Case report of a rare urinary bladder tumor variant (carcinosarcoma).

Carcinosarcoma of the bladder is a rare and aggressive variant of bladder tumor. The causes are not clear for this bladder tumor variant. Early diagnosis with immediate surgical resection is the most accepted management as reported so far in the literature, but the optimal management is unknown to date. Here, we report a case of a 62-year-old woman with bladder carcinosarcoma who presented with macroscopic hematuria. Copyright:

INTRODUCTION

Carcinosarcoma is defined by the World Health Organization as a biphasic tumor consisting of malignant epithelial and mesenchymal elements.[1]

It is a rare bladder neoplasm that has a male-to-female ratio of 2:1 and tendency to present within the seventh decade of life.

Behavior of the neoplasm and optimal management remain controversial due to disease rarity.[2]

The disease tends to present with advanced stage (70%), and the usual presenting symptoms are macroscopic hematuria and dysuria.[2]

A series of 221 cases using the surveillance, epidemiology, and end results program database has been reported, and approximately 70 cases have been reported in the literature mostly as a case report or limited series.[3]

Here, we report a 62-year-old woman who was diagnosed to have right lateral bladder wall tumor (carcinosarcoma) when she presented with right loin pain associated with macroscopic hematuria for 2 months.

CASE REPORT

A 62-year-old female, medically free, presented to our emergency department complaining of right loin pain and gross hematuria. She reported that the pain is on and off for 2 months, mild to moderate in intensity, which have been associated with on and off macroscopic hematuria for the last month, no history of stone disease, smoking, radiation exposure, or previous surgical procedures.

On examination

The well-built female patient does not look in pain and is vitally stable; the abdomen examination is unremarkable.

Bedside ultrasound showed right-sided hydronephrosis and bladder mass on the right lateral wall.

Computed tomography scan with intravenous contrast showed right-sided bladder mass with bladder wall thickening involving the right ureterovesical junction [Figure 1a and b] with right-sided hydroureteronephrosis; no lymph nodes or distal metastatic lesions were seen.

Figure 1

(a) Computed tomography scan showing right hydronephrosis with right hydroureter with tortuosity and enhancing bladder mass on the right bladder wall and (b) right bladder wall mass at the UV junction which was the cause of ureteric obstruction

The patient underwent diagnostic cystoscopy which showed bladder lesion at the right lateral wall obscuring the right ureteric orifice, which could not be identified due to the tumor.

Transurethral resection of the bladder tumor (TURBT) was done.

Postoperative hospital course was smooth and uneventful, and the patient was discharged home and given outpatient department appointment.

Histopathology report

The histopathology report for the resected bladder mass showed a urinary bladder tumor, nonpapillary undifferentiated variant, high-grade muscle invasion [Figure 2a] with both epithelial [Figures 2 and 3b] and sarcomatous pattern [Figure 3a]; the final histopathology diagnosis reported as carcinosarcoma.

Figure 2

(a) Malignant cells infiltrating through the bladder wall muscular layer. (b) Sheet of malignant cells show pleomorphic nuclei (more epithelioid)

Figure 3

(a) Microscopic picture showing cells positive for vimentin stain representing mesenchymal component (sarcomatous component). (b) Microscopic picture showing cells positive for pan-cytokeratin stain representing epithelioid component

Management

After TURBT, diagnosis of muscle invasive bladder carcinosarcoma was made. The situation was explained to the patient. She was referred to the oncology center where she underwent radical cystectomy with ileal conduit. She will be followed up with periodic imaging monitoring for recurrence.

DISCUSSION

Bladder carcinosarcoma is a rare bladder tumor entity, with few case reported with no clear management path for, as reviewed in literature. There was no clear cause for this bladder tumor variant with some reporting smoking or cyclophosphamide chemotherapy or radiotherapy as possible causes.[4] The disease tends to be aggressive and usually presents at an advanced stage, and from reported cases, surgical resection is the proper decision, due to the aggressiveness of the disease.

CONCLUSION

Bladder carcinosarcoma is a rare and aggressive disease that progresses rapidly. Radical cystectomy at early stage as soon as diagnosis is made should be considered as observed in the various reported cases. Still, larger case study is needed for better understanding of the pathophysiology of the disease and therefore tailoring an optimal management guideline.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.