Small cell carcinoma of the ovary presenting in a urine cytology specimen: a case report

BACKGROUND

Small cell carcinoma (SMCC) is rarely diagnosed in urine specimens. Cytologically, this tumor is similar to pulmonary SMCC. However, clinicopathologic correlation may be required to differentiate between primary urinary bladder SMCC and metastatic SMCC from a remote primary or secondary bladder involvement by direct extension of the tumor from nearby organs (prostate, uterus, or ovary). A unique case of a rare pulmonary-type ovarian SMCC, the tumor cells of which were detected in a voided urine specimen, is described herein.

CASE

A 79-year-old female presented to the urologic clinic with a history of metastatic SMCC of unknown primary with hematuria. The voided urine specimen examination revealed tumor cells cytomorphologically consistent with small cell neuroendocrine carcinoma. Following cytologic diagnosis, cystoscopic examination and bladder biopsy were performed. The histopathology revealed a widely invasive tumor with a morphology typical of SMCC. The overlying urothelium was unremarkable. By immunohistochemistry, tumor cells were found positive for neuroendocrine markers, EMA and WT-1. The morphologic and immunohistochemical features of the tumor were most consistent with urinary bladder involvement by pulmonary-type primary ovarian SMCC.

CONCLUSION

It is justified to think that SMCC cell detection in urine specimens does not necessarily imply their origin from primary bladder malignancy. Performing additional studies may be prudent in order to exclude secondary involvement of the bladder in this tumor as the correct diagnosis has significant clinical implications.

Evidence for elevated telomerase activity in small cell carcinoma of the bladder

Telomerase activity was found to be elevated using a quantitative assay on snap-frozen protein extracts of exfoliated cells in urine and bladder washings and tumor tissue obtained from a male patient with small cell carcinoma of the bladder. To the best of our knowledge, this is the first demonstration of elevated values of telomerase activity in genitourinary small cell carcinoma and is in keeping with the findings in primary lung locations.

Small cell carcinoma of the bladder. Two cases diagnosed by urinary cytology

BACKGROUND

Primary small cell carcinoma (SCC) of the bladder is a rare but important entity. We report two cases of SCC of the bladder diagnosed by urinary cytology.

CASES

A 71-year-old male (case 1) and a 79-year-old female (case 2) presented with asymptomatic gross hematuria. Urinary cytology in case 1 showed the presence of a few undifferentiated malignant small cells and many transitional cell carcinoma (TCC) cells with a bloody and necrotic background. The former cells were small and round, with naked, hyperchromatic nuclei and finely granular chromatin. Pathologic diagnosis after total cystectomy was TCC > SCC > adenocarcinoma, T2M0N0. Urinary cytology of case 2 showed the presence of many undifferentiated malignant small cells and many TCC cells with or without squamous metaplasia. Cytologic features of the former cells were almost the same as those in case 1. Moreover, these cells were neuroendocrine marker positive by immunocytochemistry. Pathologic diagnosis after tumor resection was SCC and TCC > squamous cell carcinoma, T1b.

CONCLUSION

The prognosis of primary SCC of the bladder is usually poor. Because our cases were found by urinary cytology at a relatively early stage, both have been well, without any evidence of recurrence, 30 and 25 months after surgery even without adjuvant therapy.

Cytologic diagnosis of a primary pure oat cell carcinoma of the bladder in voided urine. A case report

BACKGROUND

The urinary bladder is an uncommon site for primary oat cell carcinoma, with as few as 30 histologically diagnosed cases described in the literature. The first reported cytologic diagnosis was made in 1991.

CASE

A 76-year-old female presented with gross hematuria. Voided urine cytology showed small, dark cells with little visible cytoplasm and coarse chromatin. Subsequent histopathologic, immunopathologic and electron microscopic studies confirmed the diagnosis of primary oat cell carcinoma.

CONCLUSION

The diagnosis of oat cell carcinoma is well recognized in respiratory cytology. The same cells found in a urinary specimen may suggest a primary oat cell tumor in conjunction with negative clinical and radiologic investigations for a primary tumor elsewhere.

Biomarker evidence of DNA oxidation in lung cancer patients: association of urinary 8-hydroxy-2'-deoxyguanosine excretion with radiotherapy, chemotherapy, and response to treatment

Ratios of urinary 8-hydroxy-2'-deoxyguanosine to urinary creatinine (8-OHdG/creatinine) have been considered as a good biological indicator of DNA oxidation. Urinary 8-OHdG/creatinine levels of lung cancer patients were evaluated by enzyme-linked immunosorbent assay using a monoclonal antibody N45.1 during radiotherapy and chemotherapy. An increase in urinary 8-OHdG/creatinine was found in non-small-cell carcinoma (non-SCC) patients during the course of radiotherapy. SCC patients showed higher levels of urinary 8-OHdG/creatinine than the controls. Furthermore, SCC patients with complete or partial response to the chemotherapy showed a significant decrease in urinary 8-OHdG/creatinine while patients with no change or progressive disease showed an increase.

Urinary excretion of ifosfamide, 4-hydroxyifosfamide, 3- and 2-dechloroethylifosfamide, mesna, and dimesna in patients on fractionated intravenous ifosfamide and concomitant mesna therapy

The oxazaphosphorine antineoplastic ifosfamide (IF) is metabolized by two different initial pathways: ring oxidation ("activation"), forming 4-OH-IF ("activated IF"), and side-chain oxidation with liberation of chloroacetaldehyde (CAA), forming the inactive metabolites 3-dechloroethylifosfamide or 2-dechloroethylifosfamide (3-DCE-IF, 2-DCE-IF). 4-OH-IF and 4-OH-IF-derived acrolein are thought to be responsible for IF-induced urotoxicity (hemorrhagic cystitis), whereas CAA may be involved in IF-associated nephrotoxicity (renal tubular damage). The thiol compound 2-mercaptoethane sulfonate sodium (mesna) has proved to inactivate sufficiently the urotoxic metabolites of oxazaphosphorine cytostatics and is therefore routinely given to patients receiving IF chemotherapy. The cumulative urinary excretion of IF, 4-OH-IF, 3-DCE-IF, 2-DCE-IF, mesna, and its disulfide dimesna was studied in 11 patients with bronchogenic carcinoma receiving IF on a 5-day divided-dose schedule (1.5 g/m2 daily) with concomitant application of mesna (0.3 g/m2 at 0,4, and 8 h after IF infusion). On day 1 the mean cumulative 24-h urinary recoveries (percentage of the IF dose) recorded for IF, 4-OH-IF, 3-DCE-IF, and 2-DCE-IF were 13.9%, 0.52%, 4.8%, and 1.5%, respectively. On day 5 the corresponding values were 12.2%, 0.74%, 9.9%, and 3.6%, respectively. This time-dependent increase in urinary excretion of IF metabolites, which is caused by rapid autoinduction of hepatic oxidative metabolism, may result in a higher probability for the development of urotoxic and nephrotoxic side effects during prolonged IF application. The mean 24-h urinary recoveries (percentage of the daily mesna dose) recorded for mesna/dimesna on day 1 (day 5) were 23.8%/45.2% (21.2%/39.8%), respectively. The mean molar excess of urinary reduced ("free") mesna over 4-OH-IF ranged from 11 to 72 on day 1 and from 6 to 40 on day 5. This indicates that although urinary excretion of 4-OH-IF rises with repeated IF application, mesna in standard doses should sufficiently inactivate the urotoxic IF metabolites.

Undifferentiated small-cell carcinoma of the urinary bladder: report of two cases with a primary urinary cytodiagnosis

Two undifferentiated small-cell carcinomas of the urinary bladder are reported. The patients, 68- and 55-yr-old men, respectively, presented with painless hematuria. In the first case, numerous small, lymphocyte-like cells with coarse chromatin, sometimes with small nucleoli, and high nuclear/cytoplasmatic ratios were found in cytologic urine specimens. A cytodiagnosis of undifferentiated small-cell cancer was made. In the second case, urine samples showed rare aggregates of small, undifferentiated cells in association with malignant urothelial cells. The cytodiagnosis of mixed tumor composed of undifferentiated small cell and transitional carcinoma was confirmed by histologic examination. The presence of focal reactivity with anti-chromogranin antibody and neurosecretory granules via electron microscopy supports a neuroendocrine differentiation for the small neoplastic cells. The patients died 13 and 8 mo after diagnosis, respectively.

Small cell anaplastic carcinoma of the prostate: report of a case with positive urine cytology

A case of small-cell anaplastic carcinoma of the prostate, occurring in an 82-year-old man with prior prostatic adenocarcinoma, is reported. The exfoliated tumor cells in the urine were seen singly or in loose aggregates with molding. They showed scant cytoplasm and slightly pleomorphic, hyperchromatic nuclei with inconspicuous nucleoli. By electron microscopy the tumor consisted of primitive epithelial cells without glandular or neuroendocrine differentiation. The tumor pursued a highly aggressive course, and the patient died of metastatic disease 4 mo after the diagnosis.

Primary urinary cytodiagnosis of a bladder small-cell carcinoma

A small-cell undifferentiated tumor of the bladder in a 69-yr-old man with asymptomatic hematuria is described. Urine cytology showed abundant, small, round-to-oval hyperchromatic cells with coarse chromatin, nuclear molding, and high nuclear/cytoplasmic ratios. A primary cytodiagnosis of small-cell undifferentiated cancer with associated severe urothelial atypia was made. Immunohistochemical stains were negative for neuron-specific enolase, leukocyte common antigen, chromogranin, epithelial membrane antigen, prostatic acid phosphatase, and prostate-specific phosphatase. The diagnosis was confirmed histologically by studies performed on cystoscopic bladder biopsy material.

A human inhibitor of tumor necrosis factor alpha

Urine of some febrile patients exhibits a TNF-alpha inhibitory activity (TNF-alpha INH), sensitive to heat and trypsin, with an apparent mol wt of 40-60 X 10(3) and a pI range of 5.5-6.1. As for the Il-1 INH, the TNF INH activity involves a competitive mechanism of action suggesting the existence of a family of negative feedback-regulating molecules interfering with cytokines actions.

Hypouricemia and urate excretion in small cell lung carcinoma patients with syndrome of inappropriate antidiuresis

Urate concentrations in serum and renal urate clearance were prospectively evaluated in patients with small cell lung cancer (SCLC). Serum urate and renal urate clearance were measured before and during cytostatic treatment until disease progression (PD) in 12 patients with the syndrome of inappropriate antidiuresis (SIAD) and in 8 patients without. Hypouricemia occurred in 4 SIAD patients before treatment and also when tumor regression was obtained. Two normouricemic SIAD patients developed hypouricemia when PD occurred. No patient without SIAD experienced hypouricemia. Serum urate in patients with SIAD was lower than in those without SIAD before cytostatic treatment but not 3 months after the treatment. Hypouricemic patients had higher urate clearance than normouricemic and it remained higher even after tumor regression. Serum urate was invalid as marker of tumor regression or relapse. SIAD patients have higher glomerular filtration rates than patients without SIAD, which may influence the renal excretion of cytostatic drugs.

Urinary pseudouridine as a tumor marker in patients with small cell lung cancer

The urinary concentration of pseudouridine, primarily a degradation product of transfer ribonucleic acid, was determined by high-performance liquid chromatography in 22 patients with small cell lung cancer, 30 patients with non-small cell lung cancer, 13 patients with pulmonary infectious diseases and 24 healthy controls. The concentration of pseudouridine in both groups of patients with lung cancer was on the average significantly higher than that in the patients with pulmonary infectious diseases or in healthy controls. Thirteen (59%) of the patients with small cell lung cancer and 8 (27%) of those with non-small cell lung cancer had a urinary pseudouridine level above the mean value plus 2 for the healthy controls. In 11 patients followed up during chemotherapy, urinary pseudouridine levels changed almost in parallel with the changes in the clinical responses.

Urinary polyamines for evaluating the course of disease for patients with small cell carcinoma of the lung

Clinical correlates with urinary excretion of polyamines were evaluated for 29 newly diagnosed and 35 previously treated patients with small cell carcinoma of the lung (SCC). The frequencies of pretreatment abnormalities were 12 (41%) for putrescine, 18 (62%) for spermidine, and 20 (69%) for spermine. In assessing disease parameters, the combined use of the abnormalities of spermidine and spermine as a discriminant was more effective than that of all three polyamines; it correlated significantly with extent of limited and extensive disease (P less than 0.001), and also resulted in significant separation of survival curves, the median survival of 11 months for both elevated compared to 19 months for neither or only one elevated (P = 0.062). No significant difference was seen in the abnormalities between no metastasis and one metastasis, whereas the frequencies of the abnormalities was highly increased in two or more metastases. The distribution of polyamines determined at regular treatment intervals showed distinctively more elevated patterns in progressive disease than in stable disease or partial and complete responses (P less than 0.01). In order to evaluate therapeutic effects on the relationship between polyamine excretion and tumor regression, correlations between urinary putrescine and spermidine were determined. The values of the ratio of spermidine to putrescine were significantly smaller in responders than in nonresponders (P less than 0.01); and these may be related to smaller tumor mass and higher tumor proliferative activity in responders, and larger tumor mass and lower tumor proliferative activity in nonresponders.

Biological markers and small cell carcinoma of the lung: a clinical evaluation of urinary ribonucleosides

Five minor base ribonucleosides, primarily degradation products of transfer ribonucleic acid (tRNA), were evaluated as potential biological markers for patients with small cell carcinoma of the lung. The urinary concentration for pseudouridine, 1-methyladenosine, 1-methylinosine, N2-methylguanosine, and N2,N2-dimethylguanosine was determined by means of reversed-phase high performance liquid chromatography and quantitatively expressed as a function of creatinine excretion. Comparisons were made with carcinoembryonic antigen (CEA) plasma levels. The total frequency of elevated values for the five nucleosides in pretreatment urine samples was directly related to stage of disease with 24/60 (40%) determinations increased in 12 patients with limited disease and 69/85 (81%) in 17 patients with extensive disease. For these same patients, CEA levels were elevated respectively in 2/11 (18%) of the former and 9/17 (53%) of the latter group. The frequency and degree of elevation of the nucleoside/creatinine ratios in pretreatment samples from patients with extensive disease was correlated directly with increasing number of metastatic sites. Of the five nucleosides, the mean number elevated was two for limited disease, 3-4 for extensive disease with one metastatic site, 4 for two or three, and 5 for four or more sites of metastases. Based on a summation of pretreatment nucleoside/creatinine ratios, a discriminant for survival was derived giving curves separating patients (P = 0.086) similar to the discriminant based on stage of disease. Although discordant results were noted, an overall correlation of 75% agreement with clinical assessment was estimated in response categories when monitoring changes associated with therapy.

Modified ribonucleosides as biological markers for patients with small cell carcinoma of the lung

A variety of individual modified ribonucleosides may be elevated in the urine of cancer patients. They can be readily measured quantitatively in a single reversed-phase high-performance liquid chromatographic run. A total of 41 patients with small cell carcinoma of the lung were studied. For 5-ribonucleosides determined in the pretreatment urine of 28 patients, the respective frequency of elevation was directly related to stage of disease. One or more nucleosides were evaluated in the pretreatment urine of 27 out of 28 patients (96%). Included were 11 patients with limited disease and 10 (91%) had 2 or less than 2 nucleosides elevated, whereas 16 out of 17 (94%) with extensive disease had 3 or more elevated. Based on this same discriminant, median survival was significantly extended for patients with 2 or less nucleosides elevated (24 months) in contrast to 3 or more (10 months). Using a single number to represent the summation of equally weighted individual nucleoside values as a composite score, a direct relationship was found between increasing extent of disease or tumor burden. This was in contrast to more variable results for carcinoembryonic antigen analyzed in plasma samples obtained at the same time. When determined serially the composite score paralleled in general the clinical response categories for individual patients.

Biological markers and small cell carcinoma of the lung: a clinical evaluation of urinary ribonucleosides

Five minor base ribonucleosides, primarily degradation products of transfer ribonucleic acid (tRNA), were evaluated as potential biological markers for patients with small cell carcinoma of the lung. The urinary concentration for pseudouridine, 1-methyladenosine, 1-methylinosine, N2-methylguanosine, and N2,N2-dimethylguanosine was determined by means of reversed-phase high performance liquid chromatography and quantitatively expressed as a function of creatinine excretion. Comparisons were made with carcinoembryonic antigen (CEA) plasma levels. The total frequency of elevated values for the five nucleosides in pretreatment urine samples was directly related to stage of disease with 24/60 (40%) determinations increased in 12 patients with limited disease and 69/85 (81%) in 17 patients with extensive disease. For these same patients, CEA levels were elevated respectively in 2/11 (18%) of the former and 9/17 (53%) of the latter group. The frequency and degree of elevation of the nucleoside/creatinine ratios in pretreatment samples from patients with extensive disease was correlated directly with increasing number of metastatic sites. Of the five nucleosides, the mean number elevated was two for limited disease, 3-4 for extensive disease with one metastatic site, 4 for two or three, and 5 for four or more sites of metastases. Based on a summation of pretreatment nucleoside/creatinine ratios, a discriminant for survival was derived giving curves separating patients (P = 0.086) similar to the discriminant based on stage of disease. Although discordant results were noted, an overall correlation of 75% agreement with clinical assessment was estimated in response categories when monitoring changes associated with therapy.

Transforming growth factors in the urine of normal, pregnant, and tumor-bearing humans

Transforming growth factor (TGF) activities could be detected in the urine of normal, pregnant, and tumor-bearing humans. These acid- and heat-stable polypeptides competed for binding to epidermal growth factor (EGF) membrane receptors and promoted the anchorage-independent growth of nontransformed rodent cells. They differed from human EGF in their apparent molecular weights and soft-agar growth-stimulating activity. The urine from pregnant females contained TGF activities with apparent molecular weight(s) (relative) (Mr) of 10,000 ad 17,000--20,000. In the case of a lung cancer patient, an additional major activity of approximately 30,000--35,000 Mr was found. All urine specimens examined also contained a "common" 8,000-Mr soft-agar growth-stimulating activity, which competed for binding to EGF membrane receptors and which was chromatographically separable from EGF (urogastrone). Thus urine may provide a convenient and readily available source for the biochemical characterization of these TGF-like activities, some of which may be clinically useful biologic markers for certain types of cancer.

Urine calcitonin levels in patients with bronchogenic carcinoma

We demonstrated previously that high serum calcitonin values in bronchogenic carcinoma are useful clinically as a parameter of progress of the disease and response to therapy. After developing a procedure for the measurement of calcitonin in urine, we studied serum and urine levels in 41 patients with lung cancer, using both a carboxyl terminus and a midportion recognizing antiserum. In general, midportion antiserum was more useful. Urine calcitonin measurements alone were superior to serum in terms of numbers of patients having increased values with one or both antisera (76% vs 46%). When both antisera were used to assay both serum and urine, 90% of patients had abnormal values. Once a tissue diagnosis has been established, the radioimmunoassay of urinary calcitonin offers a new dimension to the utility of this hormone as a marker for bronchogenic carcinoma.

Oat cell carcinoma of the bronchus and the carcinoid syndrome

A man with high urinary levels of 5-hydroxyindole acetic acid had an oat cell carcinoma of the bronchus. The patient had symptoms of the carcinoid syndrome and at autopsy was found to have evidence of carcinoid heart disease. This report supports the hypothesis that bronchial carcinoids and oat cell carcinomas are derived from argentaffin (Kulchitsky)-type cells of the lung.