A Case of Bladder Cancer after Radiation Therapy for Prostate Cancer
An 86-year-old Japanese male with a history of prostate cancer and cerebral infarction presented to our urology outpatient clinic. He was taking an oral anticoagulant (100 mg of cilostazol) once a day. He received external beam radiation therapy (EBRT) by means of a 4-field technique. A cumulative dose of 60 Gy in 30 fractions was delivered over a period of 5 weeks. There was no neoadjuvant and adjuvant maximum androgen blockade or chemotherapy (prostate specific antigen 8.7, Gleason score 4 + 4, cT2a) in 2001. Neither recurrence nor metastasis was detected in the following 11-year period. In the follow-up period, his PSA level was about 0.10 ng/dl.\nThe patient presented to a local outpatient clinic with the chief complaint of intermittent gross hematuria that had lasted for 2 months. Bladder irrigation was performed, and his urine became clear. However, 5 days later, he presented to our hospital complaining of gross hematuria and clot retention.\nHe did not have lower urinary tract symptoms, fever, nausea, chills, flank pain, or weight loss. However, lower abdominal distention was noted at this time. On physical examination, his eyes were anemic, but otherwise, the examination was unremarkable. Laboratory data showed marked anemia with a hemoglobin level of 7.1 mg/dl. Other data, including liver function tests and coagulation studies, were within normal limits. Abdominal ultrasonography showed clots in the bladder. He was immediately admitted to our hospital and taken off cilostazol. After insertion of a transurethral catheter, bladder irrigation was performed to remove the clots. Continuous bladder irrigation was then started, and 4 units of component blood transfusion were administered. The findings suggested the presence of bladder cancer and radiation cystitis or stone-related disease as a differential diagnosis. Cystoscopic examination was performed to determine the cause of the hematuria and revealed irregularity of the mucosa on the posterior wall and a papillary tumor with active bleeding on the left side of the posterior wall. MRI revealed non-muscle invasive bladder cancer (fig. ).\nWe performed transurethral resection of the bladder tumor (TURBT). A nodular tumor was found on the posterior wall (fig. ). The trigon, neck and two lesions in the posterior wall were reddish, which was compatible with radiation-induced cystitis. Bilateral orifices were not involved and had clear efflux of urine. There were no other notable lesions. The tumor along the posterior wall and the reddish lesion were resected and coagulated. Urine cytology was negative for bladder cancer before and after TURBT. Pathological diagnosis revealed urothelial carcinoma, G2, pTa (fig. ).\nAfter TURBT, the patient's gross hematuria resolved. The Foley catheter was removed on postoperative day 6. The patient was discharged and cilostazol administration was resumed. He is still being followed-up and there has been no recurrence of the hematuria or bladder cancer in the 12 months since TURBT.