Concomitant squamous cell carcinoma of the bladder and renal tuberculosis: A case report from northern Tanzania

Abstract

Concomitant squamous cell carcinoma (SCC) and renal tuberculosis (TB) are a rare presentation. It is associated with poor prognosis and poses a challenge in the management. To the best of our knowledge, we present a challenging first document case of locally advanced SCC of the bladder with coactive renal tuberculosis.

1. INTRODUCTION

Concomitant tuberculosis (TB) of the kidney and squamous cell carcinoma (SCC) of the urinary bladder are a new entity and rare finding. The association between TB and urinary tract malignancy mainly transition cell carcinoma has been documented previously by Falagas et al. ¹ SCC of the urinary bladder is the second most common urological malignancy while urogenital TB account for 27% of extrapulmonary tuberculosis. ² , ³ , ⁴ Karthikeyan et al in 20,013 reported occurrence of concomitant metastatic SCC of the bladder with tuberculosis in pelvic lymph nodes in a patient who was using bacille Calmette‐Guerin intravesical therapy. ⁴

A high index of suspicion is required to suspect TB in a bladder cancer patient and most of the time the diagnosis is incidental. Patients with concomitant occurrence of TB and genitourinary malignancy have poor prognosis and need aggressive treatment. Up to now there is no guideline on management of concomitant occurrence of TB and genitourinary malignancy; however, in view of previous document cases, anti‐TB drugs are recommended for 6 weeks followed by initiation of chemotherapy. ⁴

We report the case of a patient who presented with abdominal pain and hematuria who was confirmed to have coexisting right renal TB and SCC of the urinary bladder. The patient underwent radical cystectomy and urine diversion. She was initiated anti‐TB following diagnosis; however, succumbed before initiation of chemotherapy. Despite TB and SCC individually are not uncommon in Tanzania, to our knowledge, this is the first case report of concomitant SCC of the urinary bladder and renal TB in our country.

2. CASE REPORT

A 48‐year‐old woman presented with complaints of gradual onset of intermittent lower abdominal pain for 4 months that was worsening with time. The pain was radiating to the back and was associated with painful urination, reduced urine output, increased urinary frequency, and sense of incomplete bladder emptying. Also, she gave a history of on off hematuria mixed with blood clots, fever, and excessive night sweats. However, was no history of significant weight loss or lower limb swelling.

During the course of her illness, she attended multiple health facilities where she was treated as a case of urinary tract infection (UTI) with antibiotics and analgesia without improvement. Her past medical history revealed subtotal hysterectomy that was performed 10 years ago due to uterine myoma. She also suffered from and was diagnosed to have TB of spine 3 years ago where she was treated with anti‐TB for 1 year.

A working diagnosis of urinary bladder cancer was entertained. Abdominal ultrasound picked a bladder mass measuring 2 × 1 × 2 cm and was therefore planned for examination under anesthesia (EUA), urethrocystoscpy, and biopsy. During EUA there was a bimanually palpable bladder mass that was freely mobile. At urethrocystoscopy, an exophytic bladder mass was seen extending from 8 o'clock to 1 o'clock position that was encroaching the bladder neck at one o'clock position. A transurethral resection biopsy was taken that revealed a well‐differentiated SCC of the urinary bladder.

Following histology results, a staging CT‐IVU scan was done which showed confined large bladder mass 9 × 10 × 7 mass from right lateral to anterior wall of the bladder, severe hydronephrosis with nonfunctioning right kidney. The left kidney, ureter, liver, and lungs were normal with no lymph node metastasis.

The patient was counseled for and underwent cystectomy and modified ureterosigmoidostomy (Mainz 2 pouch). Intra operatively, the uterus, right ovary, and fallopian tubes were absent (as per previous history of subtotal hysterectomy), both pelvic and para‐aortic/paracarval nodes were not enlarged, and the whole of right ureter and the ipsilateral kidney were dilated. Following transection of the ureters during cystectomy, the right ureter drained thick pus. Upon palpation of the right kidney after draining the pus, there was no significant cortical tissue; hence, right nephrectomy was done and on dissection it contained residual pus (Figures 1 and 2). Sigmo‐rectal segment was identified, and a Mainz 2 pouch urinary diversion was accomplished. The patient recovered well and was allowed home on day 12 post‐surgery.

FIGURE 1.

Pus in the dissected kidney.

FIGURE 2.

Dissected bladder occupied by solid tumor with necrotic areas.

Postoperative histology results confirmed invasive SCC of the urinary bladder with lympnode metastasis, kidney abscess with caseous necrosis and chronic granulomatous inflammation with giant cells suggesting TB (Figures 3, 4, 5, 6). Furthermore, in the ureter margin, there were features of TB and metastatic squamous cell carcinoma (Figure 4). A Ziehl‐Neelsen stain of the kidney biopsy confirmed the diagnosis of TB (Figure 5). However, the patient was lost to follow‐up for 3 months following discharge after surgery, and therefore, not received nor anti‐TB neither chemotherapy during perioperative period but later returned with the complain of abdominal pain, lower back pain, and diarrhea. Control computerized tomography scan revealed a mixed cystic and solid mass arising from the pelvis infiltrating vagina and anterior abdominal wall measuring 9.6 cm × 11.9 cm × 22 cm in size and enlarged multiple para‐aortic, mesenteric, and iliac lymph nodes (Figure 7). The patient was discussed in the multidisciplinary team (tumor board) and then planned to receive anti‐TB treatment for 6 weeks and this was to be followed by adjuvant cisplatin‐based chemotherapy in medical oncology department, respectively. However, 3 weeks after initiation of anti‐TB she became progressively weaker to the extent that she was unable to walk and also developed an enterocutaneous fistula which was managed conservatively and got healed. The pouchogram was done, and the pouch was intact (Figure 8). Unfortunately, she passed away 3 months after initiation of anti‐TB before receiving chemotherapy.

FIGURE 3.

Photomicroscopy of invasive squamous cell carcinoma of bladder, well‐differentiated, H&E staining × 100 original magnification.

FIGURE 4.

Coexistance of invasive carcinoma with chronic granulomatous inflammation with multinucleated giant cells formation and extensive caseous necrosis, H&E staining × 40 original magnification (suggestive of TB).

FIGURE 5.

Ziehl‐Neelsen stain demonstrating acid fast bacilli, AFB staining ×200 original.

FIGURE 6.

Lymph node involvement by the tumor, H&E staining ×20 original magnification.

FIGURE 7.

CT scan showing a pelvic mass and hydronephrosis in the left kidney 3 months postradical cystectomy, right nephrectomy, and Mainz 2 urinary diversion.

FIGURE 8.

A pouchogram showing an intact pouch following occurrence of enterocutaneous fistula 4 months postcystectomy, right nephrectomy, and Mainz 2 urinary diversion.

3. DISCUSSION

Urinary bladder cancer is 9th commonest malignancy globally and the second most common urological malignancy. ¹ The proportion of SCC is higher in northern Tanzania (18%) compared with developed countries which is less than global prevalence (5–7%). ³ , ⁴ This is due to high prevalence of schistosomiases haematobium in this region. Radical cystectomy and pelvic lymphadenectomy are the standard treatment for SCC of the urinary bladder. ⁴

Urogenital TB accounts for approximately 27% of extra pulmonary TB. ⁵ It is also the third most common form of TB after pleural TB and lymphatic TB and is generally thought to spread through hematological dissemination in almost all cases. ⁴ In our case report, however, there was no evidence of pleural or lung TB and the diagnosis was incidental following nephrectomy.

To the best of our knowledge, the concomitant occurrence of SCC and renal TB has not been documented; however, there is a documented case of SCC and TB of pelvic lymph nodes. ⁴ In the literature, few cases are reported, and those that have reported the concomitant occurrence of renal TB and transitional cell carcinoma of the urinary bladder but not association with SCC. Few reviews have shown there is an association between transitional cell carcinoma and TB. ¹ , ⁴ , ⁵ A cohort study in Taiwan showed an association between urinary TB and the development of urothelial carcinoma (1.2% of patients with urinary TB versus 0.3% of nonurinary TB patients developed urothelial carcinoma, respectively, p < 0.001). ⁶ The suggested pathophysiology is chronic urinary tract inflammation which can lead to obstructive uropathy and in turn contribute to development of urinary tract cancer. ⁶ However, no such association between SCC of the urinary bladder and TB has ever being established.

Retrospective studies have shown there is no difference in clinical response of anti‐TB drugs in patients receiving chemotherapy. ⁷ , ⁸ A review study by Nair et al showed that there was no risk of TB reactivation while using anticancer chemotherapy in patients with the history of TB. ⁹ In another case report of concomitant SCC and TB of obturator lymphnode, it was both possible to control locoregional recurrence of the tumor and TB by administering anti‐TB for 6 weeks followed by four cycles of gemcitabine and cisplatin‐based chemotherapy with anti‐TB. ⁴ The current renal TB could have been activated from previous latent TB following decrease in immunity from the malignancy.

In our case, the patient was lost to follow‐up for 3 months. During which time the disease was already advanced when the patient reappeared, and therefore, the prognosis became worse. In view of above literature, the patient was sent for initiation of both chemotherapy and anti‐TB. The anti‐TB was initiated first, to be followed by adjuvant cisplatin‐based chemotherapy. However, due to poor performance status the patient could not receive adjuvant chemotherapy even after 6 weeks of intensive phase of anti‐TB therapy as she was extremely weak to the extent she could not walk without assistance and passed away 2 months after initiation of anti‐TB.

4. CONCLUSION

Concomitant bladder SCC and renal TB have a poor prognosis and are made much worse with the delay of initiating anti‐TB therapy and adjuvant chemotherapy. Therefore, strict follow‐up together with early aggressive treatment should be executed in patients with concomitant SCC of the urinary bladder and renal TB.

AUTHOR CONTRIBUTIONS

Orgeness Jasper Mbwambo: Conceptualization; writing – original draft. Alex Mremi: Supervision; writing – review and editing. Sabina Mugusi: Writing – review and editing. Jasper Said Mbwambo: Writing – review and editing. Frank Bright: Writing – review and editing. Alfred Mteta: Writing – review and editing. Bartholomeo Nicholaus Ngowi: Writing – review and editing.

FUNDING INFORMATION

Not applicable.

CONFLICT OF INTEREST STATEMENT

Not applicable.

ETHICS STATEMENT

There was exemption of ethical clearance.

CONSENT

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal on request.

Guarantor: Orgeness Mbwambo is the guarantor of this work.

Mbwambo OJ, Mremi A, Mugusi S, et al. Concomitant squamous cell carcinoma of the bladder and renal tuberculosis: A case report from northern Tanzania. Clin Case Rep. 2023;11:e7127. doi: 10.1002/ccr3.7127

DATA AVAILABILITY STATEMENT

Data available on request from the authors.