This 71-year-old man presented with gross hematuria and a bladder mass. He had a history of asbestos exposure and other medical issues. Evaluation revealed a large fungating bladder lesion, and biopsies confirmed adenocarcinoma. Further testing found prostate cancer involving 30% of tissue with a Gleason score of 7. The tentative diagnosis was urothelial carcinoma of the bladder neck, prostate urethra, or both, but immunohistochemical staining was positive for PSA, suggesting the final diagnosis was prostate adenocarcinoma with invasion into the bladder.

1. Case
presentationGroup 14
2016.05.20

2. Chief
problem
History
Personal, Past,
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

3. Chief problem
A 71-year-old man had
gross hematuria and
a mass in the bladder

4. Chief
problem
History
Personal, Past
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

5. Personal history
• He was married, had adult children,
• retired from the shipping industry,
• where he had been exposed to asbestos.
• He was physically active in outdoor
activities.

6. Past history
Erectile
dysfunction
Hypertrophic
cardiomyopathy
Diverticulosis
Obstructive
sleep apnea
Nephrolithiasis
(had treated)
Hypertension
Hyperlipidemia

7. Past history
• Results of a colonoscopy
performed 1 year earlier were
normal.
• Medications included atorvastatin
and verapamil ; other medications
had recently been stopped.
• other medications : doxazosin, amlodipine,
valsartan, telmisartan, hydrochlorothiazide,
potassium aminobenzoic acid, oxybutynin
chloride, and potassium chloride
supplement
• NO smoke & NO alcohol

8. Family history
There was no family
history of urologic cancers.

9. Chief
problem
History
Personal, Past,
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

10. Transurethral resection of the prostate :because of lowerurinary tract
symptoms and urinary retention. Pathological examination of the
tissue reportedly had shown an area of focal high-grade prostate
intraepithelial neoplasia.
prostatic biopsies : negative .Four subsequent prostatic biopsies,
the most recent performed 4 years before
Results of a colonoscopy were normal
12 years
ago
4 years
ago
Present illness
1 year
ago

11. gross hematuria(血尿) and a mass in the bladder for 6 weeks
painless hematuria had developed, with passage of clots
prostate-specific antigen (PSA):13.0 ng per millilite
CT :After 2 days,computed tomography (CT) reportedly
revealed a multilobulated(多房性) mass (isodense to
hyperdense and measuring 8 cm by 7.5 cm by 6.5 cm) in
the urinary bladder, diffuse fat stranding in the perivesical
and left periurethral regions, and bilateral intrarenal
calculi(結石) and cysts
cystoscopic examination:The next day, cystoscopic
examination revealed an open prostatic urethra and brisk(輕
微) bleeding. A fungating lesion at the anterior bladder neck
at the 12 o’clock position, with an adherent clot, was
partially excised. Pathological examination of the tissue
reportedly showed focal adenocarcinoma in situ
Two mons
ago
3weeks
ago
Present illness
1 mon ago

12. Ultrasonography of the abdomen and pelvis revealed
bilateral renal cysts and bilateral nonobstructing
nephrolithiasis
The next day, repeat cystoscopy reportedly revealed a large
fungating lesion and clot at the anterior bladder neck at the
12 o’clock position. Flushing of the bladder and biopsies
were performed. Pathological examination of the biopsy
specimens reportedly showed adenocarcinoma;
consultation with outside experts was pending. CT of the
abdomen, performed the next day, reportedly revealed no
evidence of metastatic disease. After decompression of the
bladder with a catheter(導管), irregular thickening of the
bladder wall was seen, with an irregular, multiloculated gas
collection, 2.5 cm by 3.5 cm, in the suprapubic(恥骨) region.
2 weeks
ago
Present illness

13. Transrectal biopsies of the prostate with ultrasonographic guidance:
adenocarcinoma in one of two cores from the right base, with a
Gleason score of 7 (grade 3 plus grade 4) on a scale of 1 to 10 (with
higher scores indicating a worse prognosis), involving 30% of the
tissue, and adenocarcinoma in a core from the left lateral midportion,
with a Gleason score of 6 (3+3), involving 10% of the tissue.
Present illness
5 days after
2nd
cystoscopy

14. the pulse was 50 beats/min and the blood
pressure, temperature, respiratory rate, and
oxygen saturation were normal.
Rectal examination was not performed, and
the remainder of the examination was normal.
Blood examination
K+ 3.3mmol/L(3.3-4.8)
creationine 1.3mg/dL(0.6-1.5)
Urea nitrogen 15mg/dL(8-25)
eGFR 59 ml/min/1.74m2 (>=60)
The complete blood count and levels of other
electrolytes, calcium, and glucose were normal.
Present illness
This
evaluation

15. Chief
problem
History
Personal, Past,
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

16. Review of system
CONSTITUTIONAL
HEENT
RESPIRATORY
BREASTS
CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
SKIN
ENDOCRINE/
METABOLISM
HEMATOLOGIC
ALLERGIC AND
IMMUNOLOGIC

17. Review of system
CONSTITUTIONAL
HEENT
RESPIRATORY
BREASTS
CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
SKIN
ENDOCRINE/
METABOLISM
HEMATOLOGIC
ALLERGIC AND
IMMUNOLOGIC
● No night sweats. No fatigue, malaise,
lethargy. No fever or chills.
● Eyes: No visual changes. No eye pain. No
eye discharge. ENT: No runny nose. No
epistaxis. No sinus pain. No sore throat. No
odynophagia.
No ear pain. No congestion.
● No breast pain, soreness, lumps, or
discharge.
● Mild obstructive sleep apnea No cough. No
wheeze. No hemoptysis. No shortness of
breath.
● Hypertrophic cardiomyopathy, hypertension
● Diverticulosis No abdominal pain. No
nausea or vomiting. No diarrhea or
constipation. No hematemesis. No

18. Review of system
CONSTITUTIONAL
HEENT
RESPIRATORY
BREASTS
CARDIOVASCULAR
GASTROINTESTINAL
GENITOURINARY
MUSCULOSKELETAL
NEUROLOGICAL
PSYCHIATRIC
SKIN
ENDOCRINE/
METABOLISM
HEMATOLOGIC
ALLERGIC AND
IMMUNOLOGIC
● No musculoskeletal pain. No joint swelling. No
arthritis.
● He had an episode of mild confusion. He has
chronic right hemiplegia. No headache or neck
pain. No syncope or seizure.
● He gets occasionally confused.
● No rashes. No lesions. No wounds.
● No urgency. No frequency. No dysuria.
hematuria. Lower urinary tract symptoms, urinary
retention. Erectile dysfunction, nephrolithiasis No
discharge. No pain. No significant abnormal
bleeding
● No anemia. No purpura. No petechiae.
No prolonged or excessive bleeding
● No pruritus. No swelling.

19. Physical examination
• PE by Dr. Donald S. Kaufman
– HR: 50/min, blood pressure, temperature,
respiratory rate, and oxygen saturation
were normal. BMI: 30
– Rectal examination was not performed
• PE by Dr. Olumi
– Digital rectal examination: the rectal tone
was intact, the pelvic organs were mobile,
the prostate weight was estimated to be 40
to 50 g, and there was no palpable prostate
nodule or rectal mass.
admissio
n

20. Chief
problem
History
Personal, Past,
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

21. Laboratory data
• CBC and other electrolytes, calcium, and
glucose；Cr、urea nitrogen were normal
Abnormal
blood potassium 3.3 mmol (3.4-4.8)
eGFR 59 ( ≧60)

22. Laboratory data

23. Laboratory data

24. Chief
problem
History
Personal, Past,
& Family
Present
illness
Physical
examination
Review of
Systems
Lab data
Tentative
diagnosis

25. Tentative diagnosis
Urothelial carcinoma of the bladder neck,
the prostatic urethra, or both.
But after Immunohistochemical staining
P63 - PSA +

26. Division of work
Yao Chung-hsia
Yu Hung-Chun, Li jia-xuan, Li
ho
Lee Yi-zhang
Wu Zon-han
Chan Po-Kai

27. Thank you for
your attention