IJCRI 2012;4():**–**. www.ijcasereportsandimages.com Amr et al. CASE REPORT 1 OPEN ACCESS Sigm oid carcinom a: Rare presentation and diagnostic challenge Bassem Am r, Kom al Munir, Natasha Santana-Vaz, Venkateswarlu Velineni ABSTRACT In tro d u ctio n : Ad e n o carcin o m a re p re s e n ts le s s th an 2 % o f all blad d e r carcin o m as . Me tas tatic ad e n o carcin o m a is th e m o s t co m m o n fo rm an d u s u ally re p re s e n ts a d ire ct e xte n s io n fro m a p rim ary le s io n e ith e r in th e co lo n , p ro s tate o r th e fe m ale ge n ital o rgan s . Oth e r cate go rie s in clu d e p rim ary ve s ical o r u rach al. Cas e Re p o rt: W e p re s e n t a cas e o f 79 ye ar o ld fe m ale p re s e n te d w ith m icro s co p ic h e m atu ria, fre qu e n cy, u rge n cy, an d w e igh t lo s s . An ad e n o carcin o m a o f th e u rin ary blad d e r o f in te s tin al o rigin w as fo u n d e d . Co n clu s io n : Prim ary ad e n o carcin o m a o f u rin ary blad d e r is an u n co m m o n n e o p las m an d th e re p o rte d in cid e n ce o f th e p rim ary ad e n o carcin o m a is 0 .5– 2 %. It re p re s e n ts a d iagn o s tic ch alle n ge rais in g th e in qu iry abo u t th e s ite o f th e le s io n . Th re e m ajo r clas s e s w e re id e n tifie d : p rim ary ve s ical ad e n o carcin o m a, u rach al ad e n o carcin o m a, an d e xtrave s ical ad e n o carcin o m a in vo lvin g th e blad d e r. Th e m e tas tatic ad e n o carcin o m a is th e m o s t co m m o n cate go ry re p re s e n tin g a d ire ct e xte n s io n fro m a n e arby o rgan o r m e tas tatic s p re ad . Th e m o s t co m m o n tre atm e n t fo r u rin ary blad d e r ad e n o carcin o m a is s u rge ry. Ge n e rally s p e akin g, tre atm e n t o p tio n s in clu d e : s u rge ry, rad iatio n th e rap y, im m u n o th e rap y, an d ch e m o th e rap y. In o u r cas e , p atie n t w as tre ate d by s u rge ry an d Bassem Amr1, Komal Munir1, Natasha Santana-Vaz1, Venkateswarlu Velineni1 Affiliations: 1Worcestershire Acute Hospitals NHS Trust, Woodrow Drive, Redditch, B98 7UB. Corresponding Author: Mr. Bassem Amr, Worcestershire Acute Hospitals NHS Trust, Woodrow Drive, Redditch, B98 7UB. Ph: +44 1527 50 3030, Mob: +44 78 256 356 24; Email: dr_bassem277@yahoo.com Received: 23 July 2012 Accepted: 23 February 2013 Published: 25 July 2013 ch e m o th e rap y. Me tas tatic ad e n o carcin o m a to th e u rin ary blad d e r e s p e cially o f co lo n ic o rigin is o f p articu lar in te re s t an d n e e d to be ru le d o u t be fo re m akin g a d iagn o s is o f p rim ary ad e n o carcin o m a o f th e u rin ary blad d e r. Ke yw o rd s : Bo w e l Blad d e r tu m o r can ce r, Ad e n o carcin o m a, ********* Am r BA, Munir K, Santana-Vaz N, Velineni V. Sigm oid carcinom a: Rare presentation and diagnostic challenge. International J ournal of Case Reports and Im ages 20 13;():*****. ********* doi:10 .5348/ ijcri-20 13- IN TROD U CTION Adenocarcinom a represents less than 2% of all bladder carcinom as [1]. Prim ary adenocarcinom a is an uncom m on m alignant neoplasm and is a source of a diagnostic challenge. It is less frequently encountered in areas where bilharziasis is endem ic whereas the squam ous cell carcinom a is m ore prevalent. This incidence ranges between 5– 11.4% [2]. Chronic vesical irritation and infection are predisposing factors for m etaplastic changes of the urothelium [2]. Based on the original tum or site, adenocarcinom a of the bladder could be classified into three categories: prim ary, urachal and m etastatic. Prim ary vesical adenocarcinom a needs to be distinguished from the m ore com m on extravesical m etastatic adenocarcinom a (direct spread, lym phatic, and hem atogenous). The principal prim ary organs to be considered include prostate, colon, fem ale genital tract, appendix, stom ach, and breast. Clinical association with bladder exstrophy and schistosom iasis has been well docum ented. Clinical assessm ent, im aging, histologic, IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 12, December 2012. ISSN – [0976-3198] IJCRI 2013;4(*):**–**. www.ijcasereportsandimages.com and im m unohistochem ical correlation should be done while investigating this diagnosis due to histologic and im m unohistochem ical overlapping between prim ary bladder adenocarcinom a and m etastatic adenocarcinom a [3]. Prognosis and therapeutic options for prim ary versus m etastatic adenocarcinom a vary widely. CASE REPORT We present a case of 79-year-old fem ale presented to her general practitioner in J anuary 20 12 with urinary sym ptom s in form of frequency, urgency and passing dark urine. She had also noted recent weight loss of 3 kg. Urine dipstick was positive for leucocytes, protein and blood. Antibiotic was prescribed by her doctor for urinary tract infection. The sym ptom s recurred once the course of treatm ent was com pleted; for which she was given three separate courses of antibiotics as her m id-stream urine sam ples showed E. coli. She had ultrasound scan of the urinary tract which showed a sim ple cyst on the right kidney and incidental finding of a bulky uterus; therefore pelvic scan was undertaken. A retroverted bulky fibroid uterus m easuring 6.5x2.9x4.6 cm was revealed. A heterogenous m yom etrium dem onstrating echogenic foci throughout anteriorly was founded. Also a well-defined echogenic area within the left adnexa m easuring 2.5 cm with sm all am ount of free fluid was seen on the scan. She was referred to the hem aturia clinic on April 20 12, where a flexible cystoscopy was perform ed under local anaesthesia. There was an inverted granulom a present at the trigone and an area of inflam m ation on the right hand side of the posterior wall. She had a com puted tom ography (CT) scan of the abdom en and pelvis which showed m arked sigm oid colon thickening with associated diverticulosis suggestive of com plicated sigm oid diverticulitis with a localized perforation. Also a focal urinary bladder wall thickening was likely secondary to the colonic abnorm ality with no definitive evidence of a colovesical fistula on this scan (Figure 1). She was adm itted to our hospital for cystoscopy and biopsy. Exam ination under anesthesia revealed a 5-cm pelvic m ass extending into the left iliac fossa. Cystoscopy revealed a lesion in the trigone (Figure 2) which was biopsied. Histopathological findings of the cystoscopic biopsy revealed m oderately differentiated adenocarcinom a of an intestinal appearance infiltrating bladder m ucosa. Her case was discussed at the urology and colorectal m ultidisciplinary team (MDT) m eetings. She had a staging CT scan which showed a sigm oid colon tum or, possibly involving the roof of the bladder with lym phadenopathy and no evidence of distant m etastatic disease. Her blood investigations were within norm al before she was scheduled for anterior resection, partial cystectom y and total abdom inal hysterectom y. She was adm itted to intensive care unit after a long procedure where she received noradrenaline support for 48 hours and transfused two units of blood before discharging her back to the ward. She m ade an uneventful recovery Amr et al. 2 before being discharged with a long-term catheter and an outpatient appointm ent for cystogram and chem otherapy. Patient was followed-up on J uly 20 12 after satisfactory cystogram and again on October 20 12 by consultant surgeon. She was doing well and m anaged to m aintain her weight. The final histology confirm ed a m oderately differentiated adenocarcinom a of colonic origin (pT4 pN0 ) invading the detrusor m uscle of the bladder. The m yom etrium , both adnexa and cervix were unrem arkable. Figure 1: Thickened wall of sigm oid colon and area of possible perforation with gas bubbles. Figure 2: Cystoscopic picture dem onstrating a lesion at the trigone. IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 12, 2013. ISSN – [0976-3198] IJCRI 2013;4(*):**–**. www.ijcasereportsandimages.com Amr et al. 3 D ISCU SSION CON SEN T Adenocarcinom a of the urinary bladder is uncom m on, representing less than 2% of m alignant neoplasm s at this site. Adenocarcinom a can arise anywhere in the urinary bladder. Nevertheless, in m ost cases they involve the trigone and posterior bladder wall [1]. About two-thirds of these tum ors present as solitary, discrete lesions, unlike the ‘usual’ urothelial carcinom as, which tend to be m ultifocal [2]. These tum ors are m ore com m on in m en with a m ale-fem ale ratio of 3:1. It is usually occurring in the fifth to seventh decades. Direct extension of adenocarcinom a from adjacent organs, such as the prostate, colon, or ovary, is m ore com m on than prim ary adenocarcinom a of the urethra or urinary bladder [3]. Metastatic lesions to urinary bladder often infiltrate the wall of the bladder rather than ulcerating the m ucosa. In som e cases, the bladder is the only genitourinary organ involved in m etastasis, m ainly from the breast. Most of these patients with urinary bladder m etastases are asym ptom atic. Sym ptom s produced by these m etastases occur only when the bladder m ucosa is involved [4]. These tum ors show varied histological pictures and degrees of differentiation. Prim ary adenocarcinom a of the urinary bladder exhibit several histological subtypes: glandular not otherwise specified (NOS), m ucinous (colloid), colonic (enteric) type, signet ring cell, clear cell (m esonephric) type and m ixed type [5, 6].The m ajority of the prim ary adenocarcinom a is of the enteric type, and it is m orphologically indistinguishable from m etastatic adenocarcinom a of colonic origin when evaluated by the cytological, histopathological, histochem ical and im m unological techniques. However certain features, including the location of the tum or, growth pattern, and clinical history, have been suggested as useful aides for differentiating m etastatic colonic adenocarcinom a from prim ary enteric-type adenocarcinom a of urinary bladder [7, 8]. It is im portant to discrim inate prim ary adenocarcinom a of the urinary tract from m etastatic colonic adenocarcinom a because of their differing treatm ent protocols as well as its m orphological sim ilarity. Clinical and radiological correlation and ultim ately histological confirm ation are strongly recom m ended for confirm ation of the diagnosis especially in cases of unknown prim ary [9]. Treatm ent options include: surgery, radiation therapy, im m unotherapy, and chem otherapy. For sm all bladder tum ors, partial/ segm ental cystectom y could be perform ed. However, for large size tum ors radical cystectom y is recom m ended [10 ]. Written consent was obtained for publication of this case report and accom panying im ages. ********* Au th o r Co n tribu tio n s Bassem Am r – Kom al Munir – Natasha Santana-Vaz – Venkateswarlu Velineni – Gu aran to r The corresponding author is the guarantor of subm ission. Co n flict o f In te re s t Authors declare no conflict of interest. Co p yrigh t © Bassem Am r et al. 20 13; This article is distributed under the term s of Creative Com m ons attribution 3.0 License which perm its unrestricted use, distribution and reproduction in any m eans provided the original authors and original publisher are properly credited. (Please see www.ijcasereportsandim ages.com / copyright-policy.php for m ore inform ation.) REFEREN CES 1. 2. 3. 4. 5. 6. 7. CON CLU SION The diagnosis of urinary bladder adenocarcinom a raises the challenging question of whether the lesion is prim ary vesical, urachal in origin, or m etastatic from a distant or an adjacent organ. 8. 9. Gill HS, Dhillon HK, Woodhouse CR. Adenocarcinom a of the urinary bladder. Br J Urol 1989;64(2):138– 42. Thom as DG, Ward AM, William s J L. A study of 52 cases of adenocarcinom a of the bladder. Br J Urol 1971;43(1):4– 15. El-Bolkainy MN, Mokhtar NM, Ghoneim MA, Hussein MH. The im pact of schistom iasis on the pathology of bladder carcinom a. Cancer 1981;48(12):2643– 8. 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IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 12, 2013. ISSN – [0976-3198] IJCRI 2013;4(*):**–**. www.ijcasereportsandimages.com 10 . Grignon DJ , Ro J Y, Ayala AG, J ohnson DE, Ordóñez NG. Prim ary adenocarcinom a of the urinary bladder: a clinicopathologic analysis of 72 cases. Cancer 1991;67(8):2165– 72. IJCRI – International Journal of Case Reports and Images, Vol. 3 No. 12, 2013. ISSN – [0976-3198] View publication stats Amr et al. 4