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case_images: Imaging examination of patients before operation. (A) Coronal view of pelvic X-ray film revealed a shadow on the left bladder wall (white arrow). (B) Axial view of pelvic enhanced computed tomography (CT) revealed a cauliflower-like space-occupying lesion in the left anterior wall of the bladder.
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case_images: His enhanced computed tomography (CT) scan conducted last month revealed a mass that had invaded the serous membrane layer on the left bladder sidewall ( Figures 1A, B ). Additional pathology H&E images showcasing a magnified view of the large pleomorphic cells with mitosis can be accessed in  Supplementary Figure 1 .
case_images: Pathological morphology and immunohistochemical results. (A) The tumor cells showed pleomorphism and invasive distributions (hematoxylin-eosin, x200). (B) Typical mitotic phase can be seen in tumor cells (red arrow) (hematoxylin-eosin, x400). The immunohistochemical staining of tumor cells showed (C) broad positivity for CD56 (x100), (D) diffuse positive expression of synaptophysin (x100), (E) focal positive expression of CK7 (x100), (F) negative expression of CgA (x100), (G) wildly positive expression of Ki-67 (x100), and (H) local positive rate of PD-L1 stain (x200).
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case_images: The tumor primarily consisted of large pleomorphic cells with moderate cytosolic volume and coarse nuclear chromatin, arrayed in trabecular and rosette patterns, as disclosed by microscopic examination ( Figures 2A, B ). The result revealed broad positivity for cytokeratin (CK), CD56 ( Figure 2C ), and synaptophysin ( Figure 2D ), as well as localized positivity for CD138 and CK7 ( Figure 2E ). The results for GATA3, NSE, HER2, and CgA ( Figure 2F ) were found to be negative. The Ki-67 proliferation index was found to be greater than 90% ( Figure 2G ). The expression of PD-L1 by tumor cells was seen to be 3% ( Figure 2H ), whereas the expression by infiltrating immune cells was 1%. The tumor exhibited infiltration of the outer mold of the bladder, with several invasions of vascular, lymphatic arteries, and nerves.
case_images: The timeline from disease discovery to patient diagnosis and treatment.
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case_images: His final CT reexamination in July 2023 revealed no recurrence, and he did not exhibit any immune-related adverse reactions during the two years after the primary diagnosis.  Figure 3  depicts the onset, examination, and treatment schedule for this patient.