Contributed by Anca Florea, MD and Anil Parwani, MD, PhD
The patient is a 94 year old male who on a recent CT scan for evaluation for renal stones was discovered to have a bladder mass. No other significant past medical history is present.
On gross examination, there was a firm, irregular, partly fungating, partly ulcerated with necrotic base tumor, tan-white at the edges (Figures A and B), measuring 6.0 x 3.5 x 1.5 cm which appeared to extend through most of the posterior bladder wall (Figure C).
Microscopic examination shows an infiltrating, poorly differentiated predominantly spindle cell tumor composed of very pleomorphic looking cells (Figure 1). The tumor cells are large with high nuclear to cytoplasmic ratio, irregular nuclear contours, many bizarre nuclei, prominent nucleoli and numerous mitoses (Figures 2 and 3). Extensive necrosis and focal areas of calcification are present (Figure 4). The tumor extensively invades through the detrusor muscle and into the perivesical fat (Figure 5). No urothelial carcinoma in situ was appreciated. Perineural invasion was present.
The tumor cells are diffusely positive for Pankeratin (Figure 6). Thrombomodulin highlights vasculature but it is negative in tumor cells (Figure 7). Staining for Desmin, Actin, S100, Cytokeratin 20, p63 and CD34 were all negative.