Sarcomatoid Carcinoma of Urinary Bladder
Description
● Background
➣Profile of the Patient
•65-year-old man
•History: Intermittent turbiduria and chronic lower urinary tract obstructive symptoms.
Comorbidities: Diabetes mellitus with diabetic nephropathy (eGFR 61 mL/min, serum creatinine 1.6 mg/dL).
➣There are several uncommon histological variations of bladder urothelial carcinoma, including squamous, glandular, micropapillary, nested, lymphoepithelioma-like, plasmacytoid, and sarcomatoid.
Sarcomatoid carcinoma is an uncommon kind that accounts for 0.1% to 0.3% of bladder tumours.
aggressive, has a bad prognosis, and frequently exhibits advanced illness.
The diagnosis might be challenging, thus immunohistochemistry (IHC) and histopathology are crucial.
●Investigations:
➣Ultrasound examination: bladder dome tumour measuring 3 × 4 cm.
➣MR Urography:
•Heterogeneously enhancing bulk near the bladder dome, 35 × 47 mm.
•Planes with rectum preserved, perivesical fat infiltration.
•Seminal vesicles, vas deferens, and prostate are all normal.
•No lymphadenopathy in the pelvis.
➣Normal metastatic work-up (bone scan, chest X-ray).
➣First Step: TURBT
➣Endoscopy:
Solid mass with superficial calcifications near the bladder dome, 4 x 5 cm in width.
➣Histopathology (TURBT chips):
High-grade malignant spindle cell tumour pT1.
➣Deep biopsy:
There is a muscular invasion.
● Discussion Points
➣Epidemiology: M:F = 3:1, mean age ~66 years, rare (0.1–0.3%).
Radiation and cyclophosphamide treatment are risk factors.
➣Clinical presentation: big aggressive tumours, LUTS, and haematuria (most prevalent).
➣Gross pathology: broad-based, polypoidal, often cystic or hemorrhagic.
➣Biphasic histology: mesenchymal (spindle cell) and epithelial (urothelial) components.
IHC (vimentin, CK, EMA, SMA, etc.) is necessary for the diagnosis.
➣Prognosis: Very poor; more aggressive than high-grade urothelial carcinoma.
5-year survival: around 17%, compared to about 47% for urothelial cancer.
➣ Final Histopathology
•High-grade muscle-invasive spindle cell tumor.
•Margins: Negative (prostate, seminal vesicles, vas deferens, ureter).
•Perivesical fat: Free of tumor.
•Lymph nodes: 37 nodes examined → all negative.
•Stage: pT2, N0, Mx.
Protocol
● Management: Radical cystectomy = mainstay (better survival than TURBT/partial cystectomy).
Surgery plus adjuvant chemotherapy or radiation treatment is a multimodal strategy.
In certain advanced instances, neoadjuvant treatment is being examined.
● Definitive Surgery
➣ Bilateral extended pelvic lymph node dissection (EPLND) combined with radical cystoprostatectomy.
Ileal conduit with Wallace uretero-ileal anastomosis is one method of urinary diversion.
● Problem: Haematuria, turbiduria, blockage, frequency, and urgency of lower urinary tract symptoms
➣ Medical Management
•Alpha-blockers (for blockage) and anticholinergics (for urgency) can relieve symptoms.
•Urinary retention may need catheterisation.
•Hydration and bladder irrigation are used to treat haematuria in cases with clot retention.
➣ Interventions in Nursing:
•Track urine production using an I&O chart.
•Check urine for turbidity, odour, haematuria, and clots.
•Encourage the patient to report any acute discomfort, difficulty voiding, or an increase in blood clots.
•If there is an indwelling catheter, take care of it to avoid infection.
•To lower the risk of infection and clot formation, promote fluid intake (unless otherwise recommended).
● Problem: Pain and Discomfort (pelvic pain, dysuria, post-operative pain)
➣ Medical Management
•NSAIDs and postoperative opioids are examples of analgesics.
•Anticholinergics are used to control bladder spasms.
➣Nursing Interventions:
•Use a pain scale to measure pain severity on a regular basis.
•As directed, provide analgesics and assess their efficacy.
•Employ non-pharmacological strategies, such as deep breathing, relaxation, and diversion.
•After surgery, keep your posture comfortable to lessen pain at the incision site.
•Teach the patient how to splint their abdomen wounds when they cough or sneeze in order to reduce discomfort.
● Problem: Renal Function Impairment (due to diabetes + obstructive uropathy)
➣ Medical Management
•Frequent monitoring of kidney markers, such as eGFR and serum creatinine.
•Drink enough water and stay away from nephrotoxic medications.
•blood sugar regulation to stop further nephropathy.
➣Interventions in Nursing:
•Keep an eye on your daily urine production and fluid balance.
•Keep an eye out for symptoms of renal impairment, such as oedema and hypertension.
•For a renal-friendly diet (limited protein, minimal salt, and enough calories), be sure to visit a dietician.
•Teach the patient to stay away from over-the-counter NSAIDs.
● Problem: Anxiety and Fear (diagnosis of cancer, upcoming major surgery, fear of death)
➣Management: Psychological and medical: Urologist and oncologist preoperative counselling.
psychological assistance and counselling referral.
➣Interventions in Nursing:
•Encourage the patient to share their worries by facilitating therapeutic conversation.
•Clearly explain the procedure, the associated lifestyle modifications, and the healing period (ileal conduit).
•Involve family members in conversations to offer consolation.
•Offer relaxing techniques (meditation, guided visualisation).
•Refer bladder cancer survivors to support groups.
●Problem: Post-operative Recovery after Radical Cystoprostatectomy Management:
➣Medical:
•Prophylactic antibiotics, wound treatment, and pain control.
•Avoiding complications: prevention of DVT (compression stockings, heparin).
•Respiratory and early ambulation physiotherapy.
➣Interventions in Nursing:
•Keep an eye on vital signs and the wound site for infection or bleeding.
•Change the dressings sterilely.
•Examine the stoma site (ileal conduit) and drains.
•Promote coughing, deep breathing, and using an incentive spirometer.
•Early ambulation with assistance to avoid DVT or pneumonia.
● Problem: Stoma (Ileal Conduit) Care and Body Image Disturbance
➣Medical Management: Urostomy education and provision of appropriate appliances.
➣Interventions in Nursing:
•Show the patient how to replace and empty the urostomy bag.
•Preserve the integrity of the skin surrounding the stoma by washing with a mild soap and water and making sure the appliance fits properly.
•Inform others about leaks or illness symptoms.
•To help them deal with their changed body image, offer them emotional support.
•For long-term recovery, consult a stoma therapist.
● Problem: Side Effects of Chemotherapy (Gemcitabine + Carboplatin)
➣Medication for nausea and vomiting: antiemetics (ondansetron).
•If necessary, colony-stimulating factors for neutropenia.
dose modifications in the event of severe toxicity.
➣Nursing Interventions:
•Check for diarrhoea, vomiting, nausea, and mucositis; provide mouthwashes and antiemetics.
•Check for suppression of the bone marrow (CBC monitoring).
•Inform the patient about infection control and crowd avoidance as neutropenic measures.
•Encourage a diet heavy in calories and protein to combat weariness and weight loss.
•To control fatigue, promote relaxation and gradually increasing activities.
Notes
For more information visit 10.1007/s13193-018-0769-z
