Complete en bloc urinary exenteration for synchronous multicentric transitional cell carcinoma with sarcomatoid features in a hemodialysis patient

Abstract

The incidence of transitional cell carcinoma (TCC) in patients submitted to hemodialysis is low. The presence of TCC with sarcomatoid features in this cohort is even scarcer. Herein, we describe a very rare case of synchronous multicentric muscle invasive bladder carcinoma with prostate invasion in a hemodialysis patient, submitted to complete en bloc urinary exenteration. CASE REPORTA 58 years-old white obese man, submitted to a hemodialysis program due to diabetic nephropathy, was referred to our department because of painless macroscopic hematuria.Ultrasound and cystoscopy revealed multiple pediculated and sessile lesions in different parts of the bladder. Pre-operative computed tomography (CT) scan showed no extravesical dissemination or node enlargement.The patient was submitted to a deep transurethral resection of bladder tumor (TURb) in part of the visible masses, but not all due to its extent. Pathologic examination showed high-grade urothelial tumor, with invasion of the lamina propria layer only.Based on the pathological report, the patient was submitted to en bloc urinary exenteration associated to extended pelvic lymphadenectomy (Figure-1). Operative time, blood loss and hospital stay were 300 minutes, 770 mL and 5 days, respectively. No complications were observed.Final pathology evidenced high-grade muscle invasive bladder carcinoma with extravesical invasion to adipose tissue and bladder neck. Prostate invasion by the urothelial tumor was observed, presenting sarcomatoid features (Figure-2). Surgical margins, kidneys, ureters and nodes were free of tumor. No chemoteraphy treatment was administered.On postoperative month 6, CT scan showed multiple lesions in both lungs and brain. Pleural biopsy evidenced bladder tumor metastasis. Six days later, the patient died of metastasis complications. COMMENTSIt is well known that uremic patients have a higher risk to develop cancer, in which the most common types are the urological ones (1).

Characteristics and treatment outcomes of pan-urothelial cell carcinoma: a descriptive analysis of 45 patients

“…Previous studies recommend CUTE for panUCC patients, especially those with ESRD 7 8 9 10 18 19 . Patients with severe CKD or dialysis have been shown to manifest a higher risk of developing urothelial carcinoma 18 20 , and of experiencing tumor recurrence 4 21 22 .…”

“…Several case reports found patients with both bilateral UTUC and BT 7 8 9 10 . Nguyen et al proposed the term pan-urothelial urothelial cell carcinoma (panUCC) to describe cancer in both upper urinary tracts and the bladder 11 .…”