Advances in Human Biology

CASE REPORT
Year
: 2018  |  Volume : 8  |  Issue : 2  |  Page : 124--126

A rare case of small cell carcinoma of urinary bladder in a bladder diverticulum: Case report and review of literature


Kandarp Priyakant Parikh, Ravi Jineshkumar Jain, Aditya Kandarp Parikh 
 Department of Genito Urinary Surgery, Minimal Access Surgery Training Institute, Shyam Urosurgical Hospital, Ahmedabad, Gujarat, India

Correspondence Address:
Ravi Jineshkumar Jain
Department of Genito Urinary Surgery, Minimal Access Surgery Training Institute, Shyam Urosurgical Hospital, Parimal Garden Cross Roads, Ellisbridge, Ahmedabad - 380 006, Gujarat
India

Abstract

Small cell carcinoma of the urinary bladder (SCCB) is a rare and aggressive non-urothelial tumour of the urinary bladder. It represents neuro endocrine type of malignancy, being diagnosed on histopathology and immuno histo chemistry. Bladder diverticulum tumours are rare and present with early lamina propria invasion. Furthermore, the risk of bladder perforation is high during resection due to the lack of muscle. Thus, these tumours have a risk of being under-staged and have a poor prognosis. Till now, very few cases have been reported of SCCB in bladder diverticulum. Multi-modality management in the form of combined chemotherapy and surgery is required for the optimal management. We report this rare case and review the literature for the management of SCCB in bladder diverticulum.



How to cite this article:
Parikh KP, Jain RJ, Parikh AK. A rare case of small cell carcinoma of urinary bladder in a bladder diverticulum: Case report and review of literature.Adv Hum Biol 2018;8:124-126


How to cite this URL:
Parikh KP, Jain RJ, Parikh AK. A rare case of small cell carcinoma of urinary bladder in a bladder diverticulum: Case report and review of literature. Adv Hum Biol [serial online] 2018 [cited 2020 Jan 26 ];8:124-126
Available from: http://www.aihbonline.com/text.asp?2018/8/2/124/232029


Full Text

 Introduction



Transitional cell carcinoma (TCC) is the most common urothelial malignancy of urinary bladder.[1] Small cell carcinoma of the urinary bladder (SCCB) is a rare non-urothelial malignancy with high malignant potential. It represents neuro endocrine type of malignancy, being diagnosed on histopathology and immuno histo chemistry (IHC).[2] Bladder diverticulum represents an uncommon site of tumour. Lack of detrusor muscle in bladder diverticulum leads to early penetration and poor prognosis.[3] Till date, <10 cases of SCCB in bladder diverticulum have been reported. Multi-modality management in the form of combined chemotherapy and surgery is recommended.

 Case Report



A sixty six year old male presented with 3-4 episodes of painless hematuria with clots since 1 month. He also had mild storage and voiding lower urinary tract symptoms. He was a cobbler and did not have any addiction. He was a known case of ischaemic heart disease and was on tablet Ecosprin. General examination was normal. On per rectal examination, prostate was Grade 2 enlarged with firm consistency. No mass was palpable on bimanual examination. Haemogram and coagulation profile were normal. Serum creatinine was 1.56 mg/dl (normal mean range: 0.8–1.2 mg/dl). Urine routine microscopy showed plenty of red blood cells with few pus cells. Urine culture was sterile. Ultrasound abdomen pelvis showed a 4 cm × 3 cm papillary mass lesion arising from left lateral wall of bladder, adjacent to a bladder diverticulum. Ultrasonography also showed left absent kidney with normal right kidney. Chest X-ray was normal.

With informed consent and physician fitness, the patient was posted for bimanual examination under anaesthesia and transurethral resection of bladder tumour (TURBT). Ecosprin was withheld 5 days prior. Under general anaesthesia, the tumour was not palpable on bimanual examination. Panendoscopy was performed with a 30° white light cystoscopy. Urethra and bladder neck were normal. Prostate was enlarged, and bladder showed trabeculations. A wide mouth diverticulum was seen on left anterolateral wall with a papillary growth arising from it. Left ureteric orifice could not be identified. Right ureteric orifice was normal, TURBT was performed, margins of the diverticulum were fulgurated and adjacent muscle biopsies were taken [Figure 1]. Mild haematuria was noted postoperatively. The catheter was removed on the 3rd post-operative day and patient voided well.{Figure 1}

Histopathology report came out as small cell carcinoma of bladder with lamina propria invasion. The sections showed fragments of neoplasm composed of cells arranged in nests and sheets. Tumour cells with scanty cytoplasm and round to oval hyperchromatic nuclei with granular chromatin were seen. Frequent mitotic figures and large areas of tumour necrosis were seen [Figure 2]. Detrusor muscle was not seen. On IHC, the tumour stained positive for synaptophysin and CD56 and focally positive for chromogranin A [Figure 3]a and [Figure 3]b. Post-operative computed tomography (CT) scan of the chest, abdomen and pelvis was done for local staging and metastatic workup. There was no evidence of pulmonary origin of the small cell carcinoma or chest metastasis. Patient has a solitary right kidney. Multi-management in the form of chemotherapy with radical cystectomy and suitable urine diversion is being planned.{Figure 2}{Figure 3}

 Discussion



Small cell carcinoma represents a rare malignancy of the urinary bladder. It was first reported in 1981 by Cramer et al.[4] The reported incidence is <1–9/1,000,000.[5] It is a highly aggressive tumour with poor prognosis due to metastatic potential. SCCB mostly has a pulmonary origin. However, extrapulmonary sites of origin such as urinary bladder have been documented. SCCB usually coexists with TCC, squamous cell carcinoma, adenocarcinoma or may be in pure form.[6] Multiple theories have been proposed regarding its pathogenesis such as malignant transformation of neuroendocrine cells in bladder, urothelial metaplasia and multipotent stem cell origin.[7] Bladder diverticulum is herniation of the bladder mucosa through areas of weakness of detrusor muscle. Lack of muscle predisposes to urinary stasis and malignancy.[3]

The most common presenting symptom of SCCB is haematuria and dysuria. Abdominal pain, urinary tract infection, urinary obstruction and paraneoplastic syndromes can be rare presenting features.[7] Diagnosis is based on histopathology and IHC. Immuno staining for Neuron specific Enolase, Synaptophysin, Chromogranin, epithelial markers such as CK7 and CD56, point towards the diagnosis of SCCB. CT abdomen pelvis and chest CT are required for local staging and metastatic work-up.[7] The common locations of metastasis are retroperitoneal lymph nodes, liver, lung, bone and brain.[7]

Patients with localised SCCB are considered as a surgically resectable disease (≤T1-4aN0M0). Neoadjuvant platinum-based chemotherapy followed by surgery is favoured. A study of 46 patients treated at the M. D. Anderson Cancer Centre has reported a 5-year survival of 78% for patients receiving neoadjuvant chemotherapy followed by cystectomy, versus 36% for patients undergoing cystectomy alone.[7],[8],[9] Neoadjuvant chemotherapy is proposed to target the micrometastasis, facilitate downstaging of the tumour, is better tolerated preoperatively with normal renal function and has a good response in chemo-sensitive SCCB. Etoposide and cisplatin remain the first-line platinum-based chemotherapy. No clear data define the role of adjuvant CT after primary surgery of invasive bladder SCCB.[7],[8],[9]

The gold standard treatment for TCC of bladder diverticulum is radical cystectomy. Due to rarity of SCCB in bladder diverticulum, no clear guidelines are available for management. Bladder-preserving strategies, such as partial cystectomy ± lymphadenectomy ± prostatectomy, have also been advocated for diverticular tumours.[10]

Patients with regional or non-regional (retroperitoneal or distant) lymph nodes or with distant metastasis have surgically unresectable disease (≥cT4bN+M+) and require systemic chemotherapy.[7],[8],[9] Radiotherapy is reserved for symptomatic brain or bone metastasis or cord compression.

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.

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