A 40-year-old woman, with no relevant pathological history, came to the clinic for presenting during the last month 8-10 episodes of macroscopic hematuria, painless and without clots.
He also reported increased micturition frequency, voiding and tenesmus of the bladder, so he has followed treatment with ciprofloxacin and Diclofenac for one week without evidence of improvement.
Physical examination showed no evidence of interest (non-painful radiation-signs, negative bilateral percussion).
Ultrasound showed an intravesical mass of 35.7 mm in maximum diameter, with sonographically normal kidneys.
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Flexible cystoscopy revealed a large bilobulated mass in the posterior wall of appearance with partially necrotic areas.
Thoracoabdominal computed tomography (CT), bone scintigraphy and transurethral resection (TUR) biopsy were performed to establish the diagnosis and assess the extent of the disease.
CT shows a well-defined 8.5 cm bladder mass with no signs of bladder inversion or evidence of lymphadenopathy of significant size.
The extension study was completed with a normal bone scintigraphy.
The pathological study of TUR shows the presence of a mesenchymal, fusocellular tumor with long bundles of spindle cells and frequent mitosis.
Immunohistochemical study showed intense immunoreactivity with vimentin and specific muscle actin.
With the diagnosis of clinically localized bladder leiomyosarcoma it was decided to perform anterior pelvic exenteration (radical cystectomy, hysterectomy plus double adnexectomy and ileal urinary diversion).
The pathology report of the surgical specimen revealed a tumor in the posterior wall of the bladder with exophytic and elastic growth of 8.5 x 4 cm, with consistency of 3 cm in diameter.
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It was a malignant mesenchymal tumor of elongated cells, with long-silent margins and rome cytoplasms.
Mitosis figures (20 mitosis per 10 high-power fields) are shown in some areas.
The tumor was located in the bladder wall, without affecting the surface urothelium or the bladder muscular layer, and its origin was in the muscular layer of the submucosa (Muscularis Mucosae).
The study of the iliac and ilio-obturatric ganglia, as well as the perivesical fat and the rest of the studied structures showed no alteration.
After a postoperative period with no relevant incidents, it was decided to complete the treatment with adjuvant chemotherapy that the patient, with Adriamycin and Ifosfamide performed in her reference center, receiving a total of 6 cycles (1 monthly) with good tolerance.
The onset of the cycle was established on one occasion due to fever.
One year after concluding the regional treatment, the patient presented a locoregional recurrence in a CT performed during a review.
The lesion was excised, with a pathological report of leiomyosarcoma measuring 6.5 cm in diameter with an affected border.
It was decided to complete the adjuvant chemotherapy-based quiciotherapy treatment with high-dose Ifosfamide (3,520 mg every 24 hours for 5 days), of which 6 cycles were administered, one monthly.
After completing the first two cycles of chemotherapy, she received external radiotherapy, at a rate of 1.8 Gy/day, until completing a total dose of 45 Gy on the tumor bed and then a pelvic overprint of 16 Gy until completing a single dose.
Later he went to regular reviews.
Eight months after the end of the second adjuvant treatment, 32 months after the diagnosis, the patient again presented a pelvic recurrence of 5 x 5.8 cm, with probable rectum-sigma and bladder recurrence.
Rectosigmoidoscopy was performed with needle aspiration biopsy, with pathological result of malignant cytology, fusocellular sarcoma compatible with leiomyosarcoma.
Immunohistochemical studies were performed with antibodies against Caldesmon and smooth muscle myosin, intense immunoreactivity of tumor cells against both antibodies.
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With the diagnosis of second recurrence it was recommended to perform surgical resection with consolidation with brachytherapy.
The patient was discouraged performing surgery with brachytherapy for fear of complications of brachytherapy, so she was operated in another center, performing posterior pelvic exation.
In the first follow-up after surgery, three months after surgery, the patient presented a new recurrence at the level of the incision, with resection of the incision.
Currently, and 41 months after the initial diagnosis, the patient is asymptomatic, in periodic controls and without evidence of disease.
