Case Report Carcinoma In Situ Developing in an Ileal Neobladder Hiroki Ide, Eiji Kikuchi, Kazunobu Shinoda, Makio Mukai, and Masaru Murai We report a case of carcinoma in situ of urothelial carcinoma (UC) developing in an ileal neobladder. Some cases of secondary UC in the ileal segment of a urinary diversion have been reported. However, none were cases of carcinoma in situ. After cystectomy for bladder cancer, a 73-year-old man developed UC at the left ureteral-neobladder and urethral-neobladder anastomoses. Left nephroureterectomy, resection of the neobladder, and total urethrectomy were performed. The pathologic examination revealed UC (papillary, grade 3) at these anastomoses and carcinoma in situ in the ileal neobladder. UROLOGY 69: 576.e9 –576.e11, 2007. © 2007 Elsevier Inc.
ome cases of secondary adenocarcinoma developing in the replaced bowel segment of urinary diversion have been reported. Secondary adenocarcinoma developed 20 years after surgery in about 25% of patients in whom the colon was used for urinary diversion and in 0.5% of those in whom an ileal segment was used.1,2 The etiology of the secondary adenocarcinoma established in the urinary diversion is not clearly understood. According to studies done in experimental animals, urinary stasis, proliferative instability of the urointestinal anastomosis, and the carcinogenic effects of nitrosamines have been identified as potential risk factors.3 Some cases of urothelial carcinoma (UC) developing in urinary diversion using the colon have been reported; however, cases of UC developing in the urinary diversion using the ileum have been infrequently reported.1 To our knowledge, no case of carcinoma in situ (CIS) of UC in the urinary diversion using the ileum has ever been reported. We report a case of CIS developing in an ileal neobladder. This case suggests that CIS can invade the nonurothelial epithelium.
CASE REPORT In November 1993, a 73-year-old man who had been exposed to benzidine 28 years previously presented with a bladder tumor and underwent total cystectomy with ileal neobladder replacement (hemi-Koch pouch method). The histopathologic examination revealed UC, grade 3, Stage pT1. In July 2004, abdominal computed tomography revealed recurrent UC in the right ureter. In September 2004, right nephroureterectomy was per-
From the Departments of Urology and Pathology, Keio University School of Medicine, Tokyo, Japan Address for correspondence: Eiji Kikuchi, M.D., Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-858,2 Japan. E-mail: [email protected]
Submitted: August 20, 2006; accepted (with revisions): January 22, 2007
© 2007 Elsevier Inc. All Rights Reserved
formed. The histopathologic findings were compatible with a diagnosis of UC, grade 3, Stage pT2 with CIS. At that time, the surgical margins of the specimen were negative. In August 2005, urine cytology proved positive (class IV). Cystoscopic examination revealed no obvious tumor in the ileal neobladder; however, a nodular tumor was seen at the urethral-neobladder anastomosis. Transurethral biopsy of the tumor was performed, and the histopathologic findings confirmed grade 3 UC. Furthermore, computed tomography disclosed a tumor at the left ureteral-neobladder anastomosis and left hydronephrosis. Selective urine cytology from the left upper tract was obtained in an antegrade fashion, and the result was positive (class IV). In December 2005, left nephroureterectomy, resection of the ileal neobladder, and total urethrectomy were performed. The histopathologic findings of the main tumor at the ureteroileal neobladder anastomosis were compatible with those of UC, Stage pT2, grade 3. CIS, which was partly invading the renal parenchyma, was also recognized in the renal pelvis. The tumor at the urethral-neobladder anastomosis was UC, Stage pT3, grade 3. CIS was adjacent to the main tumor at the urethral-neobladder anastomosis in the ileal neobladder (Fig. 1). After surgery, hemodialysis was introduced. In July 2006, the patient was free of recurrence and metastasis.
COMMENT The occurrence of UC in an ileal conduit or neobladder is rare. To our knowledge, only 13 cases, including ours, have been reported (Table 1).4 –14 The age of the patients at diagnosis ranged from 52 to 73 years (mean 64). The type of urinary diversion was an ileal conduit in 11 and an ileal neobladder in 2 patients. Also, 10 patients presented a concomitant upper tract recurrence. Of the 13 patients, 7 had a recurrent tumor at the ureteroileal anastomosis, and 5 had a recurrent tumor in a focal 0090-4295/07/$32.00 576.e9 doi:10.1016/j.urology.2007.01.073
Figure 1. (A) Gross appearance and (B) schema of surgical specimen: (a) UC Stage pT3G3 in left renal pelvis with CIS, (b) UC Stage pT2G3 at ureteroileal anastomosis, (c) UC Stage pT3G3 at urethral-neobladder anastomosis, and (d) UC Stage pTisG3 in neobladder adjacent to ureteroileal anastomosis.
Table 1. Cases of secondary urothelial carcinoma arising in ileal conduit or neobladder Investigator Soloway et al.4 Soloway et al.4 Grabstald et al.5 Banigo et al.6 Allan et al.7 Wajsman et al.8 Rubin et al.9 Curran et al.10 Roberts et al.11 Rosvanis et al.12 Shioji et al.13 Sanchez Zalabardo et al.14 Present case
Patient Age (yr)/Sex 71/F 53/M 52/M 69/M 56/M 57/M 68/F 66/F 68/F 73/M 67/M Unknown 73/M
Urinary Diversion Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal Ileal
conduit conduit conduit conduit conduit conduit conduit conduit conduit conduit conduit neobladder neobladder
segment of the ileal conduit not adjacent to the urothelial epithelium. Except for our patient, no patient had CIS in an ileal conduit or neobladder. UC can develop in a bowel segment by way of two mechanisms. One is “direct invasion” and the other is “implantation.” Hara et al.15 reported a case of CIS developing in a colon neobladder. They considered that CIS had arisen by implantation because the lesion was far from the main tumor. Although the exact mechanism is still unclear, in our patient, CIS was thought to have established in the ileal neobladder by direct invasion from the main tumor into the nonurothelial epithelium, because the CIS at the ureteroileal neobladder anasto576.e10
Upper Tract Recurrence Yes Yes No Yes Yes Yes No Yes No Yes Yes Yes Yes
Recurrence Site Ureteroileal Ureteroileal Stoma Ureteroileal Ureteroileal Ileal loop Ileal loop Ileal loop Ileal loop Ureteroileal Ureteroileal Unknown Ureteroileal
anastomosis anastomosis anastomosis anastomosis
anastomosis anastomosis anastomosis
mosis protruded into the adjacent portion of the neobladder. References 1. Fichtner J: Follow-up after urinary diversion. Urol Int 63: 40 – 45, 1999. 2. Ali-El-Dein B, El-Tabey N, Abdel-Latif M, et al: Late uro-ileal cancer after incorporation of ileum into the urinary tract. J Urol 167: 84 – 88, 2002. 3. Frese R, Doehn C, Baumgartel M, et al: Carcinoid tumor in an ileal neobladder. J Urol 165: 522–523, 2001. 4. Soloway MS, Myers GH Jr, Burdick JF, et al: Ileal conduit exfoliative cytology in the diagnosis of recurrent cancer. J Urol 107: 835– 839, 1972.
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5. Grabstald H: Carcinoma of ileal bladder stoma. J Urol 112: 332– 334, 1974. 6. Banigo OG, Waisman J, and Kaufman JJ: Papillary (transitional) carcinoma in an ileal conduit. J Urol 114: 626 – 627, 1975. 7. Allan DM: Recurrent transitional cell carcinoma complicating ileal conduit. Br J Urol 48: 60, 1976. 8. Wajsman Z, Baumgartner G, and Merrin C: Transitional cell carcinoma of ileal loop following cystectomy. Urology 5: 255–256, 1975. 9. Rubin BE, Rodriguez E, Mangasarian R, et al: Recurrent transitional cell carcinoma in an ileal conduit. Urol Radiol 1: 61– 62, 1979. 10. Curran FT, and Fuggle WJ: Transitional cell carcinoma in an ileal conduit. Postgrad Med J 62: 769 –771, 1986.
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11. Roberts SD, Williams HJ, and Resnick MI: Metastatic transitional cell carcinoma in an ileal conduit following cystectomy. J Urol 137: 734 –735, 1987. 12. Rosvanis TK, Rohner TJ, and Abt AB: Transitional cell carcinoma in an ileal conduit. Cancer 63: 1233–1236, 1989. 13. Shioji Y, Morita T, and Tokue A: Transitional cell carcinoma in the ileal conduit following radical cystectomy and nephroureterectomy. Scand J Urol Nephrol 35: 416 – 417, 2001. 14. Sanchez Zalabardo D, Lopez Ferrandis J, Arocena Garcia-Tapia J, et al: [Recurrent urothelial tumor in orthotopic neobladder]. Actas Urol Esp 25: 600 – 602, 2001. 15. Hara I, Hara S, Miyake H, et al: Carcinoma in situ spread to mucosa of sigmoid colon neobladder. Urology 62: 145, 2003.