November 2021 Imaging Case of the Month: Let’s Not Dance the Twist

No abstract available. Article truncated after the first 150 words. History of Present Illness: An 82-year-old man presented to his physician for general health maintenance as well as a complaint of persistently poor quality sleep and poor appetite with weight loss. The patient had undergone robotic-assisted radical left nephroureterectomy and cystectomy with pelvic lymph node dissection and urinary diversion for left clear cell renal cell carcinoma (staged T2a, grade 2) and transitional cell carcinoma of the bladder (carcinoma in situ at surgery), approximately 9 months earlier. The patient’s bladder malignancy was initially treated with transurethral resection, with histopathology at that procedure showing high-grade papillary urothelial malignancy with lamina propria invasion, but no muscular invasion; this procedure was followed by formal complete resection approximately 3 months later. The patient’s post-operative course was complicated by significant bleeding which required transfusion of 3 units of blood. He had undergone inferior vena caval filter placement prior to surgery when preoperative testing revealed lower extremity …

PRIMARY BLADDER AMYLOIDOSIS - A GREAT MIMICKER OF UROTHELIAL MALIGNANCY.

Primary bladder amyloidosis is a rare condition that often mimics bladder malignancy. Here we report a case of primary bladder amyloidosis presenting as gross hematuria with clots which was managed by cystoscopy and fulguration. It is a diagnosis of exclusion usually revealed in the histopathological examination and is a relatively benign disease with better outcomes.

Incidence of various urothelial malignancy in patients undergoing transurethral resection of bladder tumour in tertiary care hospital

Background: Urinary bladder lesions are a great health concern as it lies among the top ten most common cancers in the world. These range from benign, harmless lesions that do not recur to life threatening tumors. The present study was undertaken to study incidence of various urothelial cancer in patients undergoing transurethral resection of bladder tumor in tertiary care hospital, as the treatment, follow up and prognosis is highly variable with different subtypes of bladder cancer.Methods: A hospital based descriptive cross-sectional study was conducted on all patients undergoing transurethral resection of bladder tumor from December 2018 to May 2020 in the Department of General Surgery of Sri Guru Ramdas Institute of Medical Sciences and Research, Amritsar. Based on World Health Organization (WHO) classification incidence of various urothelial malignancy was calculated.Results: Out of 80 patients with growth urinary bladder, 4 patients (5% of total patient) were diagnosed as case of papilloma, 26 patients (32.5% of total patients) were diagnosed as low grade papillary urothelial carcinoma, 50 patients (62.5% of total patients) were of high grade papillary urothelial carcinoma. There were no case of PUNLMP in our study.Conclusions: It can be concluded that majority of the patient undergoing transurethral resection of bladder tumor are diagnosed with high grade papillary carcinoma.

Urothelial Neoplasms of Urinary Bladder - A Clinicopathological Correlative Study

BACKGROUND Transitional cell carcinoma also known as urothelial carcinoma accounts for more than 90 % of all primary tumours of urinary bladder. It is the 4 th most common cancer in men and 8 th most common cancer in women in the western world. Nearly 80 % of patients initially present with bladder tumours confined to mucosa or submucosa. Not grading but detection of infiltration is of much value when dealing with invasive urothelial malignancy. When it invades muscle, it dictates more aggressive treatment. This study was undertaken to correlate the clinical, radiological, and pathological findings in the grading and staging of carcinoma bladder. METHODS This prospective study was conducted in the Department of Pathology for a period of two years. 55 patients with clinical features suggestive of carcinoma bladder were included in the study. Radiological and cystoscopic findings were combined to obtain a clinical staging. Materials included were H&E stained sections of biopsies, TURBT and Cystectomy. Special stains were done in indicated cases. Grading was done using WHO / ISUP grading system and staging using AJCC / UICC staging system. RESULTS 55 cases were studied. Most common age group was 60 - 69 years (40 %) with male preponderance (94.5 %). 100 % of patients presented with haematuria. Cystoscopically most common appearance was fronds (69.1 %) involving right lateral wall (40 %). Of the clinically invasive cases 29 (52.7 %), 19 (65.50 %) were pathologically invasive, 3 (10.3 %) were pathologically noninvasive, 7 (24.10) were insufficient for opinion. Of the clinically noninvasive cases (26), 5 (19.20 %) were pathologically invasive 13 (50 %) were noninvasive and rest were insufficient for opinion. CONCLUSIONS Bladder carcinomas are more common in elderly males. All patients presented with haematuria. Most common site of involvement was lateral walls. Clinicopathological correlation was more in highly advanced cases. KEYWORDS Urothelial Carcinoma, Grading, Staging

P33 Spontaneous regression of confirmed diffuse large B-cell lymphoma after withdrawal of long-term methotrexate and infliximab therapy for rheumatoid arthritis, with concurrent discovery of rare high-grade urothelial carcinoma

Background A 73 year old man was diagnosed with diffuse large B-cell lymphoma germinal centre phenotype, after presenting with a 86x70x45mm right anterior chest wall lesion. CT CAP showed no further lymphadenopathy but identified an additional solid mass in the right ureter. The patient had been on methotrexate for 15 years and infliximab for 13 years for well controlled rheumatoid arthritis, and these were both discontinued on diagnosis of lymphoma. Within three weeks of discontinuation, the lymphomatous mass had clinically noticeably shrunk, confirmed radiologically, and on PET evaluation showed just low-grade avidity. However, the ureteric tumour was avid on PET, suggestive of second pathology. Biopsy proved high grade urothelial carcinoma with neuroendocrine differentiation. Chemotherapy to treat the urothelial carcinoma was identified as a priority, and carboplatin and etoposide chemotherapy was commenced which also has activity in lymphoma. Radiotherapy will be considered in the future, if indicated following further imaging. Methods A literature search was conducted on occurrence of lymphoma and urothelial carcinoma with anti-TNFα biologics. Results The link between methotrexate and increased risk of lymphoma is well covered in literature. Anti-TNFα biologic drugs have also been linked to lymphoma, but definitive causality is difficult to establish due to low numbers of cases and confounding factors. No cases were found in literature to associate anti-TNFα drugs with urothelial, transitional cell or neuroendocrine carcinomas. Eight case studies were found which show a temporal link between discontinuation of anti-TNFα and regression of lymphoma. Of these, six cases reported regression following withdrawal of infliximab. One case involved infliximab monotherapy, three had combination therapy with methotrexate, and two with azathioprine. One case reported discontinuation of adalimumab, with continuation of methotrexate. Histology showed two cases of low grade lymphoma, two case of Hodgkin’s lymphoma, and four cases of diffuse large B Cell non-Hodgkin’s lymphoma, similar to our patient case. Conclusion This patient presented with two synchronous tumours: diffuse large B cell NHL and high grade neuroendocrine carcinoma of urothelial tract. Whereas lymphoma regressed on withdrawal of methotrexate and infliximab, there was no change in the urothelial malignancy. Lymphoma regression allowed the urothelial malignancy to take priority for oncological therapy. It can be concluded that withdrawal of anti-TNF agents can allow spontaneous regression of lymphoma, and this can modify patient treatment plans. Disclosures B.A. Jones None. A. O'Callaghan None. E.V. Ross None. A. Razack None. E. Wong None.

A rare case of primary epithelioid angiosarcoma of the ureter

Angiosarcoma is an extremely rare vascular malignancy with a 1-year survival rate of 50%, regardless of tumour origin. Distant metastases are common and occur in the lungs, bone, lymph nodes and soft tissues. The majority of patients with angiosarcoma present with localised disease, although 25–45% have distant metastases at presentation. There are few reported cases of angiosarcomas of the bladder and we report the second case in the literature of primary angiosarcoma of the ureter. We suggest that, in atypical manifestations of suspected urothelial malignancy, the multidisciplinary team considers the possibility of rarer, aggressive tumours early. This may influence clinical decision making towards offering radical treatments earlier, before it is too late to do so owing to aggressive oncological behaviour.