British Journal of Radiology (2007) 80, e227-e229
© 2007 British Institute of Radiology
doi: 10.1259/bjr/68501519
Transitional cell carcinoma in a herniated vesical diverticulum
C J Das, MD, DNB, MNAMS
J Debnath, MD
S P Thulkar, MD
L Kumar, DM
and
S Vashist, MD
Department of Radiology, All India Institute of Medical Sciences, Mahatma Gandhi Road, Ansari Nagar, New Delhi, Delhi, 110 029, India
Correspondence: Dr Chandan J Das, Department of Radiology, All India Institute of Medical Sciences, Mahatma Gandhi Road, Ansari Nagar, New Delhi, Delhi, 110 029, India. E-mail: dascj{at}yahoo.com
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Abstract
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Carcinoma in vesical diverticula is a rare clinical entity and rarer still is the herniation of the vesical diverticulum into the scrotal sac. Carcinoma arising within a vesical diverticulum often represents a diagnostic as well as a therapeutic challenge, with overall poor outcome despite all available forms of treatment. Multidetector CT helps in the diagnosis and detailed evaluation of carcinoma arising from the vesical diverticulum by allowing excellent reconstructions in any desired plane. We report here a case of transitional cell carcinoma arising in a herniated vesical diverticulum with hepatic metastasis.
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Introduction
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Bladder diverticula result from herniation of the urothelium between the interlacing muscle fibres and are usually related to chronic bladder outlet obstruction. Primary neoplasms arising from the vesical diverticula is an uncommon condition with an incidence ranging from 2% to 10% [1]. Transitional cell carcinoma is the commonest histological subtype followed by squamous cell carcinoma [2]. Neoplasms arising from the vesical diverticula have an aggressive potential with early transmural spread and also pose special diagnostic and therapeutic dilemmas. Rarely, a vesical diverticulum may extend into the inguinal canal [3] and may even get incarcerated within the hernial sac [4]. However, malignancy in a herniated vesical diverticulum has not yet been described in the literature. We present here a case of carcinoma in a herniated vesical diverticulum with multiple liver metastases.
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Case report
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A 70-year-old man, a known case of left-sided reducible inguinal hernia for the past 7 years, presented with complaints of difficulty in reducing the hernia on lying down for the last 4 months associated with a dragging sensation. He also complained of vague upper abdominal pain, weight loss of approximately 1.8 kg, generalized weakness and one episode of macroscopic haematuria in the last 2 months. Physical examination was normal except for pallor. He had a tender non-reducible left-sided inguinoscrotal swelling. He also had non-tender mild hepatomegaly. His pertinent biochemical investigations were normal. Urine examinations revealed seven red blood cells per high-power field and urine cytology for malignant cells was negative. Ultrasonography (USG) of the abdomen revealed the presence of multiple focal lesions scattered in both lobes of the liver, suggestive of metastases. Ultrasound of the urinary bladder did not reveal any gross abnormality except for small capacity. A contrast-enhanced multidetector CT (MDCT) scan (GE, Light speed, Milwaukee, WI) of the abdomen and pelvis revealed multiple hypoattenuating focal lesions in both lobes of the liver. MDCT also showed a vesical diverticulum arising from the bladder base herniating into the left inguinoscrotal region. Two enhancing polypoidal soft tissue masses were seen arising from the base and neck of the diverticulum (Figure 1a–d
). The masses did not change their position when the patient was scanned in the prone position. Based on the clinical presentation and imaging features, a diagnosis of carcinoma in the herniated vesical diverticulum with multiple liver metastases was made. Conventional cystoscopy was not performed, as CT elegantly demonstrated the masses in the diverticulum. The patient underwent an ultrasound-guided aspiration biopsy from the liver lesions and the diverticular mass. The histopathological examination revealed transitional cell carcinoma. The patient received radiotherapy for the bladder mass and hepatic metastases and has been on follow-up for the last 2 months.
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Figure 1. (a,b) A 70-year-old man with left-sided non-reducible inguinal hernia. (a) Contrast-enhanced multidetector CT axial section showing an enhancing mass (arrow) in the left scrotum. (b) Excreted contrast in the urine is seen around the mass (arrow) in delayed phase image. (c,d) A 70-year-old man with left-sided non-reducible inguinal hernia. (c) Multiplanar reconstruction (MPR) in an oblique coronal plane showing two separate masses arising from the base and neck of the herniated diverticulum (arrows). (d) Sagittal reconstruct image showing excellent detail of the neck of the vesical diverticulum and the masses arising from it (arrows).
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Discussion
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The various complications associated with vesical diverticula are recurrent/persistent urinary tract infection, calculi formation, ureteral obstruction and development of carcinoma [5]. Chronic urinary stasis due to poor emptying and a relatively narrow neck of the diverticulum causes chronic irritation to the bladder mucosa leading to epithelial dysplasia, which at a later date develops into an overt cancer. Intravenous urography (IVU) and micturating cystourethrography (MCU) represent important initial urological evaluation of patients with vesical diverticulum. MCU is the most sensitive imaging technique in the detection of vesical diverticula, but it is invasive. IVU is about 40% accurate in the diagnosis of vesical diverticula [6]. Other diagnostic modalities include USG, CT scan and MRI. With the advances in CT technology, MDCT urography and MDCT cystography play a very important role in the evaluation of the urinary tract and have completely replaced IVU in evaluation of the upper urinary tract and the bladder. Although cystoscopy is the gold standard for the diagnosis of vesical cancers and diverticulum, it has failed many times to identify the mass in the diverticulum when the scope could not be negotiated through the tight orifice of the diverticulum or the mass was overlooked, as in case of small cancer. Following initial evaluation with IVU, MCU and cystoscopy, a CT scan helps in staging by delineating the extent of the mass, depth of invasion and nodal involvement. Thus, CT helps in deciding the appropriate modality of treatment, especially the potential for surgical resection and cure. MDCT allows volume (3D) acquisition of data, enabling excellent reconstruction in any desired plane showing the exact relationship of the diverticulum to the bladder, course and morphology of the diverticular neck. At times, a diverticulum may not be opacified with contrast during IVU, MCU or CT because of inflamed or occluded diverticular neck by a mass. In such cases, the exact relationship of the diverticular mass and the vesical wall may not be established. MRI is useful as a problem-solving modality in these circumstances because of its multiplanar capability and excellent inherent soft tissue contrast [7].
Carcinoma arising within the vesical diverticula is often underdiagnosed and understaged. Compared with the normal vesical wall, the thin wall of the vesical diverticula with its relative lack of muscle fibres facilitates early invasion and complete penetration by the carcinoma. This, together with frequent delay in diagnosis and advanced disease at presentation, results in relatively poor prognosis despite all forms of treatment. Herniation of bladder diverticulum into the inguinoscrotal region with the development of metastasizing malignancy has not been described previously in the literature. In our case, MDCT allowed oblique reconstruction with an excellent demonstration of the diverticulum and its relation to the vesical wall, the enhancing mass in the diverticulum, the orientation of the diverticular neck and the presence of liver metastases. This case emphasizes the potential role of MDCT in the evaluation of vesical diverticulum and the complications associated with it.
Received for publication March 12, 2006.
Revision received June 20, 2006.
Accepted for publication July 10, 2006.
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References
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Abstract
Introduction
