Partial Cystectomy as a Viable Alternative Treatment for an Intradiverticular Non Bilharzial Squamous Cell Carcinoma of Bladder with a 5-Year Follow-up: A Case Report.

doi:10.21203/rs.3.rs-5308589/v1

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Case Report

Partial Cystectomy as a Viable Alternative Treatment for an Intradiverticular Non Bilharzial Squamous Cell Carcinoma of Bladder with a 5-Year Follow-up: A Case Report.

https://doi.org/10.21203/rs.3.rs-5308589/v1

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Background: Squamous cell carcinoma (SCC) is a rare malignancy with poor prognosis, affecting the urinary bladder. Most of the SCC present as muscle invasive or locally advanced cancer. While majority of SCC of urinary bladder are of bilharzial origin, 2% to 5% of them can be of non-bilharzial origin. The uniqueness about this case is that patient had a good disease-free survival for 5 years after partial cystectomy performed for extravesical SCC bladder.

Summary: Though most of the SCC of urinary bladder are best treated by radical cystectomy, a 68-year-old male with painless hematuria, diagnosed with an intradiverticular SCC of the bladder on magnetic resonance imaging had a recurrence and metastases free survival on 5 years follow-up after partial cystectomy (PC).

Conclusion: This case report outlines the role and effectiveness of partial cystectomy as an alternative option in such patients with a follow-up of 5 years without any recurrence or metastases.

Carcinoma

Partial cystectomy

Squamous cell

Bladder diverticulum

Case report

Bladder cancer is the 10th most common cancer in the world and is widely classified as urothelial carcinoma, non-urothelial cancer, urothelial carcinoma (UC) with varying differentiation. Squamous cell carcinoma (SCC) belongs to non-urothelial type. Bladder tumours found in a diverticulum are rare with an incidence of 1 to 9% [1]. SCC constitutes 20 to 25% of diverticular tumors with the rest being Urothelial malignancy. The pathophysiology can be attributed to the stasis of urine inside a weakly contractile diverticulum and chronic inflammation. which SCC of the bladder is a rare urological malignancy, which is more commonly associated with bilharziasis. Only 2–3% of individuals with bladder cancer have Non-bilharzial SCC (NB-SCC) [2]. While most SCC of urinary bladder are best treated as per the guidelines, no specific guidelines are available for management of SCC in a bladder diverticulum. The standard treatment for SCC of urinary bladder is radical cystectomy (RC), but in our case, the patient’s performance status was poor and was unfit for RC. This article portrays a rare case of a primary intradiverticular SCC successfully managed by partial cystectomy.

A 68-year-old man came to outpatient department with painless intermittent hematuria history for three months. Patient complained of increased frequency of micturition for one month. There was no history of fever or flank pain. He underwent cystolithotripsy for bladder stone 15 years back. He is a known diabetic and hypertensive, but not a smoker. On examination, abdomen was soft, and bladder was not palpable. Routine blood tests revealed hemoglobin of 11.8 gm/dl and creatinine of 2.6 mg/dl. Urine routine test revealed increased number of red blood cells and leukocytes. Urine culture samples were negative. Ultrasonography of the abdomen showed a hyper-echoic lesion in a diverticulum of urinary bladder. On cystoscopy, a diverticulum was spotted on the left lateral wall of the bladder with a polypoidal growth in it. Magnetic resonance urography (MRU) imaging demonstrated a solitary intra-diverticular lesion measuring 2.5 x 2 cm size in the left posterolateral wall of the bladder (Fig. 1). No hydroureteronephrosis seen. As the diverticulum lacks muscle layer, only superficial samples were taken from the growth and sent for histopathological examination. Tissue diagnosis of SCC was obtained. Patient had poor performance status and was not fit to undergo radical cystectomy. Hence, partial cystectomy (PC) with bilateral pelvic lymph node dissection was performed.

The resected specimen had bladder diverticulum with tumor, a margin of 1 cm of normal bladder wall, and pelvic lymph nodes. The histopathological impression was moderately-differentiated squamous cell carcinoma – pT3aN0M0 with surgical margins being negative. Immunohistochemistry (IHC) showed nucleus positivity for P40 (Fig. 2). Because of microscopic extravesical extension, Radiation therapy was offered as adjuvant treatment. Patient was discharged on 10th postoperative day. After 3 months, patient had no symptoms. Cystoscopy performed at regular intervals showed no signs of tumor. Computed tomography (CT) imaging of abdomen and pelvis done annually showed no evidence of tumor relapse on 5 years follow-up.

The enfeeble muscle areas of urinary bladder pave way for the formation of a diverticulum in the bladder. High intravesicular pressures due to bladder outlet obstruction or underactive detrusor is said to be the underlying cause. The various causes of non-bilharzial squamous cell carcinoma are long term smoking, vesical stones, spinal cord injury (SCI), chronic placement of catheters, foreign bodies, and UTI. They stimulate the production of growth factors which promotes cell proliferation, and angiogenesis leading to squamous metaplasia, dysplasia, and cancer [3]. SCC occurs frequently in the lateral wall and trigone of the bladder, but sometimes it may harbour in the diverticulum of the bladder [4]. Bladder SCC present as painless hematuria in majority of the cases. The negative prognostic factors for SCC are older age group (> 70 years), lymph node involvement, and T3-T4b stage. Hydroureteronephrosis is said to be an independent risk factor [5].

As SCC is poorly responsive to chemotherapy, radical cystectomy, and urinary diversion with or without radiation therapy is an effective and preferred treatment of choice. Bladder SCC are usually aggressive and exhibit worse prognosis than urothelial carcinoma. Studies suggest a 24% chance of lymph node metastases, emphasizing the importance of pelvic lymph node dissection [6]. Golijan et al. did a significant work on bladder diverticular tumors and classified them into superficial (Ta, Tis), superficially invasive intradiverticular (T1) or extradiverticular (T3a, T3b). Patients with T3 + tumors were managed by partial or radical cystectomy [7]. In SCC, Bladder preservation is generally indicated in patients, who are older and with multiple comorbidities not fit for RC. Memorial Sloan Kettering Cancer Centre (MSKCC) study developed a stringent criterion for partial cystectomy that includes solitary tumour away from VUJ that would allow for 2 cm margins, no carcinoma in situ (CIS), no tumours in bladder neck or trigone and a complete transurethral resection (TUR). Variant histology should be added in patient selection criteria [8]. Capitanio et al. did a comparative analysis between radical and partial cystectomy and reported that partial cystectomy provided similar overall and cancer-specific survival [9]. Na yin et al. reported a case of localised squamous cell carcinoma bladder with a disease-free survival of 10 years following partial cystectomy. [10].

In our case, the clinical stage was T3aN0M0. Partial cystectomy with pelvic lymphadenectomy followed by adjuvant radiation therapy was offered as management. In addition to eliminating the localised disease, partial cystectomy also helped in preventing metastasis and recurrence of the tumor. There is no sign of tumor metastasis as well as recurrence on five years of surveillance. In this case, though increased disease-free survival after Partial cystectomy was observed, more such cases and follow-ups were mandatory for the better understanding of PC in SCC disease.

Partial cystectomy can be an alternative management option for SCC located in the bladder diverticulum. Adjuvant radiotherapy should be contemplated after partial cystectomy in patients with presence of extravesical involvement or pelvic lymph nodes as it aids in reducing the local recurrence. Since SCC bladder progresses rapidly with high recurrence rate when compared to urothelial carcinoma, early diagnosis and intervention with proper systematic follow up are the significant factors to improving prognosis.

Ethics approval and consent to participate

Institutional ethical committee approval and consent was obtained for the reporting of the study

Consent for publication

Written informed consent was obtained from the patient for the publication of this case report and accompanying images.

Funding.

No sources of funding to be declared.

Author Contribution

Concept - TG.SK , SKDesign - TG.SK , BD , SKData acquisition- TG.SK , BDData processing - TG.SK , BD , SKManuscript writing - TG.SK , SKManuscript revision - TG.SK , SKAll authors read and approved the final manuscript.

Acknowledgement

Nil

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No competing interests reported.

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Partial Cystectomy as a Viable Alternative Treatment for an Intradiverticular Non Bilharzial Squamous Cell Carcinoma of Bladder with a 5-Year Follow-up: A Case Report.

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