Date of Presentation:9/2/2021

Attending pathologist: Anil Parwani, MD, PhD, MBA

Presented by: Nada Shaker, MD

Prepared by: Nada Shaker, MD, Alice Xiang, MD

Organ:Bladder

HISTORY:

A 74-year-old gentleman with multiple comorbidities including coronary artery disease status post CABG (1980s), atrial fibrillation on coumadin, hypertension, hyperlipidemia, T2DM, a history of prostate cancer (2010) treated with radiation, and atrophic right kidney. He presented to Ohio State Medical Center with gross hematuria, a supratherapeutic INR, and an elevated creatinine.

An outside hospital CT scan showed a new obstructive bladder mass with associated left hydronephrosis which contributed to his post-obstructive AKI. His gross hematuria required continuous bladder irrigation (CBI) while admitted and he was CBI dependent. He was brought to the operating room for clot evacuation, left retrograde pyelogram and transurethral resection of bladder tumor (TURBT). Rectal exam under anesthesia was performed which was significant for a palpable but mobile mass just left to midline. The clot was removed, and fluoroscopy of the GU tract revealed chronic appearing left hydroureteronephrosis with a tortuous ureter, but the ureteral orifice was not obstructed. At the time of cystoscopy for TURBT, there was 4 cm of friable sessile tissue on the floor of the bladder just above the trigone. Nodular erythematous friable tissue was also noted above the left ureteral orifice which was also suspicious for malignancy. A loop resectoscope was used to remove the tissue systematically for pathology.

Within a couple months of diagnosis, the patient passed away before receiving his staging scans or any sort of treatment.

GROSS:

The specimens are received in two containers, one specimen is from the bladder floor and consistent of cauterized, tan-brown tissue that is 1.5 x 1.4 x 0.5 cm.

The bladder tumor was on the posterior wall and consists of a 4.0-gram aggregate of red-brown, rubbery blood clot that is 4.4 x 3.0 x 0.9 cm.

What is the most likely diagnosis?

  1. Urothelial carcinoma with rhabdomyosarcomatous differentiation
  2. Small cell carcinoma with rhabdomyosarcomatous differentiation
  3. Rhabdomyosarcoma
  4. Leiomyoma
Rhabdomyosarcoma