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+A 35-year-old male patient with no pathological history of interest, except for a significant smoking habit (20-30 cigarettes/day for more than 10 years). He came to the urologist referred by his general practitioner after suffering an episode of self-limited frank haematuria. Subsequently, the patient presented with further episodes of small clots together with severe irritative voiding syndrome with repeatedly negative urine cultures. Initially, ultrasound and intravenous urography showed a tumour at the level of the bladder trigone, 3 cm in diameter, with mild left ureteral ectasia. Renal function was normal (Creatinine: 1.3 mg/dL, plasma urea: 42 mg/dL). Rectal examination revealed a certain increase in prostatic and bladder floor consistency.
+In view of the diagnosis of a primary bladder tumour, the need for transurethral resection was suggested to the patient. Intraoperative cystoscopy confirmed the presence of a sessile bladder neoplasm, measuring 2-3 cm, with a bullous and ulcerated surface located over the trigonal area. The anatomopathological result reported the presence of a neoplasm consisting of small undifferentiated cells, distributed in "single file", with some isolated foci of transitional carcinoma, PSA (-) without being able to determine the precise origin of the tumour. The infiltration affected submucosa and muscle and the resection base was positive for tumour.
+Pending the results of complementary anatomopathology and extension studies in anticipation of a possible cystectomy, 36 days after resection, the patient was admitted for a severe constitutional syndrome, with weight loss of 10-12 kg, pain in both renal fossae with bilateral grade II/IV hydronephrosis due to ureteral trapping and obstructive renal failure (Creatinine 6.2 mg/dL, Urea: 176 mg/dL, K+:5.6 mEq/L). Urinary bypass was performed urgently, percutaneous nephrostomy type, with rapid restoration of renal function, but during admission a new episode of macroscopic haematuria began. Cystoscopy revealed a large sessile tumour at the base of the bladder with infiltration of both ureteral meatus. Bimanual palpation revealed an irregular induration of the bladder floor that appeared to infiltrate the prostate. An extension study was requested with a simple chest X-ray, abdomino-pelvic CT scan and bone scan. At this time no distant metastatic disease was observed, only thickening of the bladder floor, with bilateral uretero-pelvic-calyceal ectasia and absence of adenopathies.
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+In view of these findings, a radical cystoprostatectomy with an Indiana-type continent reservoir was performed. During the operation, it was difficult to free the bladder floor due to its infiltration by the tumour. The anatomopathological result confirmed the presence of an undifferentiated small cell carcinoma, with immunohistochemical staining: cytokeratin (+), neuronal specific enolase (NSE) and Chromogranin (-), together with small foci of transitional carcinoma. The tumour affected the full thickness of the bladder wall, right perivesical and periureteral fat, rectal wall, prostate, seminal vesicles and 2 of the 8 nodes of the left common iliac (Stage:T4N2M0). The patient's postoperative course was uneventful and he was discharged one week after the operation.
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+Given the high risk of recurrence of the disease, given the involvement of the surgical edges and the presence of adenopathies, the tumour committee of our centre decided to carry out adjuvant chemo-radiotherapy. CDDP chemotherapy with concomitant radiotherapy on the pelvis with a dose of 50 Gy, at a rate of 180 cGy per session, 5 times a week, and subsequent overimpression with another 14.4 Gy, was established. The patient's tolerance to this treatment regimen was optimal.
+Three months after the operation and during the administration of the QT/RT, he came to the clinic with discomfort in the right hemiabdomen radiating to the back with no other associated symptoms. The control abdomino-pelvic CT scan showed a reservoir with good capacity, small dilatation of the right renal pelvis, with no evidence of collections or signs of tumour recurrence.
+Three months later, the patient presented epigastralgia with irradiation towards both hypochondria, a feeling of immediate postprandial distension and heartburn. Physical examination revealed a mass at the level of the right hypochondrium-vacuum, and ultrasound did not reveal a possible tumour recurrence at this level. A gastroscopy was requested, which showed a retained stomach with extrinsic pyloro-duodenal stenosis, raising the possibility of metastatic infiltration of the tumour versus possible stenosis secondary to radiotherapy. In view of these findings, surgery was decided upon, and during the course of the operation, the presence of tumour recurrence in the right flank, invasion of the duodenum by the tumour and multiple neoplastic implants in the omentum, peritoneum and other serosae were observed, and palliative gastrojejunostomy was performed. After the postoperative period, the patient was sent home for palliative care and died one month after discharge (7 months after the cystectomy and 9 months after diagnosis).
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