Successful Bladder-Sparing Partial Cystectomy for Muscle Invasive Domal Urothelial Carcinoma with Sarcomatoid Differentiation: A Case Report

Abstract

Background: High Grade (HG) Urothelial Carcinoma (UC) with variant histology has historically been managed conservatively and continues to create a conundrum for clinical urologists. The presented case details a solitary lesion of Muscle Invasive Bladder Cancer (MIBC) with sarcomatoid variant (SV) histology treated by partial cystectomy and adjuvant chemotherapy without evidence of HG recurrence in 8 years of surveillance. Case Presentation: A 71-year-old male with a 15-pack year smoking history presented to clinic after outside transurethral resection of bladder tumor (TURBT). Imaging by CT abdomen and pelvis was negative for pelvic lymphadenopathy or abnormalities in either collecting system. A 2 cm broad based papillary tumor at the bladder dome was identified. Complete staging TURBT noted a final pathology of invasive HG UC with areas of spindle cell differentiation consistent with sarcomatous changes and no evidence of lymphovascular invasion. The patient was inclined toward bladder preserving options. Partial cystectomy with a 2 cm safety margin and bilateral pelvic lymphadenectomy was performed. Final pathology revealed HG UC urothelial carcinoma with sarcomatoid differentiation and invasion into the deep muscularis propria, consistent with pathologic T2bN0 disease, a negative margin, and no lymphovascular invasion. The patient subsequently pursued four doses of adjuvant doxorubicin chemotherapy though his treatment was complicated by hand-foot syndrome. The patient continued screening with cystoscopy, urine cytology, and CT. At 21 months post operatively, the patient developed a small (<1cm) papillary lesion near but uninvolved with the left ureteral orifice. Blue light cystoscopy and TURBT revealed noninvasive low grade Ta urothelial carcinoma. To date, the patient has no evidence of high-grade urothelial carcinoma recurrence; 8 years after partial cystectomy. Patient maintains good bladder function and voiding every 3-4 hours with a bladder capacity around 350 ml. Conclusion: Surgical extirpation with partial cystectomy followed by adjuvant chemotherapy may represent a durable solution for muscle invasive (pT2) UC with SV histology if tumor size and location are amenable for partial cystectomy. Due to the sparse nature of sarcomatous features within urothelial carcinoma, large multicenter studies are required to further understand the clinical significance and optimal management options for this variant histology in the management of bladder cancer.