Solitary Fibrous tumor of Urinary Bladder with carcinoma prostate – Dual malignancy the diagnostic and management challenges involved: A Rare case report

doi:10.21203/rs.3.rs-4816539/v1

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Case Report

Solitary Fibrous tumor of Urinary Bladder with carcinoma prostate – Dual malignancy the diagnostic and management challenges involved: A Rare case report

https://doi.org/10.21203/rs.3.rs-4816539/v1

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Background: Solitary fibrous tumors (SFTs) of the urinary bladder are rare mesenchymal tumorswith occasional malignant potential. Owing to the rare nature of the disease, diagnostic and surgical management strategies remains variable. The gold standard treatment is complete surgical excision with negative margins, while recurrence and metastasis of aggressive variants during the follow-up can be managed by surgical excision and radiotherapy.

Case presentation: Here, wepresent a very rare case of dual malignancy, SFT of the urinary bladder and adenocarcinoma of the prostate, managed by radical cystoprostatectomy and bilateral extended pelvic lymph node dissection in an elderly male presenting with mixed LUTS(lowerurinary tract symptoms). The diagnosis of SFT was confirmed by immunohistochemical marker-STAT6 positivity. Postoperatively, after six monthsof follow-up, there was no evidence of disease recurrence.

Conclusion: Complete surgical resection with negative margins via open, laparoscopic or robotic surgery is the operation of choice.

Solitary fibrous tumor

Immunohistochemistry

Radical cystoprostatectomy

Dual malignancy

SFT (Solitary Fibrous Tumor) is a rare mesenchymal neoplasm usually arising from the pleura, it was first reported in 1931[1] and accounts for less than 2% of all soft tissue tumors. Origin can be both pleural and extrapleural tissues, pleural origin being more common [2]. Extrapleural origin of SFT accounts for 30% of all the reported cases [3], however its incidence in urogenital system is even rarer. Urogenital origin of SFT include prostate, urinary bladder, scrotum, testicular tunica vaginalis, ovary, vagina, cervix. The first SFT of urinary bladder was reported in 1997[4], the incidence of urinary bladder SFT is quite rare with only few cases reported in literature. Mostly detected incidentally however when symptomatic they present with symptoms of pressure effects on adjacent organs due to their large size. Presenting age is fourth and sixth decade of life with slight male predilection. Usually, a benign tumor that can be managed by organ preserving approach, in contrast to aggressive variant of spindle cell neoplasm requiring more radical treatment are much rarer. Macroscopically urinary bladder SFT are circumscribed encapsulated fleshy masses, while microscopically composed of predominantly fibrous lesions containing spindle shaped tumor cells with large collagenized areas and hyalinized vessels [5]. The diagnostic hallmark in the contemporary era is histopathological morphology and immunohistochemistry characterized by strong and diffuse CD34 and STAT6 expression. Urinary bladder STF can be managed by transurethral resection, partial cystectomy or radical cystectomy. The most important postoperative prognostic marker is complete surgical excision with negative margins. The recurrence rate of SFT is 10–30%. Therapy for local recurrence and distant metastasis is surgical excision and radiotherapy [6]. Chemoradiation therapy is the treatment of choice in nonresectable cases.

A 75-year elderly male presented to us with storage and voiding LUTS (Lower urinary tract symptoms) for six months following which he went into acute urinary retention for which he was catheterized. On examination, general and systemic findings were unremarkable. DRE (Digital Rectal Examination) was difficult with grade IV prostatomegaly, however the consistency was firm. The prostate size on ultrasound was 232 cc with 125 cc median lobe bulge, serum PSA level was 6 ng/ml, rest routine investigations were within normal limit. MRI abdomen and pelvis was suggestive of 53 cc prostate with mass lesion 73x66x56 mm arising from the median lobe of prostate and transitional zone, it was T2 hyperintense, exophytic and extending into the rectovesical pouch possibility of PIRADS 5 lesion with heterogenous contrast enhancement (Fig. 1).

TRUS (Transrectal ultrasound) biopsy of prostate was done s/o Nodular Hyperplasia of Prostate with Chronic Prostatitis. The rectovesical mass was biopsied by CT guidance since it was inaccessible via transrectal route, the histopathology was suggestive of spindle cell neoplasm. IHC (Immunohistochemistry) was diffusely positive for Vimentin, CD 34 and STAT6 - signal transducers and activators of transcription 6, confirming the diagnosis of STF. 18F-FDG (Flouro deoxy glucose) Whole Body PET-CT (Positron emission tomography- computer tomography) scan was suggestive of low-grade FDG uptake with heterogeneously enhancing mass measuring 84 x 69 x 68 mm in the rectovesical pouch with no evidence of locoregional and distant metastasis. In view of large prostate size and difficult planes between prostate and bladder patient was planned for Radical Cystectomy with ePLND (extended pelvic lymph node dissection) and conduit formation. The gross cut surface (Fig. 2) showed capsulated fleshy tumor arising from the muscularis propria of posterior bladder wall.

The microscopic examination showed spindle cell tumor with a low mitotic count (1/10 hpf) with morphology suggestive of SFT (Fig. 3) and prostate with acinar adenocarcinoma with gleason score of (3 + 3 = 6) grade group 1 and bilateral pelvic lymph nodes were negative for tumor cells.

Postoperative period was uneventful and patient got discharged after 7 days. Follow up after 6 month with CECT scan was suggestive of no local recurrence.

STFs are rare tumors, and urinary bladder tumors are rarer, the diagnosis of which requires a combination of clinical, imaging and histopathological evaluation. Depending on the size and location of the tumor, surgical treatment of urinary bladder STF can be achieved via TURBT, partial cystectomy, or radical cystectomy with fairly good oncological outcomes when resection margins are negative.

Owing to the risk of local recurrence or metastasis, long-term follow-up is necessary and can be treated by surgical excision and radiotherapy.

STF

Solitary fibrous Tumor

LUTS

lower urinary tract symptoms

ePLND

extended pelvic lymph node dissection

DRE

Digital Rectal Examination

PSA

Prostate Specific Antigen

PIRADS

Prostate Imaging Reporting & Data System

TRUS

Transrectal ultrasound

IHC

Immunohistochemistry

STAT6

Signal transducers and activators of transcription 6

FDG PET

CT-Flouro deoxy glucose Positron emission tomography-computer tomography

CECT

Contrast enhanced computer tomography

TURBT

Transurethral resection of bladder tumor

Funding: This work is not supported or funded directly or indirectly by any organization.

Ethics approval and consent to participate: Not applicable

Consent for publication: Written informed consent was obtained from the patient for publishing the data related to him.

Author Contribution

CM- conceptualization of idea and manuscript revision.SAM- Designed, Drafted the manuscript with revision of the manuscriptVG- Data acquisitionPR- Microscope slides with legendsAll the authors of this case report have read and approved the final version submitted.

Fletcher CD, Bridge JA, Lee JC. Extrapleural solitary fibrous tumor. WHO classification of tumours of soft tissue and bone. 2013:80-2.
Sun S, Tang M, Dong H, Liang C, Yan T, Li J, Liu B, Li J. Solitary fibrous tumor involving urinary bladder: a case report and literature review. Translational Andrology and Urology. 2020 Apr;9(2):766. doi:10.21037/tau.2020.01.09.
Gold JS, Antonescu CR, Hajdu C, Ferrone CR, Hussain M, Lewis JJ, Brennan MF, Coit DG. Clinicopathologic correlates of solitary fibrous tumors. Cancer. 2002 Feb 15;94(4):1057-68.
Manica M, Roscigno M, Naspro R, Sodano M, Milesi L, Gianatti A, Da Pozzo LF. Recurrent retroperitoneal solitary fibrous tumor: a case report. Tumori Journal. 2021 Dec;107(6):NP11-4.
Hui M, Xu Y, Zhang N, He XD, Qu Q. Clinical characteristics of abdominal solitary fibrous tumor: an analysis of 18 cases. Zhonghua yi xue za zhi. 2018 May 1;98(18):1439-42.
Bishop AJ, Zagars GK, Demicco EG, Wang WL, Feig BW, Guadagnolo BA. Soft tissue solitary fibrous tumor: combined surgery and radiation therapy results in excellent local control. American journal of clinical oncology. 2018 Jan 1;41(1):81-5.

No competing interests reported.

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Solitary Fibrous tumor of Urinary Bladder with carcinoma prostate – Dual malignancy the diagnostic and management challenges involved: A Rare case report

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