A 35-year-old male patient with no relevant medical history, except for heavy smoking (20-30 cigarettes/day for more than 10 years).
He came to the urologist by his bedside doctor after suffering an episode of self-limiting overt hematuria.
Later the patient presented other episodes of small clots emission along with intense irritative voiding syndrome with repeatedly negative urinocultives.
Initially, ultrasound and intravenous urography were performed, which showed a 3 cm diameter bladder trigone tumor with mild left ureteral ectasia.
Renal function was normal (Creatinine: 1.3 mg/dL, plasma urea: 42 mg/dL).
A certain increase in prostatic consistency and bladder floor was observed when rectal examination was performed.
The diagnosis of primary bladder tumor raised the need for transurethral resection.
Intraoperative cystoscopy confirmed the presence of a 2-3 cm sessile bladder neoplasm with bullous and ulcerated surface located on the trigonal area.
The anatomopathological result reported the presence of a neoplasm composed of small undifferentiated cells distributed in "Indian line", with some isolated focus of transitional carcinoma, PSA (-) without being able to determine the tumor origin.
The defect affected the submucosa and muscular base of resection was positive for tumor.
While waiting for the pathology findings in ureteral consolidation and extension studies in anticipation of a possible cystectomy, 36 days after resection, the patient was admitted for a severe constitutional syndrome mEq-12 kg, with loss of renal function
Urgent urinary diversion of percutaneous nephrostomy type was performed, with a rapid restoration of renal function, starting during admission a new episode of macroscopic hematuria.
Cystoscopy showed a large sessile tumor in the bladder base with ineffective ureteral meatus.
The bimanual touch showed an irregular bladder induration resembling prostate.
An extension study was requested by plain chest X-ray, non-pelvic CT scan and bone screening.
At this time, no distant metastatic disease was observed, with the sole objective being thickening of the soil, with bilateral ureteral ectasia, and absence of adenopathy.
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A radical cystoprostatectomy with Indiana reservoir was performed.
During the intervention release of the bladder floor was determined due to the lack of mention of the tumor itself.
The anatomopathological result confirmed the presence of an undifferentiated small cell carcinoma, with immunohistochemical staining: cytokeratin (+), specific neuronal enolase (SEN) and Cromogranin with small foci (-).
The tumor affected the entire thickness of the bladder wall, right perivesical and periureteral fat, rectal wall, prostate, seminal vesicles and 2 of the 8 left common iliac T4 ganglions (Estadium).
Postoperative period was uneventful and the patient was discharged one week after surgery.
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The high risk of recurrence of the disease, given the involvement of surgical margins and presence of lymphadenopathy, the tumor committee of our center decided to perform adjuvant chemotherapy.
The CDDP chemotherapy regimen was established with concomitant radiation therapy to the pelvis at a dose of 50 Gy, at a rate of 180 cGy per session, 5 times a week, and subsequent over-printing with another 14.4 Gy.
Tolerance to this treatment regimen by the patient was optimal.
Three months after the intervention and during the administration of the QT/RT, the patient came to the clinic complaining of discomfort in the right hemiabdomen that radiated to the back without other associated symptoms.
The control non-pelvic CT scan showed a reservoir with good capacity, small dilatation of the right renal pelvis, without evidence of signs of tumor recurrence.
Three months later, the patient developed epigastric pain radiating to both hypochondria, sensation of immediate postprandial dyspepsia and heartburn.
Physical examination revealed a mass in the right hypochondrium-vaccination level, but ultrasound did not reveal any tumor recurrence at this level.
A gastroscopy showed a retention stomach with an extrinsic pyloric-duodenal stenosis. The possibility of a metastatic stenosis secondary to radiation therapy versus a possible radiotherapy was raised.
Located. findings were surgical intervention, showing in the course of the same presence of tumor recurrence in the right flank, tumor and multiple neoplasic implants in the epiduodenum, gastrotoneal invasion.
Postoperatively, the patient was discharged home for palliative care and died one month after discharge (7 months after cystectomy and 9 months after diagnosis).
