Updates in the Pathologic Diagnosis and Classification of Epithelial Neoplasms of Urachal Origin

Urachal carcinoma initially presenting only as a liver metastasis, a diagnostic and therapeutic challenge: first case in literature

Introduction

Urachal carcinomas are uncommon malignant neoplasms comprising only 0.01% of all adult cancers. Most patients were aged from 58 to 64 years at diagnosis with 60 years being the median. It usually metastasizes to the lungs (22%), bones (22%), and liver (16%).

Presentation

We report a case of a 71-year-old female patient who initially presented with two large liver masses and a small nodule on the anterior side of the bladder. The symptoms were nonspecific with abdominal discomfort. The final diagnosis of urachal adenocarcinoma was finalized with a biopsy of the bladder mass. The patient initially received six doses of FOLFOX6 without improvement and then Gem-Carbo, showing improvement after six doses. Finally, the patient received two doses of FOLFIRI-B with no response and kept deteriorating and died after 19 months of treatment.

Discussion

About 90% of patients are symptomatic and hematuria is the most typical presenting symptom at diagnosis. The low incidence and the histopathologic similarities to adenocarcinoma from various sources pose a difficulty in recognizing the tumor. Our study presents the only case of a urachal carcinoma first manifesting with abdominal mass resulting from liver metastasis with no prior symptoms of urological origins. Also, our study presents the first attempt of using FLOFIRI-B to treat metastatic UraC.

Conclusion

This case highlights the necessity for clinicopathological correlation to make the correct diagnosis and the challenges in the treatment which urges the need for further research to identify more effective treatment strategies for this rare cancer.

Urachal adenocarcinoma with cervical invasion misdiagnosed as primary cervical adenocarcinoma: a case report and literature review

Background

Urachal carcinoma (UrC) is a rare malignancy with no known specific early symptoms. It is often diagnosed at advanced stages and is associated with poor prognosis.

Case presentation

This study presents a rare case of urachal adenocarcinoma (UrAC) invading the bladder and vagina in a female patient. Initially, the patient was misdiagnosed as having a primary cervical adenocarcinoma 2.5 years prior. Subsequently, anterior pelvic exenteration and bilateral ureterocutaneostomies were performed. Twenty months after the first surgery, the patient was diagnosed with rectal metastasis and received gemcitabine chemotherapy. After achieving a stable disease state, the patient underwent laparoscopic ultralow rectal anterior resection, ultralow anastomosis of the sigmoid colon and rectum, prophylactic transverse colostomy, and right common iliac and external iliac lymph node dissection. The patient then received a cycle of postoperative chemotherapy with oxaliplatin and capecitabine; however, treatment was stopped due to adverse reactions. The patient continues to receive regular follow-ups, and her general condition is good.

Conclusions

UrC is rare, and preoperative differential diagnosis is difficult. This is the first report of UrC being misdiagnosed as cervical cancer. The presented case highlights the importance of accurate histopathological examination and comprehensive analysis. Anterior pelvic exenteration was also identified as a potentially effective treatment strategy for patients with local pelvic recurrence of UrC, although further investigation is required.

Mucinous Cystadenoma of the Urachal Remnant Successfully Resected by Laparoscopic Surgery: A Case Report

A urachal remnant is a disorder resulting from a disturbance in the closure process of the urachus. A 55-year-old man was referred to our hospital for treatment of gallstones. The computed tomography scan revealed a cystic mass in the lower abdomen connecting to the urinary bladder. The preoperative diagnosis was a urachal cyst. Simultaneous laparoscopic cholecystectomy, mass resection, and urachectomy were performed. The mass on the cranial side of the urinary bladder was located on the median umbilical ligament. Both were resected and removed, along with the umbilicus. The postoperative course was uneventful. The histopathological diagnosis was urachal mucinous cystadenoma. There is no sign of a recurrence. A complete resection without damage is especially important for mucinous tumors of the urachal remnant because the injury to the tumor may lead to the development of pseudomyxoma peritonei. Only seven cases of mucinous cystadenoma of the urachal remnant were reported in English literature, and only one of these was treated with laparoscopic surgery. In our case, complete resection was possible by taking advantage of the magnifying effect of laparoscopic surgery. Furthermore, we are able to provide very clear intraoperative images and specimen photographs, which we believe will be useful for readers. Laparoscopic surgery will be beneficial when treating similar cases in the future. However, it should be kept in mind that a safe resection requires careful and meticulous technique.

Primary urachal adenocarcinoma: Case report

INTRODUCTION AND IMPORTANCE

Primary urachal adenocarcinoma (PUA) is a rare form of cancer that arises from the urachus, a vestigial remnant of the allantois and cloaca during embryonic development. The exact pathogenesis of PUA is not well understood, but it is believed to arise from glandular epithelium remnants within the urachus. The rarity of this type of cancer makes it difficult to comprehensively study its epidemiology.

CASE PRESENTATION

This case report describes a 47-year-old male patient who presented with intermittent painless hematuria and fatigue for two months. Cystoscopy showed a single growth at the dome of the urinary bladder, and abdominopelvic CT scan with contrast revealed a 3*2 cm enhancing growth at the dome of the bladder suspicious of urachal origin tumor. The patient was diagnosed with urachal adenocarcinoma (PT2) after pathological examination. The patient underwent partial cystectomy and umbilicectomy.

CLINICAL DISCUSSION

Patients with PUA often present with nonspecific symptoms that can delay the diagnosis. The most common symptom is hematuria, which is present in approximately two-thirds of the patients. The diagnosis of PUA is challenging and relies on a combination of clinical presentation, imaging, and histopathological examination.

CONCLUSION

The mainstay of treatment for PUA is surgical resection, which may include partial cystectomy or radical cystectomy with en bloc resection of the urachus and umbilicus. It is esential to report all cases of primary urachal adenocrcinoma.

Urachal mixed adenocarcinoma and small cell neuroendocrine carcinoma with widespread metastasis and resistance to chemotherapy: a case report

Neuroendocrine carcinoma arising from the urachus is extremely rare. We describe a case of a 33-year-old gentleman who presented with hematuria and diagnosed to have a composite adenocarcinoma and small cell neuroendocrine carcinoma arising from the urachus. The patient also had widespread metastasis at the time of presentation, therefore, he was referred for chemotherapy. However, the disease showed progression despite treatment. Recognition of neuroendocrine carcinoma component in urachal tumors, although rare, is very essential as this histologic type carries poor prognosis with aggressive clinical outcome.

Rare case of enteric type of urachal adenocarcinoma: A case report

Urachal adenocarcinomas, constituting 10 % of bladder adenocarcinomas, pose a significant challenge with limited literature. A 43-year-old male presented with haematuria and abdominal pain, leading to surgical intervention for a 13 cm pelvic tumor. Histopathology identified an intestinal-type primary urachal adenocarcinoma, staged as IIIA, no recurrence on follow-up. Early detection is crucial for improved outcomes in these rare malignancies. While surgery remains the primary treatment, outcomes vary, emphasizing the need for research on standardized protocols. Enhanced awareness and interdisciplinary collaboration are vital for effective management. Comprehensive guidelines are essential for optimizing patient prognoses in urachal adenocarcinomas.

Glandular Lesions of the Urinary Bladder: Diagnostic and Molecular Updates

Glandular lesions in the urinary tract or their associated pathologies can pose a diagnostic challenge. There is a variety of benign alterations and tumor types that need to be taken into account in differential diagnostic considerations. In recent times, efforts for better defining these alterations or lesions both on the histopathological and molecular levels have been undertaken. This article will provide an update on current diagnostic and molecular considerations of these lesions.

Rare urachal mucinous cystic tumor of low malignant potential with peritoneal pseudomyxoma: A case report

Mucinous cystic tumors of low malignant potential (MCTLMP) are rare urachal neoplasms. The morphological characteristics and clinical prognosis of MCTLMP is similar to that of mucinous cystic tumors occurring in the ovary and appendix. After complete resection, almost no cases of recurrence or metastasis have been reported. Because MCTLMP is rare, it may be missed in the clinic. MCTLMP can lead to the formation of pseudomyxoma peritonei (PMP), which manifests as the widespread production of mucus in the abdominal cavity and makes the disease complex or difficult to diagnose. At present, only 3 cases of MCTLMP with PMP have been reported in the literature. In the present study a fourth case of urachal MCTLMP in a 74-year-old male that resulted in widespread PMP is presented. Initially, a multilocular cystic lesion was revealed in the urachal duct area at the anterior upper margin of the bladder after a patient, experiencing lower abdominal pain, was imaged. As revealed using light microscopy, the cyst was lined with a mucous columnar epithelium, and part of the epithelium indicated pseudolamellar hyperplasia and papillary structures. The cells indicated mild atypia and low mitotic activity. There was no stromal infiltration of tumor cells, and a large amount of mucous exudate was observed. As preoperative computed tomography examination suggested the presence of a large amount of ascites and there were increased levels of blood tumor markers, carcinoembryonic antigen and carbohydrate antigen 125, clinicians considered that the diagnosis maybe a malignant tumor of the urachal gland with peripheral dissemination. However, the diagnosis of MCTLMP with PMP was confirmed by histopathological examination. The mass was completely removed, along with part of the peritoneum and bladder wall as these were within the tumor margin. The appendix appeared normal during surgery. A one off dose of intraperitoneal infusion chemotherapy with 1,000 mg 5-fluorouracil was performed after surgery. No recurrence was observed during the 8-month follow-up period.

Peritoneal Surface Malignancies Originating From Urachal Carcinoma: Case Reports and Review of the Literature

Urachal carcinoma (UC) is a rare and aggressive tumor arising from the urachal remnants, with the potential for peritoneal dissemination. Patients diagnosed with UC often have a poor prognosis. To date, there is no standardized treatment. Our objective is to present two cases of patients with peritoneal carcinomatosis (PC) secondary to an UC, who were treated with cytoreductive surgery (CRS) and hyperthermic peroperative intraperitoneal chemotherapy (HIPEC). A review of the literature on CRS and HIPEC in UC suggests CRS and HIPEC to be a safe and viable treatment option. Two patients with PC of UC underwent CRS and HIPEC in our institution. All available data were gathered and reported on. A literary search was carried out to find all available cases of patients with PC secondary to UC treated with CRS and HIPEC. Both patients underwent CRS and HIPEC and are currently free of recurrence. Literature research revealed nine other publications adding up to a total of 68 additional cases. CRS and HIPEC can provide satisfactory long-term oncological outcome with acceptable morbidity and mortality rates in patients with PC of urachal origin. It should be considered as a safe and feasible treatment option with curative potential.

A Huge Asymptomatic Urachal Mucinous Cystic Carcinoma: A Case Report With Differential Diagnosis and Surgical Considerations

Cystic mucinous neoplasms of urachal origin cover a wide spectrum of benign and malignant lesions arising from the remnants of the urachus. They display various degrees of tumor cell atypia and local invasion, with no reported cases of metastasis or recurrence after complete surgical resection. We present a 47-year-old man who referred to our Surgical Department due to an abdominal cystic mass incidentally found upon abdominal ultrasound. He underwent en block resection of the cystic mass along with partial bladder dome cystectomy. The histopathology of the resected specimen revealed a cystic mucinous epithelial tumor of low malignant potential with areas of intraepithelial carcinoma. The patient showed no evidence of disease recurrence or distant metastasis 6 months after resection and is scheduled for follow-up with serial MRI or CT scans and blood tumor markers over the next 5 years.

Urachal carcinoma: The journey so far and the road ahead

Urachal carcinoma, a rare cancer arising from urachus, accounts for about 1% of bladder cancer. The diagnosis at stage I shows about 63% 5-year survival whereas only 8% of the patients at stage IV shows a 5-year survival. Above 90% of urachal carcinomas are adenocarcinomas and most of the urachal carcinoma cases are invasive, showing a high resemblance to adenocarcinoma of various origins, making it hard for a conclusive diagnosis. Even though inconclusive, immunohistochemistry can play a significant role in identifying urachal carcinoma. Most cases show the biomarkers CK20 and CDX2, whereas CK7 and β-catenin are expressed at a lesser frequency. Due to the few cases available, there is a lack of evidence regarding specific markers differentiating urachal carcinoma from colorectal or primary bladder adenocarcinomas. In addition to immunohistochemistry, genomic characterization is emerging to play a role in the classification and treatment of the disease. Urachal carcinoma has been reported to have a molecular level similarity with colorectal malignancies regarding certain gene expressions. The TP53 mutations inactivating the tumor suppressor can probably be explored as a possible target in treating urachal carcinoma. Additionally, certain targets identified in gastric and breast cancer along with anti-HER2 treatment strategies can be explored. Immuno-oncology utilizes immune checkpoint inhibitors for the treatment of MSI-H tumors whereas a combination of tyrosine kinase inhibitors along with immune checkpoint inhibitors are being studied to treat MSI stable tumors. The article is an in-depth overview of urachal carcinoma addressing the current landscape with an emphasis on the future scenario.

Urothelial Carcinoma: Divergent Differentiation and Morphologic Subtypes

Urothelial carcinoma (UC) is known to encompass a wide spectrum of morphologic features and molecular alterations. Approximately 15% to 25% of invasive UC exhibits histomorphologic features in the form of "divergent differentiation" along other epithelial lineages, or different "subtypes" of urothelial or sarcomatoid differentiation. It is recommended that the percentage of divergent differentiation and or subtype(s) be reported whenever possible. Recent advances in molecular biology have led to a better understanding of the molecular underpinning of these morphologic variations. In this review, we highlight histologic characteristics of the divergent differentiation and subtypes recognized by the latest version of WHO classification, with updates on their molecular and clinical features.

Primary urachal signet ring cell carcinoma: A case report

Urachal signet ring cell carcinoma is a kind of rare but aggressive tumor, and a few cases have been reported previously. A 49-year-old male patient with primary complaints of increased frequency of urination, urodynia, and hematuria was diagnosed to have primary urachal signet ring cell carcinoma by our department. Multiple metastases were found in the sigmoid colon, terminal ileum, mesentery, and peritoneum during the operation, and palliative surgery involving partial cystectomy with en bloc resection of the urachus was then performed. A chemotherapy regimen of fluorouracil combined with cisplatin was made for this case. In addition, this patient also received anlotinib for targeted therapy. So far, this patient has done well on regular follow-up for 6 months and is in stable condition. We reported this additional urachal signet ring cell carcinoma case and conducted a literature review to strengthen our cognition of this disease.

Urachal Carcinoma, An Unusual Possibility of Hematuria; Case Report and Literature Review

Urachal cancer is very rare, accounting for only 0.5-2% of bladder-associated malignancies and 0.01% of all cancers in adults. It has an insidious appearance, an aggressive behavior and a poor prognosis. The most common symptoms are hematuria and the presence of a palpable hypogastric mass. The scarcity of cases and the low number of studies carried out explains the lack of an evidence-based management strategy, but it seems that surgical treatment (open, laparoscopy or robot-assisted) represents the gold standard, while neoadjuvant and adjuvant chemotherapy or radiotherapy has a limited impact on overall survival. Since mucinous cystadenocarcinoma of urachal origin is a very uncommon pathological condition the differential diagnosis may be difficult and pathological investigations have to elucidate this disorder. It is worth mentioning the psychological impact on the patient in addition to the medical aspects. A rare condition is associated with heightened risk for mental health and psychosocial difficulties and this must be taken into account in the subsequent follow-up of the patient. In order to increase awareness of this rare entity we report a case of a 40-year-old male with a urachal adenocarcinoma who was treated surgically, with a favorable outcome. We also perform a brief literature review about this type of tumor.

Clinical outcomes and patterns of population-based management of urachal carcinoma of the bladder: An analysis of the National Cancer Database

BACKGROUND

Given the low incidence of urachal carcinoma of the bladder (UCB), there is limited published data from contemporary population-based cohorts. This study aimed to describe demographic, clinicopathological features, and survival outcomes of patients diagnosed with UCB.

METHODS

The National Cancer Database (2004-2016) was queried for UCB patients. Descriptive analyses characterized demographics and clinicopathologic features. We assessed 5-year overall survival (OS) rates of the entire cohort and subgroups of localized/locally advanced and metastatic disease. We utilized Cox proportional hazards models to assess the association between covariates of interest and all-cause mortality and to examine the impact of surgical technique and chemotherapy.

RESULTS

We identified 841 patients with UCB. The most common histologic subtype was non-mucinous adenocarcinoma (39.6%). Approximately 50% had ≥cT2 disease, and 14.3% were metastatic at diagnosis. Altogether, partial cystectomy (60%) was most performed, and lymph node dissection was performed in 377 patients (44.8%), with specific temporal increase in utilization over the study period (p < 0.001). Overall, median OS was 59 months, and 5-year OS was 49%. In patients with localized/locally advanced disease, we found no association between partial and radical cystectomy (Hazards ratio [HR] 1.75; 95% CI 0.72-4.3) as well as receipt of perioperative chemotherapy (HR 1.97, 95% CI 0.79-4.90) and outcomes. Lastly, receipt of systemic therapy was not associated with survival benefit (HR 0.785, 95% CI 0.37-1.65) in metastatic disease cohort.

CONCLUSION

This large population-based cohort provides insight into the surgical management and systemic therapy, without clear evidence on the association of chemotherapy and survival in the perioperative and metastatic setting.

Current Management of Urachal Carcinoma: An Evidence-based Guide for Clinical Practice

Urachal carcinoma is a rare urological disease. The shortage of data about diagnosis and surgical treatment in literature makes it hard for clinicians to make a decision. Indeed, urachal carcinoma is an aggressive disease that requires prompt staging and treatment to ensure the best outcome for patients. We reviewed the last evidence about the management of urachal carcinoma to provide an easy-to-use guide for clinical practice.

Patient summary

Urachal carcinoma is a rare malignancy. The literature on this challenging disease remains limited. Herein, we provide a practical guide for its management from diagnosis to treatment, which in most cases requires surgical intervention or chemotherapy.

Distinct Gene Mutations Are Associated With Clinicopathologic Features in Urachal Carcinoma

OBJECTIVES

To investigate the gene mutational profile of urachal carcinoma in correlation with its clinicopathologic features.

METHODS

We analyzed genetic mutations in 30 cases of urachal carcinoma by next-generation sequencing (NGS) test. Histologic slides and clinical data were reviewed.

RESULTS

The patients included 21 men and 9 women, with a mean age of 53 years (range, 24-75 years). The urachal carcinomas included mucinous (11), enteric (10), signet ring cell (8), and high-grade neuroendocrine (1) subtypes. Targeted NGS analysis demonstrated genetic mutations in all the urachal tumors (mean, 2; range, 1-4). TP53 was the most mutated gene (25), followed by KRAS (9) and GNAS (8) genes. TP53 mutations were more common in the signet ring cell subtype (7/8), and GNAS mutations were present only in the mucinous (5/11) and signet ring cell subtypes (3/8) but not in the enteric subtype (0/10). KRAS mutations were significantly associated with cancer stage IV (P = .02) and younger patient age (P = .046). Furthermore, the presence of KRAS mutations in urachal carcinoma portended a poorer overall survival (P = .006).

CONCLUSIONS

Urachal carcinoma demonstrates frequent gene mutations that are associated with distinct clinicopathologic features. Gene mutation may underlie the development and progression of this aggressive disease.

Urachal mucinous cystic tumor of low malignant potential in a polymorbid female: a case report and review of the literature

Neoplasms of the urachus are exceedingly rare, representing 0.17% of all bladder cancers. The mucinous cystic tumor of low malignant potential (MCTLMP) subtype is particularly rare with just 25 previous cases reported in the literature. Although rare, MCTLMPs are important to identify due to potential devastating complications and good cure rates with surgical removal. We present a 43 year old female with a nuanced constellation of comorbidities and confirmed MCTLMP following a workup for abdominal pain and irritative lower urinary tract symptoms. Notably, this tumor did not change in size over a 3-year course of serial imaging prior to surgical excision. This urachal MCTLMP represents roughly the 26th and one of the smallest of its subtype reported in the literature. This case illustrates the diagnosis and management of this rare urachal MCTLMP. Individual patient medical history, clinical considerations, and neoplasm characteristics are examined. Although rare, the potential for increased malignancy and potential complications necessitates surgical management and further investigation by the academic community.

18F-FDG PET/CT in a Case of Urothelial Carcinoma in the Urachus Presenting as Colon Cancer

Urachal cancer arises from an embryologic remnant of the urogenital sinus and allantois and accounts for approximately 1% of bladder malignancies. The most encountered histologic subtype is adenocarcinoma. We present a 76-year-old man suspected to have an advanced sigmoid cancer infiltrating nearby organs. A supplemental 18F-FDG PET/CT showed high tracer uptake in a tumorous process coherent with the dome of the bladder wall involving the sigmoid colon. Cystoscopy revealed a normal bladder wall, except for a small edematous area in the anterior bladder. Biopsies from the sigmoid colon and transurethral resection from the bladder confirmed a urothelial carcinoma originating from the urachus.

Treatment Outcome of Different Chemotherapy in Patients With Relapsed or Metastatic Malignant Urachal Tumor

Background

Malignant urachal tumor is a rare subtype of genitourinary cancer. Our aim was to explore the optimal chemotherapy regimens for relapsed or metastatic urachal carcinoma.

Materials and Methods

We retrospectively enrolled 24 adult patients with relapsed or metastatic urachal carcinoma from January 2014 to September 2020 at Sun Yat-sen University Cancer Center. We summarized the chemotherapy regimens and classified them as fluorouracil based, platinum based, and paclitaxel based. Nine patients received XELOX (capecitabine and oxaliplatin) regimens, seven patients received TX (paclitaxel and capecitabine) regimens, and eight of them received chemotherapy including GP (gemcitabine and cisplatin), TP (paclitaxel and cisplatin), TN (paclitaxel and nedaplatin), and tislelizumab.

Results

The disease control rate was 75%. Among all patients, one patient treated with XELOX achieved partial remission (PR), while 17 patients showed stable disease. The median progression-free survival (PFS) and overall survival (OS) in all treated patients was 7.43 and 29.7 months, respectively. The patients receiving first-line platinum-based chemotherapy presented better PFS than those without platinum (median PFS 8.23 vs. 3.80 months, p = 0.032), but not significant for OS between two groups. There is no significant difference in PFS and OS for fluorouracil-based and paclitaxel-based groups as first-line regimen. Next-generation gene sequencing revealed TP53 mutation and low tumor mutational burden in five out of seven cases.

Conclusion

The platinum-based chemotherapy regimen is effective for relapsed or metastatic urachal carcinoma.

A new technological approach in diagnostic pathology: mass spectrometry imaging-based metabolomics for biomarker detection in urachal cancer

Urachal adenocarcinomas (UrC) are rare but aggressive. Despite being of profound therapeutic relevance, UrC cannot be differentiated by histomorphology alone from other adenocarcinomas of differential diagnostic importance. As no reliable tissue-based diagnostic biomarkers are available, we aimed to detect such by integrating mass-spectrometry imaging-based metabolomics and digital pathology, thus allowing for a multimodal approach on the basis of spatial information. To achieve this, a cohort of UrC (n = 19) and colorectal adenocarcinomas (CRC, n = 27) as the differential diagnosis of highest therapeutic relevance was created, tissue micro-arrays (TMAs) were constructed, and pathological data was recorded. Hematoxylin and eosin (H&E) stained tissue sections were scanned and annotated, enabling an automized discrimination of tumor and non-tumor areas after training of an adequate algorithm. Spectral information within tumor regions, obtained via matrix-assisted laser desorption/ionization (MALDI)-Orbitrap-mass spectrometry imaging (MSI), were subsequently extracted in an automated workflow. On this basis, metabolic differences between UrC and CRC were revealed using machine learning algorithms. As a result, the study demonstrated the feasibility of MALDI-MSI for the evaluation of FFPE tissue in UrC and CRC with the potential to combine spatial metabolomics data with annotated histopathological data from digitalized H&E slides. The detected Area under the curve (AUC) of 0.94 in general and 0.77 for the analyte taurine alone (diagnostic accuracy for taurine: 74%) makes the technology a promising tool in this differential diagnostic dilemma situation. Although the data has to be considered as a proof-of-concept study, it presents a new adoption of this technology that has not been used in this scenario in which reliable diagnostic biomarkers (such as immunohistochemical markers) are currently not available.

Primary urachal adenocarcinoma treated effectively with surgery and post operative chemoradiation therapy: Case Report with review of the literature

Urachal carcinomas is a rare and aggressive tumor, accounting for less than 1% of all bladder cancers. We report a case of a 32-year-old man, with no past medical history, complaining of a total hematuria. The abdominal computed tomography scan revealed an exophytic mass of 3 cm on the dome of the bladder, extending to the urachus. The computed tomography scan of chest, abdomen and pelvis did not show neither regional or distant metastasis. Partial Cystectomy with umbilectomy was performed. Histopathology was in favor of urachal adenocarcinoma, classed pT3a, based on Sheldon's staging system, pT2b based on Mayo system, and pT2 based on Ontario system.

Anterior wall adenocarcinoma of bladder with similar clinicopathological and prognostic characteristics as common bladder carcinomas should not be treated as or classified into urachal adenocarcinomas

Purpose

To discuss whether the dome or anterior wall of bladder adenocarcinoma (BAC) should be classified into urachal carcinoma (UrC) and the relationship of primary tumor location (PTL) as well as treatment with survival.

Methods

Surveillance, Epidemiology, and End Results 18 database was examined for eligible patients from 1975 to 2016. Patients were classified into adenocarcinoma originating from the urachus (UAC), the dome (D‐BAC), the anterior wall (A‐BAC), and the other sites adenocarcinoma of the bladder (O‐BAC). The clinicopathological features, treatment, and survival were compared among the groups.

Results

Comparable clinicopathologic features were obtained between UAC and D‐BAC, which were different from those of A‐BAC and O‐BAC; otherwise, the latter two had similar clinicopathologic features. Univariable and multivariable Cox regression analyses indicated that PTL was an independent predictor for survival. O‐BAC conferred the worst prognosis then followed by A‐BAC, D‐BAC, and UAC. For non‐metastatic UAC or D‐BAC, partial cystectomy (with an en bloc resection of the urachus and umbilicus) is optimal for survival. However, the worse survival of non‐metastatic D‐BAC (compared with UAC) suggested different modalities, maybe more intensive surgery approaches, should be considered for D‐BAC.

Conclusion

This study illustrates that PTL of UAC and BAC was an independent predictor for survival. A‐BAC had comparable characters and prognosis with O‐BAC and should not be classified into and treated as UrC. For non‐metastatic disease, non‐metastatic D‐BAC may need more intensive modality.

Primary signet-ring cell carcinoma of the urinary bladder

Primary signet-ring cell carcinoma of the urinary bladder is a rare tumor. The overall incidence is approximately 0.12-0.6% of all urinary bladder malignancies. The majority of the patients present in an advanced stage with a uniformly grim prognosis. As signet-ring cell carcinomas are more common in the gastrointestinal tract, a possibility of metastasis needs to be considered. Here we report, a 42-year-old patient who presented with hematuria and was diagnosed with a urinary bladder tumor. The patient was managed with partial cystectomy and pelvic lymph node dissection. The histopathological examination confirmed primary signet-ring cell carcinoma of the urinary bladder.

A rare case of urachal adenocarcinoma with bone marrow metastasis

Urachal cancer is a rare and aggressive cancer that often presents in advanced stages. Given the rarity of this malignancy, medical case studies provide one of the few sources of literature available through which clinicians can guide medical management. Surgery is widely considered to be the mainstay of therapy when disease is localised and surgically resectable, therefore most current case studies on urachal cancer focus on surgical management, occasionally with adjuvant chemotherapy. However, few case studies discuss chemotherapy alone in the treatment of metastatic disease. Most studies indicate a median overall survival between 12 and 24 months for metastatic urachal adenocarcinoma. Bone marrow metastasis of solid tumours, when considered alone, portends a poor prognosis. The patient in this case study represents a rare case of stage IV urachal adenocarcinoma metastatic to the bone marrow without progression of disease after 6 months of treatment.

Successful treatment of locally advanced urachal adenocarcinoma with peri-operative gemcitabine - cisplatin combination therapy: a case report and perspective on targeted therapies

Urachal adenocarcinoma is a rare cancer and is treated based on the experience from case series and expert opinion as no randomized studies have been performed. This report adds to the current literature the experience of a patient with locally advanced urachal adenocarcinoma who was treated with combination of neoadjuvant gemcitabine/ cisplatin chemotherapy, surgery and adjuvant chemotherapy and has obtained a long recurrence free survival currently for more than 5 years. Although 5-FU-based chemotherapy is favored by many experts in the treatment of metastatic urachal adenocarcinoma, gemcitabine-based regimens have produced partial responses in metastatic disease and have been used in peri-operative treatment with a manageable adverse effect profile. A brief discussion of molecular lesions in urachal carcinomas and of the emerging role of targeted therapies is included in the current report.

Mucinous cystadenomas of urachus: A case report and literature review

Urachal epithelial neoplasms are rare tumors that arise from the vestiges of the urachus. Mucinous cystadenomas are considered as a benign glandular tumors of the urachus. Cystadenomas are commonly found in the ovary, appendix, and pancreas. Mucinous cystadenomas of the urachus are extremely rare in the urachus, and only nine cases reported so far. We reported the 10th case of Mucinous cystadenomas of the urachus detected incidentally at the time of diagnostic laparoscopy for investigation of genitourinary tuberculosis.

Ex vivo modelling of drug efficacy in a rare metastatic urachal carcinoma

BACKGROUND

Ex vivo drug screening refers to the out-of-body assessment of drug efficacy in patient derived vital tumor cells. The purpose of these methods is to enable functional testing of patient specific efficacy of anti-cancer therapeutics and personalized treatment strategies. Such approaches could prove powerful especially in context of rare cancers for which demonstration of novel therapies is difficult due to the low numbers of patients. Here, we report comparison of different ex vivo drug screening methods in a metastatic urachal adenocarcinoma, a rare and aggressive non-urothelial bladder malignancy that arises from the remnant embryologic urachus in adults.

METHODS

To compare the feasibility and results obtained with alternative ex vivo drug screening techniques, we used three different approaches; enzymatic cell viability assay of 2D cell cultures and image-based cytometry of 2D and 3D cell cultures in parallel. Vital tumor cells isolated from a biopsy obtained in context of a surgical debulking procedure were used for screening of 1160 drugs with the aim to evaluate patterns of efficacy in the urachal cancer cells.

RESULTS

Dose response data from the enzymatic cell viability assay and the image-based assay of 2D cell cultures showed the best consistency. With 3D cell culture conditions, the proliferation rate of the tumor cells was slower and potency of several drugs was reduced even following growth rate normalization of the responses. MEK, mTOR, and MET inhibitors were identified as the most cytotoxic targeted drugs. Secondary validation analyses confirmed the efficacy of these drugs also with the new human urachal adenocarcinoma cell line (MISB18) established from the patient's tumor.

CONCLUSIONS

All the tested ex vivo drug screening methods captured the patient's tumor cells' sensitivity to drugs that could be associated with the oncogenic KRAS^G12V mutation found in the patient's tumor cells. Specific drug classes however resulted in differential dose response profiles dependent on the used cell culture method indicating that the choice of assay could bias results from ex vivo drug screening assays for selected drug classes.

Current Understanding of Urachal Adenocarcinoma and Management Strategy

PURPOSE OF REVIEW

The aim of this review is to sum up the state of the art of urachal carcinoma (UC) in order to easily guide clinicians.

RECENT FINDINGS

UC is a rare and aggressive disease with consequent few data about diagnosis and treatment. Dates are mainly based on retrospective trial and case reports with limited prospective trial. Clinical presentation is not specific, often with urinary symptoms. Diagnosis is mainly based on CT scan and MRI, useful to evaluate local invasion and nodal status and to detect the presence of distant metastases. Therefore, biopsy is needed to obtain histological confirmation. Surgery is the gold standard for localized disease, while different chemotherapy schemes have been used in metastatic setting. Novel findings based on mutational analysis of the tumor include the use of biological treatment, such as cetuximab, and immunotherapy, such as atezolizumab, with satisfactory responses, suggesting that personalized treatment could be the most suitable option for UC.

[Urachal Cancer: an update of current molecular findings]

BACKGROUND

Urachal cancer is a rare type of cancer, often following a clinically aggressive course. Due to its rarity, knowledge about its molecular background is still limited. In addition, no sufficiently reliable diagnostic markers are available.

OBJECTIVES

The aim of the present study is to give an overview of our recent molecular projects on urachal cancer and to connect it with current literature in the field.

MATERIALS AND METHODS

Three projects are introduced. The first project identified and validated diagnostic biomarkers in urachal adenocarcinomas compared to colorectal adenocarcinomas and primary adenocarcinomas of the bladder using various proteomic methods. In the second project, the most relevant differential diagnostic markers between urachal adenocarcinomas and colorectal adenocarcinomas compared to normal tissue (urachal remnants) were determined by analyzing a miRNA panel. Sequence analyses were performed in the third project. The focus was on molecular differences to colorectal adenocarcinomas and urothelial carcinomas.

RESULTS AND CONCLUSIONS

We detected potential biomarker candidates for the immunohistochemical differential-diagnosis and generated a miRNA-based diagnostic scoring system with a potentially high differential-diagnostic significance. The sequence analyses data confirm the molecular autonomy of the urachal adenocarcinomas compared to other entities.

Radical cystoprostatectomy to treat urachal carcinoma

Urachal carcinoma is a highly uncommon malignancy with an estimated prevalence of 0.01% to 0.02% of all adult cancers. Due to its rarity, no standardized management protocol for urachal cancer has been developed. Surgery is often the main therapeutic measure. A 48-year-old man presented with hematuria for 8 months. Imaging revealed a mass at the bladder dome. Biopsy indicated mixed adenocarcinoma with a small cell component. Radical cystoprostatectomy with ileal urostomy was performed. After surgical resection, he was diagnosed with urachal adenocarcinoma (mixed type). The patient tolerated surgery and was discharged home uneventfully. Follow-up computed tomography at 6 months was negative.

Urachal cancer-current concepts of a rare cancer

Urachal cancer is a rare but aggressive disease. In addition to the non-glandular tumors, non-cystic urachal adenocarcinomas are nowadays distinguished from the primary cystic variant. (Immunohistochemical) markers are only of minor differential diagnostic value and, therefore, the diagnosis is primarily established in a multidisciplinary approach. The non-cystic variant accounts for the majority of cases (83%), is more common in men (63%), shows a median age at diagnosis of 51 years and has a 5-year survival rate of about 50%. In organ-confined disease, usually a partial cystectomy of the tumor in the bladder dome, including the median umbilical ligament and umbilicus, is performed. In advanced stages, systemic therapy is needed while 5‑fuorouracil (5-FU) containing regimes have been shown to be more effective. Due to the rarity of the tumor, targeted therapy approaches based on a biological rationale are becoming increasingly relevant. As molecular data are still sparse, we compiled and analyzed the largest urachal cancer cohort to date. In 31% of the cases, MAPK-/PI3K signaling pathway alterations were detected (especially in K-/NRAS) with implications for anti-EGFR therapy approaches. Further potentially therapeutic alterations were detected in FGFR1, MET, PDGFRA, and erbB2/HER2. Additionally, PD-L1 tumor cell expression (clone: 22C3) was demonstrated in 16% of cases, therefore making anti-PD-1/PD-L1 immuno-oncological approaches worth considering despite the absence of mismatch repair deficiency (MMR-d) and/or high microsatellite instability (MSI-h). Finally, urachal adenocarcinomas seem to be a distinct entity on the molecular level with closer resemblance to colorectal adenocarcinomas than to urothelial carcinomas.

Urachal Mucinous Cystic Tumor of Low Malignant Potential with Concurrent Sigmoid Colon Adenocarcinoma

Urachal mucinous tumors are rare neoplasms with behaviour that can range from relatively benign to malignancy that can spread distantly or throughout the peritoneum as pseudomyxoma peritonei or peritoneal carcinomatosis. Here we describe a unique case of urachal mucinous cystic tumor of low malignant potential confined to an intact cyst at the dome of the urinary bladder, without rupture or peritoneal spread. The urachal mucinous tumor was an incidental finding on a staging CT scan performed for sigmoid colon adenocarcinoma. We believe that this case illustrates a potential diagnostic pitfall which could have prognostic and therapeutic implications. Due to the intestinal phenotype of these neoplasms, a urachal tumor of low malignant potential could be mistaken for metastatic spread from a colonic adenocarcinoma in the rare situation such as this case, where the two neoplasms occur concurrently.

Is excision necessary in the management of adult urachal remnants?: a 12-year experience at a single institution

OBJECTIVES

To determine the ideal management of uncomplicated adult urachal remnants and to confirm if conservative management with repeated imaging is acceptable.

PATIENTS AND METHODS

This is a retrospective review of clinical notes and imaging of 45 patients with a mean age of 54.6 years who had been diagnosed with urachal anomalies at a single urology tertiary centre from January 2005 to December 2016. Patients who underwent surgical intervention and findings from patients managed non-operatively, with a mean follow up of 31 months, were evaluated.

RESULTS

Thirty (66.7%) patients had incidental findings, while 15 (33.3%) were symptomatic. Eight underwent excision, one underwent an incision and drainage of abscess, while 34 of the 36 remaining patients elected to undergo surveillance with repeated ultrasound imaging. Two were lost to follow-up. Malignancy was confirmed in three patients. There was interval stability of the urachal remnant in all the patients in the non-operative cohort. The small sample size, limited follow-up, and retrospective nature of the study are recognised limitations.

CONCLUSIONS

It was found that simple and asymptomatic lesions can be monitored with ultrasound, but effort must be made on initial diagnosis to ensure that malignancy is excluded using CT imaging and flexible cystoscopy where possible. Long-term follow-up of this cohort is required to assess the natural history of observed urachal anomalies.

[Urachal cancer - current concepts of a rare cancer (German version)]

Urachal cancer is a rare but aggressive disease. In addition to the non-glandular tumors, non-cystic urachal adenocarcinomas are nowadays distinguished from the primary cystic variant. (Immunohistochemical) markers are only of minor differential diagnostic value and, therefore, the diagnosis is primarily established in a multidisciplinary approach. The non-cystic variant accounts for the majority of cases (83%), is more common in men (63%), shows a median age at diagnosis of 51 years and has a 5-year survival rate of about 50%. In organ-confined disease, usually a partial cystectomy of the tumor in the bladder dome, including the median umbilical ligament and umbilicus, is performed. In advanced stages, systemic therapy is needed while 5‑fuorouracil (5-FU) containing regimes have been shown to be more effective. Due to the rarity of the tumor, targeted therapy approaches based on a biological rationale are becoming increasingly relevant. As molecular data are still sparse, we compiled and analyzed the largest urachal cancer cohort to date. In 31% of the cases, MAPK-/PI3K signaling pathway alterations were detected (especially in K-/NRAS) with implications for anti-EGFR therapy approaches. Further potentially therapeutic alterations were detected in FGFR1, MET, PDGFRA, and erbB2/HER2. Additionally, PD-L1 tumor cell expression (clone: 22C3) was demonstrated in 16% of cases, therefore making anti-PD-1/PD-L1 immuno-oncological approaches worth considering despite the absence of mismatch repair deficiency (MMR-d) and/or high microsatellite instability (MSI-h). Finally, urachal adenocarcinomas seem to be a distinct entity on the molecular level with closer resemblance to colorectal adenocarcinomas than to urothelial carcinomas.

Mucinous Cystadenoma of the Urachus and Review of Current Classification of Urachal Mucinous Cystic Neoplasms

Urachal neoplasms are uncommon and represent a minor portion of bladder tumors. According to the recently updated World Health Organization classification (2016), these tumors are classified as adenomas, adenocarcinomas, nonglandular neoplasms, and mixed carcinomas. The mucinous cystic neoplasms represent a small percentage of urachal tumors with morphologic spectrum ranging from benign mucinous cystadenoma to borderline mucinous cystic tumor of low malignant potential and to malignant mucinous cystadenocarcinoma. Benign urachal mucinous cystic adenomas are exceedingly rare, and only a few cases have been reported in the literature to date. The goal of this review is to summarize the clinical features, histopathologic characteristics, treatment, and prognosis of urachal mucinous cystadenoma in light of differentiating them from mucinous cystic tumor of low malignant potential and mucinous cystadenocarcinoma.

Urachal carcinoma: from gross specimen to morphologic, immunohistochemical, and molecular analysis

Urachal carcinoma (UrC) is an exceedingly rare neoplasm that develops from the urachus, an embryologic remnant of the urogenital sinus and allantois. The most commonly encountered histologic subtype is adenocarcinoma. The aim of this study is to characterize a series of UrC by morphology, immunohistochemistry, and molecular analysis. We retrospectively investigated seven cases of UrCs and assessed patient symptoms, imaging, histologic features, immunohistochemical profile, molecular characteristics, pathologic stages, and type of treatment. Immunostaining for CK7, CK20, Muc-2, CDX2, GATA3, β-catenin, and CK34βE12 was carried out on each neoplasm and on seven non-neoplastic urachal remnants as the control group. Additionally, a mutational analysis was performed using the QIAact Actionable Insights Tumor Panel Kit, which analyzes KRAS, NRAS, KIT, BRAF, PDGFRA, ALK, EGFR, ERBB2, PIK3CA, ERBB3, ESR1, and RAF1. Our cohort comprised five females and two males with a mean age of 64 years. UrCs consisted of two mucinous cystadenocarcinomas and five invasive, non-cystic adenocarcinomas. Carcinoma antigen expression profile was positive for CK20 and negative for CK34βE12 and GATA3 in all cases. Five of seven cases stained positively for Muc-2 and CDX2. On the contrary, non-neoplastic urachal remnants were immunoreactive for CK34βE12, CK7, and GATA3. Mutational analysis gave a positive result in four out of seven (57.1%) cases. All four positive tumors showed RAS mutation and one an additional mutation in PIK3CA. Urachal tumors exhibit peculiar morphologic, immunohistochemical, and molecular features. Due to the advanced stage at presentation, individualized treatment should be undertaken.

Urachal Adenocarcinoma: A Case Report with Key Imaging Findings and Radiologic-Pathologic Correlation

Urachal pathologies are rare and can mimic numerous abdominal and pelvic diseases. Differential diagnosis of urachal anomalies can be narrowed down by proper assessment of lesion location, morphology, imaging findings, patient demographics, and clinical history. We report a case of a 60-year-old male, with a history of unintentional weight loss without associated symptoms, who was diagnosed with locally invasive urachal adenocarcinoma. With this article, we pretend to emphasize urachal adenocarcinoma clinical features along with its key imaging findings with radiologic-pathologic correlation.

Biomarkers in Urachal Cancer and Adenocarcinomas in the Bladder: A Comprehensive Review Supplemented by Own Data

Urachal cancer (UrC) is a rare but aggressive cancer. Due to overlapping histomorphology, discrimination of urachal from primary bladder adenocarcinomas (PBAC) and adenocarcinomas secondarily involving the bladder (particularly colorectal adenocarcinomas, CRC) can be challenging. Therefore, we aimed to give an overview of helpful (immunohistochemical) biomarkers and clinicopathological factors in addition to survival analyses and included institutional data from 12 urachal adenocarcinomas. A PubMed search yielded 319 suitable studies since 1930 in the English literature with 1984 cases of UrC including 1834 adenocarcinomas (92%) and 150 nonadenocarcinomas (8%). UrC was more common in men (63%), showed a median age at diagnosis of 50.8 years and a median tumor size of 6.0 cm. No associations were noted for overall survival and progression-free survival (PFS) and clinicopathological factors beside a favorable PFS in male patients (p = 0.047). The immunohistochemical markers found to be potentially helpful in the differential diagnostic situation are AMACR and CK34βE12 (UrC versus CRC and PBAC), CK7, β-Catenin and CD15 (UrC and PBAC versus CRC), and CEA and GATA3 (UrC and CRC versus PBAC). Serum markers like CEA, CA19-9 and CA125 might additionally be useful in the follow-up and monitoring of UrC.

Urachal borderline mucinous cystadenoma: A rare case report and literature review

RATIONALE

Urachal borderline mucinous cystadenoma is very rare and has only 9 cases in the current literature with the biological behavior between adenoma and adenocarcinoma.

PATIENT CONCERNS

We reported a 41-year-old man with moderate lower abdominal pain, and the imaging examination found an irregular cystic lesion extending from umbilicus to the dome of urinary bladder with significant separations and calcifications.

DIAGNOSES

The diagnosis was confirmed according to the specific anatomical location and pathological examination which was proved as mucinous cystadenoma with low malignant potential.

INTERVENTIONS

The patient undertook radical excision and partial cystectomy.

OUTCOMES

His postoperative condition was good.

LESSONS

Urachal borderline mucinous cystadenoma can be located by image examination, which may also offer several diagnostic tips according to separation, calcification, and enhancement in computed tomography scan. When combined with pathological findings, qualitative diagnosis can be determined. Surgical resection should be chosen as an optimal treatment. Our present study reviewed the clinical and biological information of all previous cases which were diagnosed as urachal borderline mucinous cystadenoma and we supplemented more data for further study.

Telomerase reverse transcriptase (TERT) promoter mutations are rare in urachal cancer

High rates of telomerase reverse transcriptase (TERT) promoter mutations have recently been described in urothelial carcinoma (UC). Unlike UC in the bladder, adenocarcinomas account for the majority of urachal cancer (UrC) cases. As data in UrC is unclear, we analyzed TERT promoter mutations in a large cohort of UrC for its differential diagnostic, clinicopathological and prognostic significance. UrC cases from six academic centers were analyzed for c.-146C>T (C250T) and c.-124C>T (C228T) TERT promoter mutations by PCR and Sanger sequencing. Clinicopathological and survival data were collected. The cohort consisted of 15 men (56%) and 12 women (44%) with a median age of 50 years including 23 adenocarcinomas, two squamous cell carcinomas (SCC), one UC and one undifferentiated carcinoma. In one case of (mucinous) urachal adenocarcinoma a C228T mutation was detected (1/23; 4%), like in a case of SCC in addition to one C250T mutation in the UC case. TERT promoter mutations are very rare in urachal adenocarcinomas (unlike in UC) with differential diagnostic implications. Additionally, the low TERT promoter mutation rate in urachal adenocarcinomas is more comparable to colorectal adenocarcinomas than to UC, giving further support to recent genetic findings and therapeutic considerations.

High-grade neuroendocrine carcinoma of the urachus-report of 3 cases

Most urachal malignancies are composed of pure adenocarcinoma with mucin production. Urachal neuroendocrine carcinoma (NEC) is extremely rare, with only a few cases reported in the literature. Here we report 3 cases of urachal NEC, the largest series of this rare disease from a single institution. The patients were young, with a mean age of 27 years (range, 23-34). The urachal tumors showed 2 distinct components: high-grade NEC and enteric-type adenocarcinoma. The urachal NECs were composed of small cell carcinoma (n=2) or large cell NEC (n=1). The subsequent resection specimens showed that all the tumors were at advanced Sheldon stages. All 3 patients developed metastases, which were composed of NEC exclusively. Two patients died from disease in 10 and 31 months, respectively, and the third patient was alive with widespread metastases at 21 months. Our findings suggest that urachal NEC is an aggressive variant with an overwhelming growth advantage over conventional adenocarcinoma. The presence of high-grade NEC in the urachus is associated with poor prognosis.