Chief complaints
A 65-year-old man presented to to the Urology Clinic with a 3-month duration of painless haematuria without any identifiable etiology.
History of present illness
The 65-year-old man had experienced macroscopic hematuria without obvious cause for three months. The blood was bright red in color without blood clots. The hematuria had occurred several times during the course of the disease. He had no other symptoms.
History of past illness
The patient's medical history was devoid of any conditions.
Personal and family history
The patient had no risk factors other than a prolonged history of smoking and alcohol usage. The patient reported no family history of any disease or cancerous growth.
Physical examination
The physical examination showed that the kidneys were symmetrical with no bulging, no tenderness to percussion, no tenderness to bilateral costovertebral points, and no vascular murmurs. There was no bulge in the lower abdomen, no tenderness over the pubic bone, and no tympanic sound on percussion. The vital signs of the patient were recorded as follows: Body temperature of 36.7 ℃; arterial blood pressure of 133/92 mmHg; SpO2 level of 98%; pulse rate of 74 beats per minute; respiration rate of 18 breaths per minute. In general, the findings of the physical examination were within normal limits.
Laboratory examinations
Laboratory analyses revealed an absolute lymphocyte value of 1.0 × 109/L, a neutrophil percentage of 77.0%, lymphocyte percentage of 16.1%, eosinophil percentage of 0.3%, albumin level of 39.1 g/L, urine erythrocyte level of 236.0/UL, urine leukocyte level of 69.0/UL, and a weakly positive result for tissue polypeptide antigen. The remainder of the laboratory test results were within normal limits.
Imaging examinations
Ultrasound showed atypical echoes in the bladder and a substantial blood supply. The results of the non-contrast computed tomography of the whole abdomen and contrast-enhanced computed tomography of the urinary system revealed the presence of an irregular mass on the right anterior wall of the bladder (Figure 1). The mass had a size of approximately 30 mm × 29 mm and was observed to project into the lumen. Additionally, the lesion exhibited multiple speckles of hyperdense shadows, which became more pronounced after enhancement.
Incisional biopsy
A histological investigation conducted after the surgery demonstrated the presence of big cell neuroendocrine bladder cancer (Figure 2), characterized by the invasion of the muscular layer of the mucosa. The immunohistochemistry and histology results indicated the presence of SMA (+), GATA3 (+), HER-2 (+), CD56 (+), SYN (+), CGA (+), INSM1 (+), P53 (+), and Ki67 (+, 60%).
FINAL DIAGNOSIS
Based on the patient's history, laboratory test results, imaging, and histopathology, he was diagnosed with large-cell neuroendocrine carcinoma of the bladder.
TREATMENT
We first performed cystoscopic non-radical resection of the bladder lesion, and the chemotherapy regimen of etoposide + cisplatin was used after clarification based on postoperative pathological and immunohistochemical results. As the patient had undergone diagnostic resection with limited surgical scope without lymph node dissection, and considering the high rate of local recurrence of the tumor, separate cyst infusion chemotherapy was used.
OUTCOME AND FOLLOW-UP
The patient received a thoracic and abdominal non-contrast computed tomography 10 days post-surgery. The results revealed the presence of scattered nodules in both lungs, which were classified as low-risk nodules. No apparent abnormalities were observed. Due to the specific pathological type of the bladder tumor, the patient was transferred to the Oncology Department for follow-up chemotherapy. After discharge, the patient received regular chemotherapy and follow-up. No obvious metastasis or recurrence was found during the 7-month follow-up after surgery.