Neuroendocrine Tumors of the Urinary Bladder According to the 2016 World Health Organization Classification: Molecular and Clinical Characteristics

Diagnosis and management of urinary bladder paragangliomas: A Sino-American-European retrospective observational study

OBJECTIVE

Paragangliomas of the urinary bladder (UBPGLs) are rare neuroendocrine tumours and pose a diagnostic and surgical challenge. It remains unclear what factors contribute to a timely presurgical diagnosis. The purpose of this study is to identify factors contributing to missing the diagnosis of UBPGLs before surgery.

DESIGN, PATIENTS AND MEASUREMENTS

A total of 73 patients from 11 centres in China, and 51 patients from 6 centres in Europe and 1 center in the United States were included. Clinical, surgical and genetic data were collected and compared in patients diagnosed before versus after surgery. Logistic regression analysis was used to identify clinical factors associated with initiation of presurgical biochemical testing.

RESULTS

Among all patients, only 47.6% were diagnosed before surgery. These patients were younger (34.0 vs. 54.0 years, p < .001), had larger tumours (2.9 vs. 1.8 cm, p < .001), and more had a SDHB pathogenic variant (54.7% vs. 11.9%, p < .001) than those diagnosed after surgery. Patients with presurgical diagnosis presented with more micturition spells (39.7% vs. 15.9%, p = .003), hypertension (50.0% vs. 31.7%, p = .041) and catecholamine-related symptoms (37.9% vs. 17.5%, p = .012). Multivariable logistic analysis revealed that presence of younger age (<35 years, odds ratio [OR] = 6.47, p = .013), micturition spells (OR = 6.79, p = .007), hypertension (OR = 3.98, p = .011), and sweating (OR = 41.72, p = .013) increased the probability of initiating presurgical biochemical testing.

CONCLUSIONS

Most patients with UBPGL are diagnosed after surgery. Young age, hypertension, micturition spells and sweating are clues in assisting to initiate early biochemical testing and thus may establish a timely presurgical diagnosis.

Differential NEUROD1, ASCL1, and POU2F3 Expression Defines Molecular Subsets of Bladder Small Cell/Neuroendocrine Carcinoma With Prognostic Implications

Small cell carcinomas (SMC) of the lung are now molecularly classified based on the expression of transcriptional regulators (NEUROD1, ASCL1, POU2F3, and YAP1) and DLL3, which has emerged as an investigational therapeutic target. PLCG2 has been shown to identify a distinct subpopulation of lung SMC with stem cell-like and prometastasis features and poor prognosis. We analyzed the expression of these novel neuroendocrine markers and their association with traditional neuroendocrine markers and patient outcomes in a cohort of bladder neuroendocrine carcinoma (NEC) consisting of 103 SMC and 19 large cell NEC (LCNEC) assembled in tissue microarrays. Coexpression patterns were assessed and integrated with detailed clinical annotation including overall (OS) and recurrence-free survival (RFS) and response to neoadjuvant/adjuvant chemotherapy. We identified 5 distinct molecular subtypes in bladder SMC based on the expression of ASCL1, NEUROD1, and POU2F3: ASCL1+/NEUROD1- (n = 33; 34%), ASCL1- /NEUROD1+ (n = 21; 21%), ASCL1+/NEUROD1+ (n = 17; 17%), POU2F3+ (n = 22, 22%), and ASCL1- /NEUROD1- /POU2F3- (n = 5, 5%). POU2F3+ tumors were mutually exclusive with those expressing ASCL1 and NEUROD1 and exhibited lower expression of traditional neuroendocrine markers. PLCG2 expression was noted in 33 tumors (32%) and was highly correlated with POU2F3 expression (P < .001). DLL3 expression was high in both SMC (n = 72, 82%) and LCNEC (n = 11, 85%). YAP1 expression was enriched in nonneuroendocrine components and negatively correlated with all neuroendocrine markers. In patients without metastatic disease who underwent radical cystectomy, PLCG2+ or POU2F3+ tumors had shorter RFS and OS (P < .05), but their expression was not associated with metastasis status or response to neoadjuvant/adjuvant chemotherapy. In conclusion, the NEC of the bladder can be divided into distinct molecular subtypes based on the expression of ASCL1, NEUROD1, and POU2F3. POU2F3-expressing tumors represent an ASCL1/NEUROD1-negative subset of bladder NEC characterized by lower expression of traditional neuroendocrine markers. Marker expression patterns were similar in SMC and LCNEC. Expression of PLCG2 and POU2F3 was associated with shorter RFS and OS. DLL3 was expressed at high levels in both SMC and LCNEC of the bladder, nominating it as a potential therapeutic target.

Updates on Urinary Bladder Tumors With Neuroendocrine Features

The most common neuroendocrine tumor in the urinary bladder is small cell carcinoma, which can be pure or mixed with components of urothelial or other histologic subtypes. Large cell neuroendocrine carcinoma of the bladder is rare and remains ill-defined but is increasingly recognized. Well-differentiated neuroendocrine tumor and paraganglioma can arise in the bladder but are very rare in this location. Recent advances in molecular characterization allowed for better classification and may offer improved stratification of these tumors.

Neuroendocrine Carcinoma of the Urinary Bladder: CT Findings and Radiomics Signature

Background: We present a case series of Neuroendocrine Carcinoma of the Urinary Bladder (NECB) to analyse their radiologic appearance on CT, find a "Radiomic signature", and review the current literature. Methods: 14 CT cases of NECB were reviewed and compared with a control group of 42 patients with high-grade non-neuroendocrine bladder neoplasm for the following parameters: ring enhancement; implantation site; dimensions; density; margins; central necrosis; calcifications; number of lesions; wall thickness; depth of invasion in the soft tissue; invasion of fat tissue; invasion of adjacent organs; lymph-node involvement; abdominal organ metastasis. To extract radiomic features, volumes of interest of bladder lesions were manually delineated on the portal-venous phase. The radiomic features of the two groups were identified and compared. Results: Statistical differences among NECB and control group were found in the prevalence of male sex (100% vs. 69.0%), hydronephrosis (71.4% vs. 33.3%), mean density of the mass (51.01 ± 15.48 vs. 76.27 ± 22.26 HU); product of the maximum diameters on the axial plane (38.1 ± 59.3 vs. 14.44 ± 12.98 cm2) in the control group, trigonal region involvement (78.57% vs. 19.05%). About the radiomic features, Student's t-test showed significant correlation for the variables: "DependenceNonUniformity" (p: 0.048), "JointAverage" (p: 0.013), "LargeAreaLowGrayLevelEmphasis" (p: 0.014), "Maximum2DDiameterColumn" (p: 0.04), "Maximum 2DDiameterSlice" (p: 0.007), "MeanAbsoluteDeviation" (p: 0.021), "BoundingBoxA" (p: 0.022) and "CenterOfMassB" (p: 0.007). Conclusions: There is a typical pattern (male patient, large mass, trigonal area involvement) of NECB presentation on contrast-enhanced CT. Certain morphological characteristics and encouraging results about Radiomic features can help define the diagnosis.

Urinary Neuroendocrine Neoplasms Treated in the "Modern Era": A Multicenter Retrospective Review

BACKGROUND

Primary urinary neuroendocrine neoplasms (U-NENs) are extremely rare thus optimal treatment is unknown. Grading and treatment are typically extrapolated from other primary sites. Since 2010, the clinical landscape for NENs has changed substantially. We performed a retrospective review of U-NENs to assess treatment patterns and oncologic outcomes of patients treated in the recent era of NEN therapy.

PATIENTS AND METHODS

A multicenter retrospective review of patients diagnosed after 2005 and alive after 2010. Time to treatment failure (TTF) was used to evaluate progression and toxicity for systemic therapy. Tumors were categorized as having either well-differentiated neuroendocrine tumor (WDNET) or poorly differentiated neuroendocrine carcinoma (PDNEC) histology.

RESULTS

A total of 134 patients from 6 centers were included in our analysis, including 94 (70%) bladder, 32 (24%) kidney, 2 (1.5%) urethra and 4 other urinary primaries (3.0%). Poorly-differentiated neuroendocrine carcinoma was more common in bladder (92%) than non-bladder tumors (8%). Median Ki-67 available in bladder primary was 90% (n = 24), kidney 10% (n = 23), ureter 95% (n = 1), urethra 54% (n = 2), and others 90% (n = 3). Patients received a median of 2 therapies (range 0-10). Median time to death was not reached in locoregional WDNETs versus 8.2 years (95% CI, 3.5-noncalculable) in metastatic WDNETs (predominantly renal primary). Median time to death was 3.6 years (95% CI, 2.2-9.2) in locoregional PDNECs versus 1 year (95% CI, 0.8-1.3) in metastatic PDNECs (predominantly bladder primary).

CONCLUSION

This is the most extensive series examining treatment patterns in patients with U-NENs in the recent era of NEN therapy. The apparent inferior survival for bladder NENs is likely due to the preponderance of PDNECs in this group. As predicted, treatments for U-NENs mirrored that of other more common NENs. In our retrospective cohort, we observed that patients with WD-UNETs treated with peptide receptor radionuclide therapy (PRRT) and everolimus suggested potential activity for disease control in WD-UNETs. Prospective studies are needed to assess the activity of new oncology drugs in UNENs.

Imaging of neuroendocrine neoplasms of the male GU tract

Male genitourinary neuroendocrine neoplasms (GU-NENs) are rare, without any definite imaging characteristics. The WHO classified neuroendocrine neoplasms in the 2016 classification of the tumors of the urinary tract and genital organs along with other GU tumors; however, no pathologic grading system is available as published for gastroenteropancreatic neuroendocrine neoplasms. Often a multimodality approach using cross-sectional imaging techniques, such as molecular imaging and histopathology are implemented to arrive at the diagnosis. This article provides a review of the pathology and imaging features of the male GU-NENs.

An Approach to Nonurothelial Malignancies of the Urinary Bladder in Urine Cytology

Urine cytology is an economical and convenient method of triaging patients who present with urinary symptoms as well as surveying those who have previously been diagnosed with urothelial carcinoma for recurrent or persistent disease. While the vast majority of malignancies diagnosed in urine cytology are urothelial carcinomas, it is important to recognize nonurothelial elements to inform patient prognosis and raise the possibility of involvement by a urothelial carcinoma variant, nonurothelial malignancy of the bladder, or a nonbladder primary, which may alter patient management pathways. As such, becoming familiar with morphologic features of nonurothelial malignancies in urine cytology as well as their related clinical risk factors, radiologic and cystoscopic features, differential diagnostic considerations, and the utility and pitfalls of ancillary tests can facilitate optimal patient care.

The 2022 revision of World Health Organization classification of tumors of the urinary system and male genital organs: advances and challenges

The fifth edition of the World Health Organization (WHO) classification of urinary and male genital organ tumors has been recently published in 2022. The application of molecular profiling has made a substantial impact on classification of urologic tumors. The new WHO classification introduces a group of molecularly well-defined renal tumor subtypes. The significant changes include addition of a category of "other oncocytic tumors" with oncocytoma/chromophobe renal cell carcinoma (chRCC)-like features, elimination of the subcategorization of type1/2 papillary RCC and inclusion of eosinophilic solid and cystic RCC as an independent tumor entity. The WHO/ISUP grading now has been recommended for all RCCs. Major nomenclature changes include replacement of histologic 'variants' by 'subtypes', 'clear cell papillary renal cell carcinoma' to 'clear cell renal cell tumor','TCEB1-mutated RCC' to 'ELOC-mutated RCC', 'hereditary leiomyomatosis and renal cell carcinoma' to 'fumarate hydratase-deficient RCC', 'RCC-Unclassified' to 'RCC-NOS', 'primitive neuroectodermal tumor' to 'embryonic neuroectodermal tumor', 'testicular carcinoid' to 'testicular neuroendocrine tumor', and 'basal cell carcinoma of the prostate' to 'adenoid-cystic (basal-cell) carcinoma of the prostate'. Metastatic, hematolymphoid, mesenchymal, melanocytic, soft tissue and neuroendocrine tumors are collectively discussed in separate chapters. It has been suggested that the morphological classification of urothelial cancer be replaced with a new molecular taxonomic classification system.

Neuroendocrine Neoplasms of the Female Genitourinary Tract: A Comprehensive Overview

Simple Summary

Primary neuroendocrine neoplasms (NENs) are a rare, heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. NENs in the urinary tract are observed in <0.05% of individuals, in whom the bladder is the most common site. In this review, we described the epidemiology, pathogenesis, imaging, staging, and management of the genitourinary NENs.

Abstract

Primary neuroendocrine neoplasms are a rare heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. An extensive literature search was used to compile the data regarding epidemiology, pathogenesis, imaging features, and management of the urinary system NENs. We also included the updated staging of the NENs at various locations of the urinary system.

Synaptophysin, CD117, and GATA3 as a Diagnostic Immunohistochemical Panel for Small Cell Neuroendocrine Carcinoma of the Urinary Tract

Although SCNEC is based on its characteristic histology, immunohistochemistry (IHC) is commonly employed to confirm neuroendocrine differentiation (NED). The challenge here is that SCNEC may yield negative results for traditional neuroendocrine markers. To establish an IHC panel for NED, 17 neuronal, basal, and luminal markers were examined on a tissue microarray construct generated from 47 cases of 34 patients with SCNEC as a discovery cohort. A decision tree algorithm was employed to analyze the extent and intensity of immunoreactivity and to develop a diagnostic model. An external cohort of eight cases and transmission electron microscopy (TEM) were used to validate the model. Among the 17 markers, the decision tree diagnostic model selected 3 markers to classify NED with 98.4% accuracy in classification. The extent of synaptophysin (>5%) was selected as the initial parameter, the extent of CD117 (>20%) as the second, and then the intensity of GATA3 (≤1.5, negative or weak immunoreactivity) as the third for NED. The importance of each variable was 0.758, 0.213, and 0.029, respectively. The model was validated by the TEM and using the external cohort. The decision tree model using synaptophysin, CD117, and GATA3 may help confirm NED of traditional marker-negative SCNEC.

A Personalized Approach to Radical Cystectomy Can Decrease Its Complication Rates

The aim of this study was to assess the influence of a patient’s general status on perioperative morbidity and mortality after radical cystectomy, and to assess which of the used scales is best for the prediction of major complications. The data of 331 patients with muscle-invasive bladder cancer, who underwent radical cystectomy, were analyzed. The general status was assessed according to the American Society of Anesthesiologists (ASA), Charlson Comorbidity Index (CCI), Eastern Cooperative Oncology Group (ECOG), and Geriatric-8 (G-8) scales. Complications were classified according to the Clavien–Dindo classification system. In a group of patients with the highest complication rate according to the Clavien–Dindo scale, (i) statistically more patients rated high according to the ASA and ECOG scales, (ii) patients had significantly higher CCI scores (minor complications (I-II), and (iii) there were significantly more patients rated as frail with G8—predominantly those with 11 points or fewer in the scale. A patient’s general status should be assessed before the start of therapy because patients with a high risk of death or serious complications (evaluated with any rating scale) should be offered conservative treatment. None of the scales can describe the risk of cystectomy, because the percentage of patients with major complications among those who achieved worse score results on any scale was not significantly different from the percentage of patients with major complications in the general group.

Small-cell neuroendocrine tumor of the bladder: A rare disease in a low-risk woman

Bladder cancer is the fourth most common malignancy in men and ninth most in woman. Most bladder cancers are urothelial, and the neuroendocrine sub-types make up 0.5-1.0% of cases. Here we present a 70-year-old female with poorly differentiated small cell carcinoma of the bladder who complains of an extensive history of gross hematuria. She was started on a neoadjuvant chemotherapy regimen of 21-day Etoposide with Carboplatin and radical cystectomy. More work needs to be done when it comes to the best treatment method for this rare cohort of patients.

Differences in clinical presentation and management between pre- and postsurgical diagnoses of urinary bladder paraganglioma: is there clinical relevance? A systematic review

PURPOSE

Paraganglioma of the urinary bladder (UBPGL) is a rare neuroendocrine tumor diagnosed in many patients only after surgery. We, therefore, assessed clinical clues relevant to presurgical diagnosis and clinical consequences in patients with a missed presurgical diagnosis of UBPGL.

MATERIALS AND METHODS

Case reports describing a UBPGL (published from 1-1-2001 and 31-12-2020) were identified in Pubmed. Two authors independently performed data extraction and assessed data quality according to the PRISMA guideline. Patients were divided into two groups: UBPGL diagnosis before and after surgery.

RESULTS

We included 177 articles reporting 194 cases. In 90 (46.4%) patients, the UBPGL was diagnosed before and in 104 (53.6%) after surgery. In presurgically diagnosed UBPGL, hypertension and catecholamine-associated symptoms were 2- to 3-fold (p < 0.001) more frequent than in postsurgically diagnosed patients whereas hematuria was twofold (p = 0.003) more prevalent in those with postsurgical diagnosis. Hypertension was an independent factor for presurgical biochemical testing (OR 4.45, 95% CI 1.66-11.94) while hematuria (OR 0.23, 95% CI 0.09-0.60) was an independent factor for not performing presurgical biochemical testing. Most patients diagnosed after surgery were not pretreated with alpha-adrenoceptor blockade (95.2%), underwent more frequently transurethral resection instead of cystectomy (70.2% vs. 23.1%) and had more frequent peroperative complications and residual tumor mass.

CONCLUSIONS

In nearly half of all patients with a UBPGL, the diagnosis was not established before surgery. Hypertension and hematuria contributed independently to a presurgical diagnosis. Postsurgical diagnosis, which was associated with suboptimal presurgical and surgical management, resulted in more peroperative complications and incomplete tumor resections.

Urinary Large Cell Neuroendocrine Carcinoma: A Clinicopathologic Analysis of 22 Cases

Large cell neuroendocrine carcinoma (LCNEC) of the urinary tract is a rare disease. We present a relatively large retrospective cohort of urinary LCNEC, 20 from the urinary bladder, and 2 from the ureter, from a single institution. The patients included 16 men and 6 women with a median age of 74.5 years. Most LCNEC presented at an advanced stage with tumors invading the muscularis propria and beyond (21/22). Eight cases were pure LCNEC, while 14 cases were mixed with other histologic types, including conventional urothelial carcinoma (n=9), carcinoma in situ (n=7), small cell carcinoma (n=6), and urothelial carcinoma with glandular (n=3) features. Most LCNEC expressed neuroendocrine markers synaptophysin (22/22), chromogranin (13/16), CD56 (7/7), TTF1 (8/8), and INSM1 (2/3). They were negative for common urothelial markers including HMWCK (0/3), p40/p63 (0/6), CK20 (0/10), and had variable GATA3 staining (4/8). Ki-67 stained 25% to nearly 100% tumor cell nuclei. Patient survival was associated with cancer stage, and pure LCNEC showed worse survival than mixed LCNEC. Compared with small cell carcinoma at similar stages from a prior study, LCNEC had a worse prognosis only when patients developed metastatic disease. For organ-confined LCNEC, neoadjuvant chemotherapy followed by radical resection is the treatment option to achieve long-term survival.

Well-differentiated neuroendocrine tumors of the lower urinary tract: biologic behavior of a rare entity

The spectrum of neuroendocrine (NE) tumors in the genitourinary tract ranges from the aggressive large and small cell carcinomas to the often benign paraganglioma and well-differentiated neuroendocrine tumor (WD-NET). At least 15 pure lower urinary tract (LUT) WD-NETs have been described. Owing to the rarity of WD-NET in the LUT and the limited number of reported cases, a better definition of their biologic long-term behavior is warranted. Herein, we aim to describe 10 new cases of WD-NET arising in the LUT and expand on follow-up findings. Ten consultation cases were identified and included 6 men and 4 women who ranged from 45 to 73 years of age. Seven cases arose in the bladder with one located in the bladder neck, 1 arose in the prostatic urethra, 1 arose in the female urethra, and 1 arose in the left ureteral orifice. All lesions were confined to the lamina propria, and tumor architecture was pseudoglandular in all cases. Associated cystitis cystica et glandularis was identified in 5 cases; urothelial papilloma and florid von Brunn's nests were found in 2 additional cases. Immunohistochemical staining for synaptophysin and chromogranin was diffusely positive in 9 cases and focal in 1 case, and the Ki-67 proliferation index was 5% or less in all tumors. Follow-up ranged from 37 to 137 months (mean = 82; median = 77), and there was no evidence of residual disease or recurrence in any of the 10 patients during the follow-up period.

Small cell carcinoma of the bladder with coexisting prostate adenocarcinoma: two cases report and literature review

BACKGROUND

Primary small cell carcinoma of the bladder (SCCB) is a rare disease of the genitourinary tract and reported limitedly. SCCB is very aggressive and always mixed with other histologic components, but coexistence of SCCB and prostate adenocarcinoma is extremely rare.

CASES PRESENTATION

Two aged males (72 and 58 years) were included in this study. Both of them presented with gross hematuria as initial symptom. Magnetic resonance imaging (MRI) demonstrated protruding lesions in the urinary bladder. Pathological examination after radical cystectomy and prostatectomy showed the concurrence of SCCB and prostate adenocarcinoma. One patient died of liver and lung metastasis 8 months after surgery, and the other patient was still alive after 19 months of follow-up.

CONCLUSION

In this paper, we reported two unusual cases of coexistence of SCCB and prostate adenocarcinoma, and reviewed relative literatures with respect to the epidemiology, clinical features, pathologic features, diagnosis, treatment and prognosis of SCCB.

Bladder Preservation for Patients With Bladder Paragangliomas: Case Series and Review of the Literature

Bladder paragangliomas are rare tumors, with no prospective studies or guidelines on the management of this disease. We present a case series of 6 patients managed with bladder preservation over a median follow-up period of 124 months. We also present a review of the recent literature on bladder paragangliomas. We aim to provide a timely synthesis of the recent evidence on bladder paragangliomas as changing paradigms necessitate individualized treatment.

The applicability and utility of immunohistochemical biomarkers in bladder pathology

Urinary bladder specimens are frequently encountered in the daily practice of surgical pathologists. The spectrum of pathologic entities encountered in bladder specimens is extraordinarily broad, and in some instances, immunohistochemical stains are used to help characterize challenging bladder lesions. Cost-effective biomarker selection tailored to the differential diagnosis facilitates an accurate diagnosis. This comprehensive review is prepared as a reference guide for the use of immunohistochemistry to categorize primary and secondary bladder neoplasms and to evaluate metastatic cancers for possible bladder origin.

Neuroendocrine tumour of urinary bladder: a rare case of aggressively behaving primary well-differentiated neuroendocrine tumour with review of literature

Neuroendocrine tumour (NET) of the urinary bladder (UB) is a rare entity and comprises of well-differentiated, small cell and large cell types. Small and large cell NET like that in lung and gastrointestinal tract have an aggressive nature and are considered high-grade disease. Well-differentiated NET has been thought to be localised and having a good prognosis. We report the first case of metastatic well-differentiated NET of the UB. Our case is a 44-year-old man with well-differentiated NET of UB presented with hepatic and peritoneal metastases on initial diagnosis. He was treated with metaiodobenzylguanidine (MIBG) therapy and had a modest survival of 16 months. The primary well-differentiated NETs can present as a metastatic disease with an aggressive nature. MIBG therapy can be considered as a useful option but overall prognosis is poor. Further research is needed for better understanding and better treatment protocol.

Role of immunohistochemistry in diagnosis of a rare bladder tumor

Neuroendocrine tumors (NETs) are commonly located in the respiratory and gastrointestinal tract; however, these tumors can rarely be found in the urinary bladder. NETs comprise <1% of all bladder tumors; usually intermixed with urothelial carcinoma and its variants. We report a case of primary neuroendocrine carcinoma of urinary bladder in an adult female with a history of smoking and hematuria. The present case highlights the importance of immunohistochemistry in arriving at an accurate diagnosis and thereby differentiating this tumor from other clinical mimics.

Urothelial carcinoma with villoglandular differentiation (UCVGD) with small cell neuroendocrine carcinoma of urinary bladder

Urothelial carcinoma with villoglandular differentiation (UCVGD) is a rare aggressive variant of urothelial carcinoma. It is usually associated with high-grade urothelial carcinoma or rarely adenocarcinoma. There is only one other previous report of UCVGD associated with small cell neuroendocrine carcinoma of urinary bladder. We report the second case of UCVGD with small cell neuroendocrine carcinoma of urinary bladder in a 74-year-old non-smoker male patient. The mass was muscle invasive and also invaded the prostate. This entity needs to be confidently diagnosed due to its prognostic and therapeutic implications.

Imaging Characteristics of a Bladder Wall Paraganglioma

A 65-year-old man with a history of hypertension and nephrolithiasis presented with flank pain. Urographic CT demonstrated a 1.7-cm nodule arising from the bladder wall. The patient was referred for cystourethroscopy. During the procedure, the patient became hypertensive while under general anesthesia. No biopsy or resection was performed. To work up for possible bladder paraganglioma, a I-MIBG scan was ordered, and the patient was referred to endocrinology. On SPECT/CT images, the bladder nodule demonstrates marked uptake of MIBG radiotracer, confirming the diagnosis of a genitourinary paraganglioma arising from the bladder wall.

Clinicopathological characteristics and survival outcomes of bladder neuroendocrine carcinomas: a population-based study

Background

Bladder neuroendocrine carcinomas (BNECs) are relatively a rare type of tumor. The aim of this study was to examine the clinicopathological characteristics and predictors of survival outcomes of patients with BNECs based on the analysis of the national Surveillance, Epidemiology, and End Results (SEER) database.

Materials and methods

Kaplan-Meier analysis with log-rank test was used for survival comparisons. Multivariate Cox regression model was employed to analyze the effect of different treatments on overall survival (OS) and cancer-specific survival (CSS).

Results

A total of 910 patients were identified between 2004 and 2014. Overall, 648 (71.2%) patients had small cell neuroendocrine carcinoma (SCNEC), 35 (3.8%) had large cell neuroendocrine carcinoma (LCNEC), 10 (1.1%) had carcinoid tumor (well-differentiated neuroendocrine tumor), 16 (1.8%) had paraganglioma/pheochromocytoma (PGL/PHEO), 619 (68.0%) had a poorly differentiated or undifferentiated histology grade, 214 (23.5%) presented with metastatic disease, 586 (64.4%) underwent transurethral ablation/destruction for bladder tumor, and 245 (26.9%) had partial/total cystectomy. Cystectomy+chemotherapy+radiotherapy (CCR) has the highest long-term survival rate among various treatments. The 1-, 3-, and 5-years CSS of CCR were 56%, 56%, and 56%, respectively. By using multivariable Cox proportional hazard model, age, histology, N stage, SEER stage, tumor size, radiotherapy, chemotherapy, and local treatment of the primary site were identified as independent predictors for OS and CSS; all P<0.05.

Conclusion

In BNEC, SCNEC has an absolute advantage in number. SCNEC/LCNEC tend to be older men. PGL/PHEO and carcinoid tumors have younger mean ages, earlier tumor stages, and better prognosis than SCNEC/LCNEC. Surgery, radiotherapy and chemotherapy are better than conservative treatment. However, whatever cystectomy or bladder sparing, chemotherapy should be a major component of treatment.

The use of Ki-67 labeling index to grade pulmonary well-differentiated neuroendocrine neoplasms: current best evidence

Although Ki-67 labeling index (Ki-67%) is not a diagnostic or grading criterion in the World Health Organization classification of pulmonary carcinoid tumor, oncologists often request this test. A survey was administered at a North American Society for Neuroendocrine Tumors meeting to understand how Ki-67% is used in oncologic practices. A systematic literature review was performed to gather best evidence regarding the use of Ki-67%. Consecutive pulmonary carcinoids were stratified into pulmonary typical carcinoids with Ki-67% <5% (group A, n = 187), typical carcinoids with Ki-67% ≥5% (group B, n = 38) and atypical carcinoids irrespective of Ki-67% (group C, n = 31). Overall survival, progression-free survival, recurrence proportions and time to recurrence were compared, by group, using the log-rank test, chi-square statistics and ANOVA, respectively. Our survey confirmed that Ki-67% is frequently used by specialists caring for these patients. Ki-67% of 1-7% significantly correlated with overall survival in the literature but we found no information about Ki-67% cut-off values that would accurately distinguish pulmonary typical from atypical carcinoids or estimate the prognosis of patients stratified by World Health Organization diagnosis and Ki-67% cut-off. Overall survival was significantly different in our 3 patient groups (p < 0.001), with survival probabilities decreasing from groups A to C. Progression-free survival was significantly longer in group A than B (p < 0.007). Our results support the concept that by combining World Health Organization diagnosis and Ki-67%, pulmonary carcinoids can be stratified into 3 grades: G1 (typical carcinoids with Ki-67% <5), G2 (typical carcinoids with Ki-67% ≥5%) and G3 (atypical carcinoids) with different prognoses.

ACUTE DECOMPENSATION OF HYPERTENSIVE HEART DISEASE IN PATIENT WITH MALIGNANT URINARY BLADDER PARAGANGLIOMA: STAGES OF DIAGNOSTICS AND TREATMENT

Hypertensive heart disease with biventricular cardiac failure is not common in clinical practice. This diagnosis requires an extensive diagnostic search. We present the clinical case of the male patient of 38 aged. He was admitted to the clinic with heart failure 3-4 NYHA class. EchoCG revealed symmetric hypertrophy of the left ventricle up to 18 mm without its dilatation, a decrease in ejection fraction up to 42%, restrictive hemodynamics, overload of the right chambers, severe pulmonary hypertension (60 mm Hg). The clinical status included persistent arterial hypertension (180-220 and 120-150 mm Hg), effusion in both pleural cavities and pericardium, ascites, renal failure. During examination (multispiral computed tomography, magnetic resonance imaging, scintigraphy with 131I-MIBG), bladder paraganglioma was diagnosed (normatenafrin 1468 μg/day). The resection of the tumor was performed, according to immunohistochemical research – neuroendocrine carcinoma, G1. After 3 months a partial regression of hypertension and cardiac failure was observed with the preservation of a high level of creatinine. The criteria and differential diagnosis of the hypertensive heart disease and the syndrome of primary myocardial hypertrophy, diagnostics of the urinary bladder paraganglioma, complex mechanisms of myocardial damage within the pheochromocytoma and its prognosis are discussed.

Small Cell Carcinoma of Urinary Bladder: Analysis from a Tertiary Cancer Care Center of India

Context: Small cell cancer of the urinary bladder. Aims: Small cell carcinoma of the bladder is a rare histological subtype, which is particularly aggressive and global literature available describing this entity is sparse. This review of our database was to evaluate clinicopathological and survival outcomes of these patients. Subjects and Methods: The present study was a retrospective analysis of patients with small cell bladder cancer for past 6 years at Rajiv Gandhi Cancer Institute and Research Center, New Delhi. Results:: Most of the patients in our study presented with limited stage disease. The overall survival and disease-free survival (DFS) was 49% and 51.07% at 2 years, respectively. Preoperative chemotherapy with surgical resection has shown significant survival and DFS benefit. Stage at presentation also affected the survival and DFS though it did not reach statistical significance. Conclusions: Small cell bladder cancer is a rare disease with dismal prognosis. Multimodality treatment with neoadjuvant chemotherapy should be the preferred treatment for limited stage disease.

Multilayered heterogeneity as an intrinsic hallmark of neuroendocrine tumors

Neuroendocrine tumors (NETs) comprise a complex and highly heterogeneous group of neoplasms that can arise all over the body, originating from neuroendocrine cells. NETs are characterized by a general lack of symptoms until they are in advanced phase, and early biomarkers are not as available and useful as required. Heterogeneity is an intrinsic, pivotal feature of NETs that derives from diverse causes and ultimately shapes tumor fate. The different layers that conform NET heterogeneity include a wide range of distinct characteristics, from the mere location of the tumor to its clinical and functional features, and from its cellular properties, to the core signaling and (epi)genetic components defining the molecular signature of the tumor. The importance of this heterogeneity resides in that it translates into a high variability among tumors and, hence, patients, which hinders a more precise diagnosis and prognosis and more efficacious treatment of these diseases. In this review, we highlight the significance of this heterogeneity as an intrinsic hallmark of NETs, its repercussion on clinical approaches and tumor management, and some of the possible factors associated to such heterogeneity, including epigenetic and genetic elements, post-transcriptional regulation, or splicing alterations. Notwithstanding, heterogeneity can also represent a valuable and actionable feature, towards improving medical approaches based on personalized medicine. We conclude that NETs can no longer be viewed as a single disease entity and that their diagnosis, prognosis and treatment must reflect and incorporate this heterogeneity.

Rare urologic tumors

PURPOSE OF REVIEW

Management of genitourinary malignancy is likely to encompass a large portion of most of the urologist's practice. The challenge for the modern urologist is not only in understanding the management of commonly seen genitourinary malignancies, but also in recognizing unusual variants and their differences in management. This is evermore important as new technologies have refined the ability to identify rare entities. This review presents a brief overview of the various genitourinary malignancy subtypes seen within urology.

RECENT FINDINGS

All major organ subtypes are highlighted along with an overview of the current understanding of their associated malignancies. An update on the current state management paradigms as well as future directions is also outlined.

SUMMARY

After reading this review, the urologist should have a deeper understanding of the breadth of disorders in genitourinary oncology and a clearer approach to the management of these problems. Additionally, ongoing avenues for research are highlighted.

Rare Occurrence of a Poorly Differentiated Neuroendocrine Tumor of the Bladder

Neuroendocrine tumors rarely occur in the urinary bladder. They can be carcinomatous, subdivided into small cell and large cell pathology. Small cell carcinoma of the bladder is a rarity that may present at an advanced pathologic stage. No treatment regimens have been standardized for local or metastatic disease. Review of the recent literature shows equivalent survival data for localized disease treated with chemoradiotherapy combined with either bladder sparing surgery or radical cystectomy. Patients with significant comorbidities are an additional challenge. We report a case of poorly differentiated neuroendocrine tumor of the bladder, which could not be classified as small or large cell carcinoma, complicated by significant comorbidities. After management with transurethral resection of the tumor, adjuvant chemotherapy, and radiation, the patient is alive and asymptomatic nearly 1 year after initial TURBT with no evidence of disease recurrence.

Prognostic value of neutrophil-to-lymphocyte ratio in urothelial carcinoma of the upper urinary tract and bladder: a systematic review and meta-analysis

The neutrophil-to-lymphocyte ratio (NLR) is an inflammation marker that has prognostic value for various tumors, but its prognostic value in urothelial carcinoma (UC) remains controversial. This meta-analysis investigated the prognostic value of NLR in UC. A systematic search was performed on PubMed, ISI Web of Science, and Embase for studies focusing on the association between NLR and clinical features or prognosis of UC and published until November 2016. Prognostic outcomes and clinical features were collected and analyzed. A total of 11,538 patients from 32 studies were included in the meta-analysis. Increased pretreatment NLR predicted poor overall survival (hazard ratio [HR] = 1.72, 95% confidence interval [CI] = 1.45–2.05), progression free survival (HR = 1.68, 95% CI = 1.44–1.96), and cancer specific survival (HR = 1.64, 95% CI = 1.39–1.93) in all the patients. The increased pretreatment NLR was correlated with increased lymphovascular invasion (HR = 1.29, 95% CI = 1.17–1.43), high tumor T stage (HR = 1.25, 95% CI = 1.12–1.39), and tumor grade (HR = 1.07, 95% CI = 1.01–1.14) but not with lymph node involvement, carcinoma in situ, multifocality, or positive margin. Our meta-analysis indicated that NLR could predict the prognosis for UC and was associated with UC progression in terms of lymphovascular invasion, tumor T stage, and tumor grade.