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LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 4  |  Page : 573-574
 

Leiomyosarcoma of urinary bladder-potential mimicker of carcinoma: Case report and short review of literature


Department of Pathology, Sri Venketeswar Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Web Publication10-Mar-2016

Correspondence Address:
R Patnayak
Department of Pathology, Sri Venketeswar Institute of Medical Sciences, Tirupati, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.178433

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How to cite this article:
Patnayak R, Jena A, Rambabu S, Reddy M K. Leiomyosarcoma of urinary bladder-potential mimicker of carcinoma: Case report and short review of literature. Indian J Cancer 2015;52:573-4

How to cite this URL:
Patnayak R, Jena A, Rambabu S, Reddy M K. Leiomyosarcoma of urinary bladder-potential mimicker of carcinoma: Case report and short review of literature. Indian J Cancer [serial online] 2015 [cited 2019 Dec 9];52:573-4. Available from: http://www.indianjcancer.com/text.asp?2015/52/4/573/178433


Sir,

Leiomyosarcoma is a rare malignant mesenchymal tumor, which accounts for less than 1% of urinary bladder malignancies. Although the etiology is unknown, leiomyosarcomas have been associated with long-term cyclophosphamide therapy.[1] Leiomyosarcomas must be differentiated from several other neoplastic and non-neoplastic spindle cell lesions, as the therapeutic and prognostic significance for these entities differ. In Indian literature, few cases have been reported.

A 46-year-old male presented with complaint of dysuria, burning micturition, increased frequency and urgency since 6 months. There was history of hematuria for last 2-3 days without any history of obstructive symptoms. There was no history of intake of drugs like cyclophosphamide, urinary tract infection, prior abdominal surgery, or cystoscopy. Digital rectal examination revealed bimanually palpable growth in urinary bladder.

Computerized tomography scan showed heterogeneously enhancing mass involving dome and anterior wall. [Figure 1] Per operatively, a large growth was noted involving dome and anterior wall of urinary bladder with enlarged bilateral pelvic lymph nodes. Following which, he underwent radical cystectomy with lymphadenectomy. The ulceroproliferative tumor was 9 × 5 cms and filled the lumen of the urinary bladder, cut section of the mass showed grayish-white whorly areas with foci of hemorrhage and necrosis.
Figure 1: Computerized tomography (CT scan) of heterogeneously enhancing mass involving dome and anterior wall of urinary bladder

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Microscopically, there were infiltrative interlacing fascicles of pleomorphic spindle cells and mitotic Figures, 1-2/High Power Field including atypical ones. [Figure 2] Necrotic areas accounted for about 30%. Immunohistochemically, it showed positivity for vimentin, smooth muscle actin, and negativity for cytokeratin, epithelial membrane antigen (EMA), myogenin, and anaplastic lymphoma kinase (ALK)-1. [Figure 3][Figure 4] The final diagnosis was high-grade leiomyosarcoma. No prior history of cyclophosphamide therapy was elicited. The post-operative period was uneventful, and he is doing well 3 years after surgery.
Figure 2: Spindle cells with nuclear pleomorphism and atypical mitotic figures. (H and E, ×40)

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Figure 3: Immunohistochemical positivity for smooth muscle actin

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Figure 4: Immunohistochemical negativity for epithelial membrane antigen

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Leiomyosarcoma, arising from urinary bladder smooth muscle, was first reported by Rowland and Eble.[1] Majority of patients present with gross hematuria. Leiomyosarcomas are large, polypoidal infiltrative masses.[2] Microscopically infiltrative interlacing fascicles of spindle cells are noted. Microscopic grading is based on nuclear atypia, mitotic activity, and tumor necrosis.[2] Immunohistochemically, vimentin, muscle-specific actin, and (often) desmin are positive, and epithelial markers. ALK-1 are usually negative.[2],[3]

Other spindle cell lesions, which need to be differentiated from leiomyosarcoma, include sarcomatoid carcinoma, leiomyoma, post-operative spindle cell nodule (PSCN), and inflammatory myofibroblastic tumor (IMT).

Sarcomatoid carcinoma or carcinosarcoma can resemble leiomyosarcoma but is usually associated with history of or presence of either in-situ or invasive high-grade urothelial carcinoma. It exhibits positivity for epithelial markers.[3]

Leiomyoma can be distinguished from leiomyosarcoma based on its small size, circumscription, low cellularity, lack of cytological atypia, and mitotic activity.[2]

Harik et al. have proposed that non-neoplastic reactive spindle cell proliferations (PSCN and IMT) should be classified as pseudosarcomatous myofibroblastic proliferation.[4] The clinical history of recent bladder operation is vital in making the diagnosis of PSCN. PSCN are reactive to low-molecular-weight keratin, vimentin, actin, and desmin but negative for EMA. IMTs may exhibit abundant mitotic activity, infiltrative growth pattern, and inflammation. But, they lack cytological atypia, which is characteristic of leiomyosarcoma. Also, IMT expresses ALK-1.[3] Lee et al. have stated that high-grade leiomyosarcomas are associated with epithelioid morphology, tumor necrosis, and mucosal ulceration. More than 60% of leiomyosarcomas patients develop recurrent or metastatic disease.[2],[5]

The spindle cell lesions arising in bladder are diverse in morphology. It is important to differentiate them by evaluating their architectural, cytological, immunohistochemical, and molecular features. Leiomyosarcomas of the urinary bladder are indeed rare. Surgery remains the mainstay of treatment.


  Acknowledgment Top


The authors wish to thank senior technicians Mrs. Ushanandini and Mr. Ramana for their help.

 
  References Top

1.
Rowland RG, Eble JN. Bladder leiomyosarcoma and pelvic fibroblastic tumor following cyclophosphamide therapy. J Urol 1983;130:344-6.  Back to cited text no. 1
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2.
Martin SA, Sears DL, Sebo TJ, Lohse CM, Cheville JC. Smooth muscle neoplasms of the urinary bladder: A clinicopathologic comparison of leiomyoma and leiomyosarcoma. Am J Surg Pathol 2002;26:292-300.  Back to cited text no. 2
    
3.
Lott S, Lopez-Beltran A, Montironi R, MacLennan GT, Cheng L. Soft tissue tumors of the urinary bladder Part II: Malignant neoplasms. Hum Pathol 2007;38:963-77.  Back to cited text no. 3
    
4.
Harik LR, Merino C, Coindre JM, Amin MB, Pedeutour F, Weiss SW. Pseudosarcomatous myofibroblastic proliferations of the bladder: A clinicopathologicstudy of 42 cases. Am J Surg Pathol 2006;30:787-94.  Back to cited text no. 4
    
5.
Lee TK, Miyamoto H, Osunkoya AO, Guo CC, Weiss SW, Epstein JI. Smooth muscle neoplasms of the urinary bladder: A clinicopathologic study of 51 cases. Am J Surg Pathol 2010;34:502-9.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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