Urothelial Carcinoma Presenting Research Articles

S2939 High-Grade Urothelial Carcinoma Presenting as a Rectosigmoid Mass: An Unusual Mimicker of a Primary Colorectal Malignancy

S2939 High-Grade Urothelial Carcinoma Presenting as a Rectosigmoid Mass: An Unusual Mimicker of a Primary Colorectal Malignancy

Abstract C161: Rare Invasive Plasmacytoid Urothelial Carcinoma Presenting as Post-Renal Acute Kidney Injury: A Case Report

Abstract Purpose: Plasmacytoid urothelial carcinoma stands out as a rare and highly aggressive histological subtype within the spectrum of bladder carcinomas, constituting only 1-3% of all variants. Summary: In this case report, we present the case of a 72-year-old patient who initially presented with significant obstructive uropathy and hydronephrosis secondary to invasive plasmacytoid urothelial carcinoma. Admission labs were concerning for a hemoglobin level of 3.8, requiring 3 units of red blood cells for correction, potassium level of 8.8, for which urgent hemodialysis was given, and a lactate level of 5.4. The patient subsequently developed delayed hematuria one month later. Follow-up CT imaging revealed an alarming increase in the size of the bladder mass, underscoring the rapid progression of the malignancy. Discussion: The aggressive nature of this malignant neoplasm can be attributed to its diffuse pattern of infiltration and high risk of residual disease following radical surgery. Clinical manifestations often include abdominal pain, but lack early-onset hematuria and other urinary symptoms typically seen with other subtypes, leading to diagnostic delays and late-stage identification. Conclusion: This case report highlights the uncommon clinical presentation of plasmacytoid urothelial carcinoma (PUC), manifesting as obstructive nephropathy. The inherent aggressiveness associated with PUC poses a challenge in treatment due to the advanced stage of the malignancy at the time of diagnosis. The scarcity of guidelines for the management of PUC underscores the need for extensive future studies to bridge this gap. Citation Format: Andressa Uzeda, Toral Shastri, Kamilia Moalem, Kendra Van Kirk. Rare Invasive Plasmacytoid Urothelial Carcinoma Presenting as Post-Renal Acute Kidney Injury: A Case Report [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C161.

Incidentally detected large upper tract urothelial carcinoma presenting without hematuria and treated with thulium fiber laser—a case report

Incidentally detected large upper tract urothelial carcinoma presenting without hematuria and treated with thulium fiber laser—a case report

The First Ever Robotic-Assisted Laparoscopic Radical Nephrectomy with Inferior Vena Cava Thrombectomy Performed in Thailand: A Case Report of Atypical Presentation of Urothelial Carcinoma with Tumor Thrombus

Background: Robotic-assisted surgery was proposed as an alternative to open surgery for management of inferior vena cava (IVC) thrombus together with radical nephrectomy in complex renal mass. Here, the authors reported the first case of this type to be managed via this surgical technique in Thailand. Case Report: A 76-year-old Thai female presented with right renal mass with tumor thrombus in the IVC extending 3 cm above the level of the renal vein. The presumed diagnosis was renal cell carcinoma of the right kidney with level 2 tumor thrombus in IVC, clinical staging T3bN0M0. The patient underwent robotic-assisted laparoscopic IVC thrombectomy together with right radical nephrectomy at Siriraj Hospital (Bangkok, Thailand) in May 2020. Results: The operation proceeded uneventfully without immediate complication. The postoperative reduction of IVC diameter was approximately 30%. Total IVC clamp time was 50 minutes, operative time was five hours, with docking time of 20 minutes and console time of 250 minutes, estimated intraoperative blood loss was 2,600 mL, and length of hospital stay was four days. At 30-days and 90-days postoperation, no thromboembolic event or compromising lower extremity venous return was detected. The pathological report revealed high-grade urothelial cell carcinoma with invasion into perinephric fat. Carcinoma involvement was observed in the tumor thrombus and IVC wall (T4N0M0). Conclusion: Robotic-assisted surgery of the IVC is a complex operation that requires robotic surgical proficiency and a highly experienced team. The observed success in the present case demonstrated the feasibly of this procedure in Thailand. Additional benefits include less postoperative pain, reduced blood loss, smaller surgical wound size, and shorter length of hospital stay. Keywords: Robotic-assisted laparoscopic radical nephrectomy; Inferior vena cava thrombectomy; Thailand

Urothelial carcinoma in situ with “overriding” features can evade detection by mimicking umbrella cells

Urothelial carcinoma in situ (uCIS) is typically recognized by overtly malignant cells with characteristic nuclear features; multiple histologic patterns have been described. A rare "overriding" pattern, in which uCIS tumor cells extend on top of normal urothelium, has previously been mentioned in the literature, but not well described. Herein, we report 3 cases of uCIS with "overriding" features. Detailed morphologic evaluation revealed somewhat subtle cytologic atypia: variably enlarged hyperchromatic nuclei and scattered mitotic figures but with abundant cytoplasmand limited to superficial urothelium. Immunohistochemical (IHC) analysis showed a distinctive diffuse positive aberrant p53 pattern, limited to the atypical surface urothelial cells; these cells also showed CK20+, CD44-, and increased Ki-67. In 2 cases, there was a history of urothelial carcinoma and adjacent conventional uCIS. In the third case, the "overriding" pattern was the first presentation of urothelial carcinoma; therefore, next-generation sequencing molecular testing was also performed, revealing pathogenic mutations in TERTp, TP53, and CDKN1a to further support neoplasia. Notably, the "overriding" pattern mimicked umbrella cells, which normally line surface urothelium, can have abundant cytoplasm and more variation in nuclear and cell size and shape, and show CK20+ IHC. We therefore also evaluated umbrella cell IHC patterns in adjacent benign/reactive urothelium, which showed CK20+, CD44-, p53 wild-type, and very low Ki-67 (3/3). We also reviewed 32 cases of normal/reactive urothelium: all showed p53 wild-type IHC in the umbrella cell layer (32/32). In conclusion, caution is warranted to avoid overdiagnosis of usual umbrella cells as CIS; however, "overriding" uCIS should be recognized, may have morphologic features that fall short of the diagnostic threshold of conventional CIS, and requires further study.

S1788 Metastatic Urothelial Carcinoma Presenting as Rectal Mass

Introduction: Colorectal cancer is the third most common malignancy worldwide. Metastases to the colon comprise 1% of colorectal neoplasms. We present a case of a new rectal mass discovered on imaging, which was subsequently found to be metastatic urothelial carcinoma. Case Description/Methods: An 81-year-old Hispanic man with history of small bowel resection secondary to mesenteric ischemia, and bladder urothelial carcinoma with metastasis to the lymph nodes, status post transurethral resection of bladder tumor, presented with subacute epigastric pain. Apart from chronic constipation, he denied other gastrointestinal symptoms including abdominal pain, changes in bowel habits, and hematochezia. An abdominopelvic CT was performed for restaging following chemotherapy, and revealed a new heterogeneous enhancing mass in the rectum with extension into the mesorectal fat. The patient underwent flexible sigmoidoscopy with findings of erythematous and congested rectal mucosa without mass or polyps (Figure 1). Biopsy was consistent with carcinoma of urothelial origin, and he was transitioned to third-line chemotherapy due to cancer progression. Discussion: Secondary metastasis to the colorectum is rare, but most prevalent in primary malignancies of the lung, ovary, and breast. Urothelial carcinoma is a malignancy of the transitional cells of the bladder. Typical sites of metastasis include liver, lungs, and bone. Urothelial metastases to the gastrointestinal tract are exceedingly uncommon, with only 33 reported cases in one literature review from 2017. Sixteen of those were metastatic to the rectum. The route of metastasis by urothelial carcinoma is often lymphogenous or hematogenous. When presenting with gastrointestinal involvement, particularly of the rectum, metastasis by direct extension is more common. In our case, there was no evidence of direct extension on imaging, and the likely route of metastasis was lymphogenous. Most patients with metastasis to the gastrointestinal tract present with gastrointestinal symptoms, though up to one-third are asymptomatic and often found on autopsy. Though imaging findings of gastrointestinal masses are concerning for primary malignancy, it is important to consider other causes, such as secondary metastasis.Figure 1.: Endoscopic image of the rectum with erythematous and congested mucosa.

S1621 Bladder in the Colon: A Rare Case of Hematochezia

INTRODUCTION: Colorectal cancer is the most common malignancy in the GI tract. Metastatic lesion to the colon are uncommon, accounting for only 1% of all colorectal neoplasms. The most common form of metastatic spread to the bowel is through peritoneal spreading. Hematogenous and lymphatic spread to the colon is reported in breast carcinoma, lung carcinoma, and melanoma. We present a rare cause of colorectal neoplasm. CASE DESCRIPTION/METHODS: A 65yo male with a history of ESRD and urothelial carcinoma presenting with hematochezia for 2 day. Symptoms began abruptly and were painless. He reported dizziness. He denied prior history of similar episodes. Patient denied melena, constipation, or any other GI symptoms. He is not on blood thinners. Of note, patient has chronic hematuria related to his malignancy, requiring blood transfusions. His most recent outpatient labs 1 week prior revealed a hemoglobin of 8.6g/dL. Patient is on neoadjuvant pembrolizumab. Surgical history included a prior bladder biopsy. He had no reported of prior colonoscopy. He is a former smoker with no other toxic habits and no pertinent family history. On admission, HR 110, BP 85/50, and was afebrile, saturating 100% on room air. Exam was remarkable for conjunctival pallor. Rectal exam revealed red blood without notable masses or lesions. Labs were significant for a hemoglobin of 7.1g/dL, creatinine of 3.5 and BUN of 42. The remainder of his CBC and CMP were unremarkable. He was transfused 1unit packed red blood cells and given IV fluids with improvement in his BP. He underwent a colonoscopy which revealed a 4 × 3 cm cecal mass with an adherent clot. The mass was injected with epinephrine, clot was successfully removed, and the mass was biopsied. Additionally, there was blood throughout the colon, and non-bleeding diverticuli in the transverse and sigmoid colon. Pathology revealed high grade carcinoma consistent with metastatic urothelial carcinoma, morphologically similar to his prior TURP specimens. Patient had a follow-up CT C/A/P that showed no other notable metastatic disease with stable bladder mass noted on a surveillance CT scan 3 months prior. Patient went for a right hemicolectomy for further management. Patient had oncologic followup for treatment. DISCUSSION: Although colon malignancy is common, metastatic urothelial cancer isolated in the colon is rare. Managing such cases is difficult as literature is unavailable. Further research is needed to understand methods of metastasis, predicting outcomes, and managing patients.Figure 1.: Cecal mass with notable adherent clot.Figure 2.: Cecal mass status post epinephrine injection and clot removal.

Clinico-pathological characteristics and outcome of upper urinary tract urothelial carcinoma presenting to a tertiary care urology unit in Sri Lanka

Upper urinary tract urothelial cancers account for 5% of urothelial tumours. In the West, the majority affect the pelvicalyceal system, with pyelocalyceal to ureteric ratio of 3:1. This study aims to describe the clinico-pathological features and outcome of upper urinary tract urothelial cancer treated surgically in a tertiary care unit in Sri Lanka. A retrospective analysis of all patients who underwent nephroureterectomy for upper urinary tract urothelial cancer at the Urology Unit at National Hospital of Sri Lanka between January1997 and December 2016 was carried out. There were 43 patients. Male: female=1.87. Median age was 65 years (range:42-83). Macroscopic haematuria was the commonest presentation (n=29; 67.4%). Median duration of symptoms was 3 months (range 0.5-6). In the majority (n=20;46.5%) the tumour was confined to the ureter. Thirty-three (75.6%) were papillary tumours. Twenty-one had non-muscle invasive tumours (pTa: n=6(14%), pT1: n=15(34.9%) and others had invasive cancers (pT2: n=11(25.6%), pT3: n=7(16.3%) and pT4: n=4(9.3%)). Majority were low grade tumours (n=23;53.5%). Twelve (27.9%) had preceding urothelial bladder cancer. Nineteen (44.2%) were lost to follow up after surgery. Median follow up duration of the rest was 40 months (range:4-224months). Of them, 9(20.9%) developed metachronous bladder tumours. Nine had recurrence free survival of ≥5years and 15 had overall survival of ≥5 years. Of them, 4 patients survived ≥10 years. Older age (p=0.015) and presence of necrosis(p=0.05) were the only clinico-pathological parameters predictive of tumour recurrence. A relatively higher number females and high number of ureteric tumours were noted compared to similar studies from Asia.

Vulvar extramammary Paget's disease secondary to urothelial carcinoma presenting with a small painful erosion of the vulva

Vulvar extramammary Paget's disease secondary to urothelial carcinoma presenting with a small painful erosion of the vulva

Abstract #509: Recurrent Urothelial Carcinoma Presenting with Hypercalcemia

Abstract #509: Recurrent Urothelial Carcinoma Presenting with Hypercalcemia

Incidental upper tract urothelial carcinoma presenting as pyonephrosis

Upper tract urothelial carcinomas (UTUCs) are uncommon and account for only 5%–10% of urothelial carcinomas. The most common symptom of UTUC is gross or microscopic hematuria (70%–80%). A 55-year-old woman admitted with the history of fever and pain in abdomen for the past 20 days. Her history was not significant. She underwent right nephroureterectomy with the provisional clinical diagnosis of pyonephrosis with nonfunctioning kidney. Histopathological examination of nephrectomy specimen showed features of high-grade urothelial carcinoma with renal parenchyma invasion (T3N0M0). Here, we present a rare case of incidental UTUC presenting as pyonephrosis.

Bladder metastasis presenting as neck, arm and thorax pain: a case report.

BackgroundA case of metastatic carcinoma secondary to urothelial carcinoma presenting as musculoskeletal pain is reported. A brief review of urothelial and metastatic carcinoma including clinical presentation, diagnostic testing, treatment and chiropractic considerations is discussed.Case presentationThis patient presented in November 2014 with progressive neck, thorax and upper extremity pain. Computed tomography revealed a destructive soft tissue mass in the cervical spine and additional lytic lesion of the 1st rib. Prompt referral was made for surgical consultation and medical management.ConclusionDistant metastasis is rare, but can present as a musculoskeletal complaint. History of carcinoma should alert the treating chiropractic physician to potential for serious disease processes.

Giant muscular metastasis of urothelial carcinoma presenting as a cause of extraspinal sciatica

Giant muscular metastasis of urothelial carcinoma presenting as a cause of extraspinal sciatica

Correction: Hydronephrotic Urine in the Obstructed Kidney Promotes Urothelial Carcinoma Cell Proliferation, Migration, Invasion through the Activation of mTORC2-AKT and ERK Signaling Pathways

Obstructive nephropathy is the most common presentation of urothelial carcinoma. The role of the urine in the obstructed kidney namely “hydronephrotic urine” in urothelial carcinoma has not been extensively explored. This study aims to evaluate whether hydronephrotic urine in the obstructed kidney could promote urothelial carcinoma. The hydronephrotic urine was collected from the obstructed kidneys of Sprague-Dawley rats induced by different periods of unilateral ureteral obstruction (UUO). By the inhibition of LY294002 and PD184352, we confirm that hydronephrotic urine promotes urothelial carcinoma cell (T24) and immortalized normal urothelial cells (E6) proliferation, migration and invasion in a dose-dependent manner through the activation of the mTORC2-AKT and ERK signaling pathways. Hydronephrotic urine also increases the expression of cyclin-D2, cyclin-B and CDK2. It also decreases the expression of p27 and p21 in both urothelial carcinoma cells and normal urothelial cells. By the protein array study, we demonstrate that many growth factors which promote tumor cell survival and metastasis are over-expressed in a time-dependent manner in the hydronephrotic urine, including beta-FGF, IFN-γ, PDGF-BB, PIGF, TGF-β, VEGF-A, VEGF-D and EGF. These results suggest that hydronephrotic urine promotes normal and malignant urothelial cells proliferation, migration and invasion, through the activation of the mTORC2-AKT and ERK signaling pathways. Further investigation using live animal models of tumor growth may be needed to clarify aspects of these statements.

Incidental Identification of Metastatic Urothelial Carcinoma Presenting In an Incarcerated Ventral Hernia Sac

Metastatic urothelial carcinoma in an incarcerated ventral hernia is exceedingly rare. Herein, we report a case of a 52 year-old man who had multiple incarcerated ventral hernias with metastatic urothelial carcinoma. Patient with a set of large abdominal wall hernias initially presented in septic shock with small bowel obstruction complicated by perforation, for which he required emergent exploration and repair of the hernias. Grossly, the “hernia sac” specimen consisted of firm fibromembranous tissue with an infiltrating tan-white mass. Histologically, the hernia sac revealed extensive tumor infiltrates in a background of desmoplastic stroma accompanied by fibrinoid necrosis. The tumor showed nests and sheets like growth pattern with predominant squamous differentiation. Immunohistochemical analysis showed the tumor to be diffusely and strongly positive for GATA3, 34betaE12, CK5/6 and P63, focally (5%) and weakly positive for CDX2, negative for CK20, D2-40, calretinin. The morphology and immunohistochemical profile supported the diagnosis of metastatic urothelial carcinoma with squamous differentiation. The patient died two weeks post-surgery. GATA3 immunoreactivity plays an important role in distinguishing urothelial carcinoma from squamous cell carcinoma and prostate carcinoma

A Rare Case of Metastatic Urothelial Carcinoma Presenting With Rectal Obstruction

Purpose: Urothelial carcinoma of the bladder is the fourth most common malignancy in men, and has metastatic potential, with the most common sites of metastasis being lymph nodes, bone, lungs, liver, and peritoneum. This is a rare case of metastatic urothelial carcinoma presenting with rectal obstruction. Methods: Case report and literature review. Results: We discuss here the case of a 59-year-old gentleman with a history of urothelial carcinoma of the kidney and bladder that was diagnosed 24 years ago and treated with BCG. Subsequently, he had involvement of both the ureters, and underwent resection as well as chemotherapy. The patient was referred to our institution for evaluation of new onset diarrhea. He had battled constipation for a few months, which responded to an aggressive bowel regimen. He had, however, noted that even after he stopped his bowel regimen, the diarrhea persisted and then started worsening. He reported having more than 10-20 liquid bowel movements daily, with some associated mild, crampy, lower abdominal pain. He also noted increased urgency, and decreased control over his bowel movements. Moreover, in the weeks preceding his appointment, the patient started wearing diapers, as he had developed almost continuous leakage of thin, yellowish, watery, stool. He was started on cholestyramine for symptomatic relief, and had an outpatient CT scan done showing gas and solid stool debris in ascending, transverse, and descending colon. The rectum and sigmoid colon were noted to have diffuse circumferential thickening, with extension into the anus. Subsequent colonoscopy demonstrated an area of annular constriction in the rectosigmoid, with biopsies consistent with metastatic urothelial carcinoma. Conclusion: It is unusual for metastatic urothelial cancer to present with rectal obstruction, and, to date, there are eight other case reports of patients with metastatic bladder cancer presenting with annular rectal constriction. Similar to our patient, the majority of these patients presented with symptoms of rectal obstruction, with symptoms varying from change in bowel habits with narrow caliber stools and rectal pain to constant, watery rectal discharge. Treatment options also varied, but the majority of patients eventually needed a colostomy. It is imperative that the clinician always approach gastrointestinal complaints with a broad perspective, and keep metastatic cancer on the differential.Figure 1

120 The curative potential of lymphadenectomy after response to chemotherapy in patients with urothelial carcinoma presenting with regional or distant nodal metastases: Analysis of a series from a tertiary cancer centre

120 The curative potential of lymphadenectomy after response to chemotherapy in patients with urothelial carcinoma presenting with regional or distant nodal metastases: Analysis of a series from a tertiary cancer centre

Hydronephrotic Urine in the Obstructed Kidney Promotes Urothelial Carcinoma Cell Proliferation, Migration, Invasion through the Activation of mTORC2-AKT and ERK Signaling Pathways

Obstructive nephropathy is the most common presentation of urothelial carcinoma. The role of the urine in the obstructed kidney namely “hydronephrotic urine” in urothelial carcinoma has not been extensively explored. This study aims to evaluate whether hydronephrotic urine in the obstructed kidney could promote urothelial carcinoma. The hydronephrotic urine was collected from the obstructed kidneys of Sprague-Dawley rats induced by different periods of unilateral ureteral obstruction (UUO). By the inhibition of LY294002 and PD184352, we confirm that hydronephrotic urine promotes urothelial carcinoma cell (T24) and immortalized normal urothelial cells (E6) proliferation, migration and invasion in a dose-dependent manner through the activation of the mTORC2-AKT and ERK signaling pathways. Hydronephrotic urine also increases the expression of cyclin-D2, cyclin-B and CDK2. It also decreases the expression of p27 and p21 in both urothelial carcinoma cells and normal urothelial cells. By the protein array study, we demonstrate that many growth factors which promote tumor cell survival and metastasis are over-expressed in a time-dependent manner in the hydronephrotic urine, including beta-FGF, IFN-γ, PDGF-BB, PIGF, TGF-β, VEGF-A, VEGF-D and EGF. These results suggest that hydronephrotic urine promotes normal and malignant urothelial cells proliferation, migration and invasion, through the activation of the mTORC2-AKT and ERK signaling pathways. Further investigation using live animal models of tumor growth may be needed to clarify aspects of these statements.

Metastases From Nested Variant Urothelial Carcinoma of the Urinary Bladder in Pancreatic Allograft Mimicking Graft Rejection

While not an uncommon tumor, urothelial carcinoma of the urinary bladder is rare in bladders draining pancreatic allografts. A case of urothelial carcinoma directly involving a pancreatic allograft with metastasis that occurred in a 49-year-old pancreas and kidney transplant recipient is described. Her initial clinical presentation and findings of CT scan of the abdomen suggested pancreatitis with features worrisome for rejection. A biopsy of her pancreatic allograft contained poorly differentiated carcinoma and cystoscopic biopsy disclosed an invasive high grade urothelial carcinoma arising in the background of extensive urothelial carcinoma in situ. Exploratory laparotomy revealed that the tumor invaded the right ovary and fallopian tube, cecum, and allograft with extensive retroperitoneal involvement. She underwent en bloc resection of distal ileum and cecum, resection of transplant pancreas, partial cystectomy, ileocolostomy anastomosis, and right salpingo-oophorectomy. Postoperatively, the patient was treated with four cycles of carboplatin and gemcitabine. She ultimately succumbed to her disease approximately 1 year after diagnosis. This case should alert physicians and radiologists to be aware of atypical presentation of urothelial carcinoma in bladder-drained pancreas grafts, the aggressiveness of such lesions, and the need for early biopsy to avoid diagnostic confusion with rejection.KeywordsBladder cancer; Nested variant of urothelial carcinoma; Pancreas and kidney transplantation

Clinical Stage T1 Micropapillary Urothelial Carcinoma Presenting With Metastasis to the Pancreas

Micropapillary carcinoma of the bladder is an extremely aggressive variant of urothelial carcinoma. Radical cystectomy is the standard treatment for all patients, including those with nonmuscle-invasive disease. We present a patient diagnosed with clinical Stage T1 micropapillary carcinoma of the bladder who was found to have a 2-cm metastasis to the head of the pancreas. To our knowledge, this case represents the first report of a solitary metastatic urothelial carcinoma to the pancreas.