuroendocrine epithelial component: first report of an unusual biphasic tumour of the urinary bladder

This article describes the first reported case of carcinosarcoma of the urinary bladder with a large cell neuroendocrine epithelial component. A 61 year old man presented with gross haematuria and underwent resection of a biphasic bladder tumour. The malignant epithelial component showed large cell neuroendocrine differentiation with immunohistochemical reactivity for neurone specific enolase, synaptophysin, and chromogranin. The malignant mesenchymal component did not show specific differentiation by histological or immunohistochemical examination. The differential diagnosis of biphasic tumours in the urinary bladder is discussed, along with a review of the literature.

Carcinosarcoma of the urinary bladder following cyclophosphamide therapy: evidence for monoclonal origin and chromosome 9p allelic loss

We report a case involving a 45-year-old man with a 12-year history of Wegener granulomatosis, who developed a carcinosarcoma of the urinary bladder after long-term cyclophosphamide therapy. Cyclophosphamide is well recognized as an etiologic agent for urothelial carcinoma of the urinary bladder. However, only 5 cases of carcinosarcoma of the urinary bladder following cyclophosphamide therapy have been reported. We used loss of heterozygosity studies and microsatellite markers to define the molecular basis of this rare neoplasm. These studies revealed evidence supporting a monoclonal origin for the 2 components of this tumor. We also demonstrated allelic loss of chromosome 9p. This loss associated with carcinosarcoma of the urinary bladder is in agreement with previous studies, suggesting a possible role for the tumor suppressor gene p16 in the pathogenesis of this tumor.

[Bladder carcinoma with osteoclast-type giant cells. A case with a rare presentation. Review of the literature]

We report a case of neoplasm of the urinary bladder with pseudosarcomatous stromal differentiation. Heterologous carcinosarcomas are extremely rare malignant neoplasms (seventy-eight cases have been previously described). This is a case of carcinoma containing numerous osteoclast type giant cells that stained for vinmentin and acid phosphatase and were negative for cytokeratin and lysozyme.

A carcinosarcoma/sarcomatoid carcinoma arising in a urinary bladder diverticulum

We describe an invasive polypoid carcinosarcoma/sarcomatoid carcinoma arising within a urinary bladder diverticulum in a 65-year-old patient with synchronous, moderately differentiated prostatic adenocarcinoma. Histologically, the diverticular tumor exhibits an admixture of different morphologic components, including invasive high-grade urothelial carcinoma, malignant glandular structures in a cellular background of malignant spindle cells, and areas formed exclusively by spindle and pleomorphic cells. There was full-thickness involvement of the diverticulum with extension of the tumor into the perivesical fat and ipsilateral seminal vesicle. In view of the early invasive behavior of carcinosarcoma/sarcomatoid carcinoma combined with the paucity of the muscular layer in the diverticulum wall, a graver prognosis was expected for this aggressive tumor that occurred in this unusual site.