present in 72% of urachal adenocarcinoma cases and is more commonly peripheral than ... necrosis, and cystic degeneration. Encrustation of calcium salts on ...
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E-JCRT Correspondence
Calcification in transitional cell carcinoma of urinary bladder: Does it have any implication on calcium metabolism and its management? ABSTRACT Although transitional cell carcinoma (TCC) is most common histological subtype, calcification in TCC is rarely seen. We report a 64-year-old gentleman who on evaluation found to have calcification in TCC of urinary bladder and its implication on calcium metabolism and management. KEY WORDS: Calcification, calcium metabolism, transitional cell carcinoma, urinary bladder
INTRODUCTION Calcification in urinary bladder carcinoma is uncommon. Different types‑nodular, arched, nodular and arched, multiple fine punctuate, and plaque‑like massive calcifications have been described in the literature. These may be located on the surface or scattered within the mass. Location and pattern of calcification may suggest the pathological subtype. CASE REPORT A 64‑year‑old gentleman, chronic smoker for last 30 years, presented with hematuria, with no irritative voiding symptoms for last 2 weeks. Physical examination was unremarkable. His hemogram and biochemical investigations were within normal range. Urinalysis revealed 30–40 red blood cells per high power field (RBC/HPF), 15–18 white blood cells (WBC/HPF) and serum creatinine-0.84mg/dl. Urine culture revealed no growth. Serum calcium was 9 mg/dl. Ultrasonography [Figure 1] and plain, contrast‑enhanced computed tomography (CT)‑abdomen with CT-Urogram [Figure 2] revealed bladder mass. Cystoscopy revealed a solid growth with broad base occupying left posterolateral wall, abutting left orifice with peripheral calcification all around the tumor. Transurethral resection of bladder tumor (TURBT) revealed TCC‑bladder, infiltrating deeper muscularis propria with foci of calcium
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encrustration [Figure 3a]. Subsequently, patient underwent robotic radical cystectomy with bilateral pelvic lymphadenectomy with ileal conduit. Histopathology revealed moderately differentiated papillar y transitional cell carcinoma (TCC)‑bladder, with outer half deeper muscle invasion. Section from radical cystectomy specimen also showed calcium deposition in subepithelial region with areas of necrosis [Figure 3b]. Stage: pT2bN0M0. Postoperatively, patient developed persistent hypocalcemia for about 2 weeks, requiring supplemental intravenous calcium infusion and subsequently he was put on oral calcium supplementation.
Suresh Kumar, Pranjal R. Modi, Bipin C. Pal, Jayesh Modi Department of Urology, Institute of Kidney Disease and Research Centre, Institute of Transplant Sciences, Ahmedabad, Gujrat, India For correspondence: Dr. Suresh Kumar, Department of Urology, Institute of Kidney Disease and Research Centre, Institute of Transplant Sciences, Civil Hospital Campus, Asarwa, Ahmedabad - 380 016, Gujarat, India. E-mail: sureshsingla08@ gmail.com
DISCUSSION CT may improve detection of calcification (5–7%) than plain X‑ray (0.69–6.7%). [1‑3] CT is most sensitive modality for calcification, which is present in 72% of urachal adenocarcinoma cases and is more commonly peripheral than stippled. Multiple soft punctuate calcification within tumor mass is suggestive of mucin‑secreting adenocarcinoma, which may show calcification in 50% of cases because of chondroitin sulfuric acid. TCC produces calcification in 5% of cases, usually on the surface which may be related to infection. Central calcification may be related to hemorrhage, necrosis, and cystic degeneration.
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Encrustation of calcium salts on non-necrotic neoplasm may reflect a local pH interaction of
Journal of Cancer Research and Therapeutics - October-December 2015 - Volume 11 - Issue 4
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Kumar, et al.: Calcium metabolism and calcification in transitional cell carcinoma of urinary bladder
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Figure 1: (a) Full bladder sonography showing bladder mass from left posterolateral wall, confusing with bladder calculus. (b) Post-micturition view showing hypoechoic bladder mass with an hyperechoic rim
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the tumor with urinary calcium. Calcium precipitation is favored by alkaline urinary pH and favors the tumor surface. Dystrophic calcification is usually found in necrotic or degenerating tissue and usually occurs with normal blood calcium level, but may be augmented by hypercalcemic states and occurs in subepithelial location. Dystrophic calcification in bladder carcinoma has been reported in animals. [4] Moreover, tumor matrix may actually produce calcium or osteoid. Lower serum calcium and higher urinary calcium may suggest that suffering from carcinoma may induce calcium ion metabolism abnormal. Therefore, higher urinary calcium is also related with calcification of carcinoma. In addition to metabolism and calcification, carcinoma autocrine is not absolutely denied. Many experiments showed that in bladder carcinoma, calcium‑related transport proteins are varied, then the balance of calcium level between intracell and extracell is broken.[5] In our case, calcium was located on the surface of neoplasm, being intermingled with papillary fronds. He also had calcium deposited in subepithelial region in the tumor, with calcification adjacent to areas of necrosis. Urine was alkaline with urine culture sterile. Probably alkaline urinary pH favors the tumoral surface calcification. Subepithelial calcification may be related to necrosis.
c Figure 2: (a) Computed tomography (CT)-plain: Lobulated predominantly hyperdense lesion, measuring 41 × 39 × 42 mm along left posterolateral wall with peripheral curvilinear calcification. (b) CT-contrast enhanced showing minimal enhancement. (c) CT-Urogram: Mass abutting left vesicoureteric junction (VUJ), no hydroureter/hydronephrosis on either side
Hypercalciuria might further explain postoperative hypocalcemia as noted in our case. Hence, calcification in TCC of urinary bladder might alter calcium metabolism, should not be ignored and needs frequent monitoring, particularly during postoperative period. REFERENCES
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b2 Figure 3: (a) Transurethral resection of bladder tumor (TURBT) specimen: Cluster of tumor cells in papillary fronds with calcification (hematoxylin and eosin (H and E), ×100). (b) Radical cystectomy specimen: (b1) Tumor cells in papillary frond, (b2) Calcification in subepithelial region (H and E, × 200)
1. Ferris EJ, O’Connor SJ. Calcifications in urinary bladder tumors. Am J Roentgenol Radium Ther Nucl Med 1965;95:447‑9. 2. Braband H. The incidence of urographic findings in tumors of urinary bladder. Br J Radiol 1961;34:625‑9. 3. Moon WK, Kim SH, Cho JM, Han MC. Calcified bladder tumors. CT features. Acta Radiol 1992;33:440‑3. 4. O’Brien, TR. Neoplasia with dystrophic calcifications in dogs. Radiologic diagnosis. J Am Vet Med Assoc 1970;157:974‑6. 5. Guo KF, Zhang Z, Wang JY, Gao SL, Liu J, Zhan B, et al. Variation of urinary and serum trace elements (Ca, Zn, Cu, Se) in bladder carcinoma in China. Asian Pac J Cancer Prev 2012;13:2057‑61.
Cite this article as: Kumar S, Modi PR, Pal BC, Modi J. Calcification in transitional cell carcinoma of urinary bladder: Does it have any implication on calcium metabolism and its management?. J Can Res Ther 2015;11:1028. Source of Support: Nil, Conflict of Interest: None declared.
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