Clinical diagnosis
Case 312
【Progress】
They hesitate to receive the management of radical surgical treatment because of poor body strength, shortage of nutrients and high age. It takes time for them to do the final decision.
【Discussion】
ADC values indicate strength of water molecules diffusion, the greater value, the more motion of water molecules. Then, the lowering ADC values imply dens accumulation of cellular component or fluids not allowing water molecules movable such as mucin, keratin, highly protein fluids. In solid tumors, ADC values of dens tumor tend to be lower than those of sparse one. On bladder cancer, similar as other tumors, ADC values of the high - grade differentiated or undifferentiated are reported to be lower than the low-grade differentiated (1). The average ADC values cutting off recurrence of urinary bladder cancer are 1.12 (-3) mm2/s (with vs without recurrence, 1.08 vs 1.28)(1). In our series, ADC values are 0. 8959 in Case1 and 0.5191 in Case 2. ADC values of around 0.5 are too low for bladder cancer but not contradictory to malignant lymphoma (2). This case is now waiting for evaluation by follow-up study.
Pathologically more than 80% of urinary bladder cancer is urothelial tumor (transitional cell carcinoma) followed by adenocarcinoma, squamous cell carcinoma, undifferentiated carcinoma, malignant lymphoma and metastatic bladder cancer (1, 3). Lymphoma of urinary bladder is rare but can occur from mucosa associated lymphoid tissue as MALT lymphoma (3-6). MALT lymphoma predominantly occurs in 60 to 70 ages of woman (In Case 2, her age was 81) (3-6).
On CT and MRI, staging of urinary bladder cancer is demanded. Urinary bladder mural composes of mucosa, thin connective tissue, muscle layer and capsule. When tumor advances beyond mural microscopically, its stage is defined T3a. When advanced macroscopically, its stage, T3b. When tumor is localized in mucosa, it is defined T1. When the invasion to muscle layer, it is defined T2 (T2a: less than 1/2 invasion of muscle layer, T2b: beyond 1/2). When the invasion to the adjacent organ such as prostate gland or uterus, it is defined T4a and when its invasion reaches to pelvic bone, it is defined T4b (7, 8).
The incidence of urinary bladder cancer is 6.6/one hundred thousand/year.
The ratio of urinary bladder cancer of male versus female is 4 vs 1, indicative of male predominance vice versa on the ratio of urinary bladder malignant lymphoma (male versus female: 1vs 4) (3 - 8). The population of Hannan city is 50000, indicative of rare happening of two cases with bladder tumor encountered a week. Our case of Case 1 with ADC values of 0. 8959 was male and Case 2 with ADC values of 0.5191 was female.
【Summary】
We presented two cases with bladder tumor. ADC values of bladder tumor of Case 1 and Case 2 were 0. 8959 and 0.5191, respectively. The ADC values of Case 1 were compatible with urinary bladder cancer of urothelial tumor (transitional cell cancer) but are not in Case 1. ADC values of around 0.5 are compatible with malignant lymphoma of the urinary bladder. It is borne in mind that ADC values of urothelial tumor are around 1.1 corresponded to intrahepatic cholangiocarcinoma, the upper limit of malignant tumors. Tumor invades beyond mural microscopically, indicative of T3a and macroscopical invasion beyond mural, indicative T3b. T4a indicates invasion of the tumor to adjacent organ such as prostate gland or uterus and T3b, invasion to pelvic bone.
【References】
1.Funatsu H, et al. Can pretreatment ADC values predict recurrence of bladder cancer after transurethral resection? Eur J Radiol. 2012 Nov;81(11):3115-9
2.Maeda M, et al. Apparent diffusion coefficient in malignant lymphoma and carcinoma involving cavernous sinus evaluated by line scan diffusion-weighted imaging. J Magn Reson Imaging. 2006 Sep;24(3):543-8.
3.Bates AW, et al. Malignant lymphoma of the urinary bladder: a clinicopathological study of 11 cases. Journal of Clinical Pathology. 2000;53(6):458–461.
4.Kempton CL,et al. Malignant lymphoma of the bladder: evidence from 36 cases that low- grade lymphoma of the malt-type is the most common primary bladder lymphoma. American Journal of Surgical Pathology. 1997;21(11):1324–1333.
5.Al-Maghrabi J,et al. Primary low-grade B-cell lymphoma of mucosa-associated lymphoid tissue type arising in the urinary bladder: report of 4 cases with molecular genetic analysis. Archives of Pathology and Laboratory Medicine. 2001;125(3):332–336.
6.Venyo AKG, et al. Lymphoma of the Urinary Bladder. Adv Urol. 2014; 2014: 327917. Published online 2014 Jan 9. doi: 10.1155/2014/327917
7.Nishiyama H：Asia Consensus Statement on NCCN Clinical Practice Guideline for bladder cancer. Jpn J Clin Oncol 48：3-6, 2018
8.Antoni S, et al. Bladder Cancer Incidence and Mortality：A Global Overview and Recent Trends. Eur Urol 71：96-108, 2017
2023.9.29