Modified FOLFOX6 chemotherapy in patients with metastatic urachal cancer

Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) as treatment choice of metastatic Urachal carcinoma

INTRODUCTION

Urachal carcinoma accounts for approximately 0.01 % of all adult malignancies and 1 % of bladder cancers. Its prognosis remains poor, with a 5-year overall survival rate of less than 50 %.

PRESENTATION OF CASE

A 51-years-old black female, affected by peritoneal malignancies from urachal carcinoma, underwent multiple surgical cytoreduction (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with different chemotherapy regimen, alternating with intravenous chemotherapy. Thirty-two months recurrence-free survival was registered, and overall survival was more than 5 years.

DISCUSSION

Our case suggests the importance of rigorous follow-up with both tumor marker testing (CEA) and imaging studies. Optimal debulking surgery plays a pivotal role in controlling primary and recurrent disease. The use of combined intraperitoneal and intravenous chemotherapy may have contributed to her long-term survival.

CONCLUSION

CRS and HIPEC combined with intravenous chemotherapy may be potential candidates for treating patients with urachal carcinoma with peritoneal metastases. Our patient is a challenging case in daily surgical practice.

One Size Fits Some: Approaching Rare Malignancies of the Urinary Tract

OPINION STATEMENT

Urothelial carcinoma is the predominant cancer of the urinary tract but when divergent and subtype histology (non-urothelial) are identified at time of pathologic diagnosis, therapeutic and diagnostic challenges transpire. To this end, pathologic review to confirm any non-urothelial histology is key since these subtypes can often be overlooked. Few prospective trials are dedicated to understanding these non-urothelial histologic types; however, current, and past trials did allow patients with these non-urothelial histologic types to enroll, and inferences can be made about treatment efficacy and survival. Existing treatment regimens for non-urothelial bladder cancers are akin to standard urothelial cancer regimens using surgical approaches for localized disease and platinum-based chemotherapy for advanced disease. The reported clinical trials, that will be discussed, center on non-urothelial histologic types. These studies, albeit limited, provide critical insight into tumor biology and response to standard platinum-based chemotherapy, immune checkpoint inhibitors, and antibody drug conjugates. The inclusion of non-urothelial histologic types will be essential for clinical trials in development to provide further therapeutic advances and provide essential efficacy data.

Relapsed urachal carcinoma responding to first-line chemotherapy with capecitabine-oxaliplatin plus bevacizumab

Introduction

Advanced urachal carcinoma has a poor prognosis; however, a standard systemic treatment has not been established. We treated a patient with relapsed urachal carcinoma with capecitabine-oxaliplatin plus bevacizumab, a standard regimen for colon cancer, and obtained favorable responses.

Case presentation

A 47-year-old woman presented with hematuria. Under the diagnosis of non-metastatic urachal carcinoma, an extended partial cystectomy was performed. Histopathological examination revealed adenocarcinoma with negative surgical margins and lymph nodes. Thirty-two months postoperatively, lung metastases and local recurrence were confirmed, along with elevated carcinoembryonic antigen levels, and nine chemotherapy cycles were administered. Subsequently, the recurrent lesion regressed, and tumor marker levels normalized. Fourteen months after treatment discontinuation, the disease remained stable without progression.

Conclusion

This is the first report of advanced urachal carcinoma treated with capecitabine-oxaliplatin plus bevacizumab, demonstrating the potential of this treatment as first-line chemotherapy for this disease.

Urachal Adenocarcinoma: A Rare Primary Cancer Managed With FOLFOX Chemotherapy

Urachal adenocarcinoma (UA) represents a rare subset of bladder tumors involving a urachal remnant. Incidental gross hematuria is often the only presenting symptom, with patients often presenting late in their course, thereby imparting an overall poor prognosis. Although there are prior case reports, there is little literature reported and no standardized treatment guidelines. We report a case of a middle-aged male who presented with incidental gross hematuria after a fall. Workup indicated the presence of a calcified bladder dome mass and pathology reported a primary urachal adenocarcinoma with pelvic nodal involvement. Patient underwent surgical resection and subsequent adjuvant, systemic chemotherapy regimen with leucovorin, fluorouracil, and oxaliplatin (FOLFOX). We hope to bring greater awareness to this rare cause of bladder malignancy.

Treatment approaches for urachal cancer: Use of immunotherapy and targeted therapies

Urachal cancer is a rare genitourinary malignancy that arises from the embryologic remnant of the urachus. The malignancy is considered to be aggressive, with no clear consensus on appropriate management for advanced disease. Although traditionally considered to be related to bladder cancer given its embryologic origin, several next generation sequencing studies have revealed the genomic profile of this genitourinary malignancy most closely resembles colorectal cancer. Moreover, these studies have identified potentially actionable mutations including EGFR, KRAS and MET. In addition, recent data suggests that immunotherapy may benefit some patients with advanced urachal cancer. Nonetheless, continued research is warranted to better understand how to treat this rare genitourinary cancer.

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.

Challenges and opportunities in the management of non-urothelial bladder cancers

Urothelial carcinoma accounts for approximately 90% of all bladder cancer diagnoses. Localized, muscle-invasive disease is often managed with a multidisciplinary approach including either neoadjuvant chemotherapy (NAC) followed by radical cystectomy or concurrent chemoradiation, whereas multiple immunotherapies and novel antibody drug conjugates have recently joined platinum-based chemotherapy as standard of care therapy for metastatic disease. However, the clinical trials leading to these standards often require majority if not complete urothelial histology for eligibility. As many as one quarter of patients diagnosed with bladder cancer will have either divergent differentiation of their urothelial carcinoma or an alternate epithelial tumor such as squamous cell carcinoma, adenocarcinoma, or small cell carcinoma; even more rare are non-epithelial tumors such as sarcoma. The rarity of these diseases and their general exclusion from treatment within prospective clinical trials has created a challenging situation where treatment plans are often derived from case series or extrapolated from other disease types and outcomes are poor compared to pure urothelial carcinoma. In this review, we summarize the existing data on the diagnosis and treatment of epithelial, non-urothelial bladder cancers including adenocarcinoma, squamous cell carcinoma, and small cell carcinoma in their localized and advances stages. We will also review the current clinical trial landscape investigating novel approaches to these diseases.

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.

Clinical, Pathological, and Prognostic Analysis of Urachal Carcinoma

OBJECTIVE

The aim of this study was to improve understanding the clinical, pathologic, and prognostic features of urachal carcinoma (UrC), a retrospectively descriptive study was done in 2 clinical centers.

METHODS

After excluding the 2 missed patients, the clinical and pathological data of 59 patients with UrC, who were diagnosed or treated at 2 clinical centers between 1986 and 2019, was retrospectively analyzed. SPSS 22.0 (IBM) and GraphPad Prism 8.0.1 were used for statistics and data visualization. Survival data were analyzed by the Kaplan-Meier method and Log-rank tests. Cox proportional hazards regression were performed for find risk factors on predicting the prognosis.

RESULTS

Of all 59 patients, 47 were male and 12 were female. The median age at diagnosis was 51.6 years (range: 22-84 years). Gross hematuria was the most common symptom (79.66%). The majority of urachal neoplasms were adenocarcinomas (94.92%). Forty-two patients (72.41%) underwent extended partial cystectomy with en bloc resection of the entire urachus. The mean follow-up was 52 months (3-277 months). Median overall survival was 52.8 months (4-93 months). The 3-year cancer-specific survival (CSS) rate and 5-year CSS rate were 69.1% and 61.2%. There was no significant difference among localized T stage, tumor histologic grade and surgical procedures in determining prognosis by survival analyze. While patients with high-risk TNM stage (local abdominal metastasis, lymph node metastasis, or distant metastasis) (p = 0.003) and positive surgical margin (p < 0.001) had significantly worse prognosis.

CONCLUSIONS

The results indicate that high-risk TNM stage and positive surgical margin are risk predictors of prognosis. Localized T stage, histologic grade, and surgical procedure cause no significant effect on patient prognosis. The extended partial cystectomy is the recommended surgical approach for patients with UrC. Active multimodal treatments may improve the survival of patients with recurrent and metastatic disease.

The Prognosis and Oncological Predictor of Urachal Carcinoma of the Bladder: A Large Scale Multicenter Cohort Study Analyzed 203 Patients With Long Term Follow-Up

Aim

This study evaluated the prognosis and survival predictors for bladder urachal carcinoma (UC), based on large scale multicenter cohort with long term follow-up database.

Methods

A total 203 patients with bladder UC treated at 19 hospitals were enrolled. Clinical parameters on carcinoma presentation, diagnosis, and therapeutic methods were reviewed for the primary cancer and for all subsequent recurrences. The stage of UC was stratified by Mayo and Sheldon pathological staging system. Oncological outcomes and the possible clinicopathological parameters associated with survival outcomes were investigated.

Results

The mean age of the patients was 54.2 years. Among the total of 203 patients, stages I, II, III, and IV (Mayo stage) were 48 (23.8%), 108 (53.5%), 23 (11.4%), and 23 (11.4%), respectively. Gross hematuria and bladder irritation symptoms were the two most common initial symptoms. The mean follow-up period was 65 months, and 5-year overall survival rates (OS), cancer-specific survival rates (CSS), and recurrence-free survival rates (RFS) were 88.3, 83.1, and 63.9%, respectively. For the patients with Mayo stage ≥III, OS, CSS, and RFS were significantly decreased to 38.0, 35.2, and 28.4%, respectively. The higher pathological stage (Mayo stage ≥III, Sheldon stage ≥IIIc), positive surgical margin (PSM), and positive lymphovascular invasion (PLM) were independent predictors of shorter OS, CSS, and RFS.

Conclusion

The pathological stage, PSM, and PLM were significantly associated with the survival of UC patients, emphasizing an importance of the complete surgical resection of tumor lesion.

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.

Facing treatment of non-urothelial bladder cancers in the immunotherapy era

Non-urothelial Bladder Cancer (BC) and variants of urothelial carcinoma account for up to 25 % of all BCs. Given their heterogeneity, these entities are not well represented in clinical trials and treatment remains challenging. Checkpoint inhibitor therapy has shown a role in the treatment of urothelial BC. By contrast, robust evidence regarding its use in other histological types is lacking. We aimed to provide a comprehensive update of non-urothelial and variant urothelial BC, exploring the evidence for immune checkpoint inhibitor therapy. A detailed analysis of the literature was conducted regarding epidemiology, aetiology, diagnosis, prognosis, treatment and outcomes of these patients in the immunotherapy era. A growing body of evidence suggests that immune checkpoint inhibition might have a role to play in non-urothelial BC, similarly to what happened with urothelial carcinomas.

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.

The Challenge of Managing Bladder Cancer and Upper Tract Urothelial Carcinoma: A Review with Treatment Recommendations from the Spanish Oncology Genitourinary Group (SOGUG)

Bladder cancer is the fourth most common cancer in men and the ninth most common in women in the Western world. The management of bladder carcinoma requires a multidisciplinary approach. Optimal treatment depends on several factors, including histology, stage, patient status, and possible comorbidities. Here we review recent findings on the treatment of muscle-invasive bladder carcinoma, advanced urothelial carcinoma, upper tract urothelial carcinoma, non-urothelial carcinoma, and urologic complications arising from the disease or treatment. In addition, we present the recommendations of the Spanish Oncology Genitourinary Group for the treatment of these diseases, based on a focused analysis of clinical management and the potential of current research, including recent findings on the potential benefit of immunotherapy. In recent years, whole-genome approaches have provided new predictive biomarkers and promising molecular targets that could lead to precision medicine in bladder cancer. Moreover, the involvement of other specialists in addition to urologists will ensure not only appropriate therapeutic decisions but also adequate follow-up for response evaluation and management of complications. It is crucial, however, to apply recent molecular findings and implement clinical guidelines as soon as possible in order to maximize therapeutic gains and improve patient prognosis.

Clinicopathological features of malignant urachal tumor: A hospital-based cancer registry data in Japan

OBJECTIVES

To identify the clinicopathological features of malignant urachal tumor in Japan, and analyze the 5-year overall survival of malignant urachal tumor patients.

METHODS

We used the hospital-based cancer registry data to extract malignant urachal tumor cases that were diagnosed in 2008-2009 and 2012-2015, histologically confirmed, and received the first course of treatment. We analyzed the 5-year overall survival using the 2008-2009 cohort's data.

RESULTS

We identified 456 patients, and malignant urachal tumor accounted for 0.4% of all malignant bladder cancers. The median age was 61 years (range 2-97), and 66% were men. The most common histology was adenocarcinoma (80%), followed by urothelial carcinoma (11%) and squamous cell carcinoma (3%). The proportions of patients were: 19% Ta/Tis/T1N0M0, 55% T2-3N0M0, 13% T4/N+ and 13% M+. Regarding the initial treatment, the proportions of surgery alone were 79% and 33% in cases of T3 or less N0M0 and T4/N+, respectively. The proportion of combination therapy including surgery and chemotherapy were 13% and 44% in T2-3N0M0 and T4/N+, respectively. Radiation therapy was not common at any stage. In the 2008-2009 cohort, the 5-year overall survival rate in Ta/Tis/T1N0M0, T2-3N0M0, T4/N+ and M+ were 60%, 64%, 63% and 12%, respectively.

CONCLUSIONS

Malignant urachal tumors are quite rare in Japan, and most of those without metastasis are likely to be treated by surgery alone, even at advanced stages. A standard of care must be established for malignant urachal tumor patients at advanced stages or with metastasis, as the prognosis of these patients can be poor.

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.

Metastatic urachal cancer treated effectively with gemcitabine/cisplatin combination chemotherapy and radiotherapy: A case report

Urachal cancer often presents at an advanced stage with poor prognosis due to the lack of an effective systematic therapeutic strategy. We experienced a case of metastatic urachal cancer treated effectively by combination chemotherapy and radiotherapy. A 55-year-old female presented to our department with right lower abdominal pain. A transurethral biopsy of an urachal tumor suggested urachal adenocarcinoma. The patient underwent chemotherapy with gemcitabine and cisplatin for metastatic urachal cancer. As tumor markers declined and the radiological findings indicated stability of disease, external beam radiotherapy was then administered to the primary site. Chemotherapy was then administered again in response to tumor markers gradually increasing and the progression of multiple peritoneal metastases. However, the patient did not complete chemotherapy due to hematological toxicity. The patient succumbed to primary disease 23 months after initial diagnosis. Previous studies have reported that the median time from the diagnosis of metastatic urachal cancer to mortality is just over 1 year. By contrast, in the present case the patient survived up to 2 years with combination chemotherapy and radiotherapy, a rare incidence worthy of reporting.

Cisplatin and S-1 for urachal carcinoma: A single-institution case series

Introduction

Urachal carcinoma is a rare cancer, manifesting predominantly as adenocarcinoma, and could be treated with chemotherapy in patients with advanced or recurrent disease. However, any standard chemotherapy regimens are yet to be determined.

Case presentation

We retrospectively reviewed five patients with urachal adenocarcinoma treated with a potent first-line chemotherapy, cisplatin and S-1, between 2011 and 2014. Among the five patients, three were males. The median age at diagnosis was 61 years, ranging from 47 to 67. The most common symptom at their first visit was macroscopic hematuria. The best response was stable disease in four patients, which persisted for 7 months. Three patients experienced only one episode of grade 3 toxicity. Cisplatin and S-1 was well tolerated and safe.

Conclusion

The activity of cisplatin and S-1 is modest and more efficacious treatment is desired against urachal carcinoma.

[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.

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.

Advanced primary nonurachal adenocarcinoma of urinary bladder responding to modified FOLFOX6 and capecitabine: a case report

Careful morphology and immunohistochemistry study can make an accurate differential diagnosis of primary adenocarcinoma of urinary bladder from metastatic lesions involving bladder, especially cancer arising in colon, but there is yet no consensus regarding the standard chemotherapy for advanced adenocarcinoma of urinary bladder among medical oncologists. Sustained response to modified FOLFOX6 (fluorouracil, oxaliplatin plus leucovorin) regimen and oral capecitabine for multiple metastases in a patient with primary nonurachal adenocarcinoma of urinary bladder is presented here as a strong support that the frontline chemotherapy for this infrequent malignant disease is just like what could be chosen for colorectal cancer.

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.

Variant histology in bladder cancer: how it should change the management in non-muscle invasive and muscle invasive disease?

Bladder cancer (BC) is a frequent type of carcinoma with an estimated incidence of approximately 100,000 men and women each year in the European Union (EU) with an associated mortality of 30,000 of these patients. In more than 70% the disease is diagnosed in a non-muscle invasive stage with the chance of minimally invasive, local treatment only, which might be required repetitively due to high rate of recurrence. In contrast, muscle invasive or metastatic stages need multimodal treatment strategies including surgical treatment and chemotherapy (CTX) in neoadjuvant (NAC), adjuvant, or palliative settings. Therapy recommendations and guidelines mainly refer to the most common histological type of BC, pure urothelial carcinoma (UC). However, BC can be classified as urothelial and non-UC. Non-urothelial BC and variants of UC account for up to 25% of all BCs. Further discrimination can be made into epithelial and non-epithelial non-UC. Most of the non-UCs are of epithelial origin (approximately 90%) including squamous-cell carcinoma, adenocarcinoma and small-cell carcinoma. Non-epithelial tumors are rare and include variants as sarcoma, carcinosarcoma, paraganglioma, melanoma and lymphoma. Even though it is unclear whether the prognosis of non-urothelial cancer truly differs from that of UC, there is evidence that additional variant histology might prognosticate an impaired prognosis. Accordingly, aggressive behavior and often advanced stages at primary presentation are frequently observed in non-UC arguing for radical and sometimes different treatment strategies as compared to pure UC. This review aims to summarize the available data for the most common histological variants of non-urothelial BC.

Genetics and biological markers in urachal cancer

Urachal cancer (UraC) is a rare tumor entity that usually develops at the basis of the remnant embryologic urachus. Consisting of mostly adenocarcinomas, most patients present with secondary symptoms due to an advanced stage with urinary bladder infiltration. One third of patients are already metastasized at presentation rendering them unsuitable for curative surgical treatment. In order to improve staging, treatment and follow-up, adequate knowledge about the genetic origin and potential markers is necessary. This paper reviews the English literature until December 2015. Pathologists argue for and against metaplasia or remnant enteric cells as origin for the adenomatous tissue found in UraC. Mutations in KRAS, BRAF, GNAS and Her2 have been associated with UraC. Immunohistochemical (IHC) markers like CEA, 34βE12, Claudin-18 and RegIV are indicative for mucous producing UraC. So far, IHC markers fail as prognosticators when matched to clinical data. Little is known about serum markers for UraC. CEA, CA19-9, CA125 and CA724 are mentioned as being elevated in UraC by some reports. Regarding the literature for biological markers in UraC, knowledge is mostly derived from case reports or cohort studies mentioning markers or predictors. More genetic research is needed to show whether UraC stems from progenitor cells of the cloaca or is due to metaplasia of transitional cells. Few IHC markers have shown indicative potential for UraC. A useful panel for differential diagnostics and clinicopathologic prognostication needs to be developed. Serum markers show very little potential for neither diagnosis nor follow-up in UraC. Further research on larger cohorts is necessary.

Urachal adenocarcinoma that metastasized to breast was misinterpreted as primary breast mucinous carcinoma: A rare case report and literature review

BACKGROUND

The urachus is a vestigial tubular structure that connects the urinary bladder to the allantois during early embryonic development. Urachal carcinoma develops in the urachus, which is an embryological remnant of the urogenital sinus and allantois. The estimated annual incidence of urachal carcinoma in the general population is 0.01% of all cancers in adults. Moreover, urachal carcinoma accounts for 0.34% to 0.7% of all bladder carcinoma cases. And breast metastasis is extremely rarer.

METHODS AND RESULTS

A 42-year-old woman was admitted to our hospital with a palpable mass in the outer upper quadrant of the right breast, which was misinterpreted as a carcinoma that originated from the breast. Subsequently, she underwent surgery without any further meticulous examination. Immunohistochemistry analysis revealed positivity for CK20, Villin, and CDX-2 and negativity for CK7. After further inspection, a mass was found in the bladder dome using 18F-fluorodeoxyglucose positron emission tomography and computed tomography. The mass was surgically removed.

CONCLUSION

Pathologic and immunohistochemical examination confirmed that the mass was urachal mucinous adenocarcinoma and mucinous adenocarcinoma to the right breast. The patient has been followed up without recurrence for 8 months.

Urachal Carcinoma Shares Genomic Alterations with Colorectal Carcinoma and May Respond to Epidermal Growth Factor Inhibition

Metastatic urachal carcinoma is a rare, understudied, and aggressive malignancy with limited treatment options. Histologically, urachal carcinomas resemble enteric adenocarcinomas and anecdotally respond to systemic therapies utilized in colorectal cancer. Targeted exome sequencing of archival primary tumor tissue from a patient with metastatic urachal cancer revealed EGFR amplification and wild-type KRAS. The patient was treated with cetuximab, a monoclonal antibody directed against EGFR, as a single agent, and achieved a response lasting more than 8 mo. Subsequent whole-exome sequencing revealed no additional alterations likely to be associated with cetuximab sensitivity. Formalin-fixed, paraffin-embedded tumor specimens from nine additional urachal cancers were subjected to targeted exome sequencing. Mitogen-activated protein kinase (MAPK) pathway mutations were found in four of the nine samples, but no EGFR amplification was detected. Importantly, APC mutations were detected in two of the nine patients. To our knowledge, this is the first report of a response to single-agent cetuximab in a patient with metastatic urachal cancer and of molecular analysis to probe the basis for sensitivity. On the basis of these findings and the histologic, and now genomic, similarities with colorectal cancer, monoclonal antibodies directed at EGFR could be used in the treatment of metastatic urachal cancer.

PATIENT SUMMARY

Urachal cancers are morphologically and genomically similar to colon adenocarcinomas and may respond to drugs targeting the epidermal growth factor receptor.

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

Since the publication of the World Health Organization "blue book" in 2004, several recent studies have provided new insights on the pathologic aspects of urachal neoplasms. The proposed updates include modified criteria for the diagnosis of urachal carcinoma. A uniform nomenclature for cystic tumors was lacking, and it is recommended that urachal mucinous cystic tumors should be separated and classified in a manner similar to ovarian mucinous neoplasms. The spectrum includes mucinous cystadenoma, mucinous cystic tumor of low malignant potential, mucinous cystic tumor of low malignant potential with intraepithelial carcinoma, and microscopically or frankly invasive mucinous cystadenocarcinoma, with 65% of cystic tumors classified as mucinous cystic tumor of low malignant potential. Most importantly, it has been shown that progression-free survival of noninvasive mucinous cystic tumors is significantly better than noncystic invasive adenocarcinoma. This development, along with prior descriptions of urachal villous adenoma, has also reaffirmed the occurrence of benign tumors of urachal epithelial origin. For noncystic (usual) invasive adenocarcinomas, the traditionally described histologic subtypes of enteric, mucinous, signet ring cell, not otherwise specified, and mixed remain appropriate, with 50% of tumors classified as mucinous subtype. Although this subtyping is helpful in diagnosis and differential diagnosis, the clinical significance of subtyping adenocarcinoma is still uncertain. Rare nonglandular morphologies such as urothelial, squamous, and neuroendocrine carcinoma in urachal carcinomas have been described in detail with proposals for their own set of diagnostic criteria. These criteria are based on unique features of urachal nonglandular carcinomas. Among the immunomarkers studied, only β-catenin and CK7 may be of help in the distinction of urachal from colorectal adenocarcinoma. Awareness of the expression profile of immunomarkers such as CDX2, P504S (racemase), PSMA, claudin-18, and REG IV in urachal tumors and in tumors in the differential diagnosis is important to avoid overreliance of these markers in the diagnosis. Limited studies have identified KRAS mutations interestingly only in mucinous adenocarcinoma and exclusive of MSI loss, and mutations in BRAF are not present. Several alternative tumor staging approaches (eg, Mayo, Ontario, TNM systems) different from the traditional staging proposed by Sheldon are used that provide better tumor distribution across stages; however, the prognostic utility of the stage substratification has yet to be validated in large prospective studies. Evidence though suggests that staging urachal cancer is most pertinent when dichotomized to tumors that have spread outside versus within the perivesical tissue. Only high tumor stage and residual tumor after surgery have been shown to be independent predictors of outcome. This review updates the contemporary classification of urachal epithelial tumors, which has informed the upcoming 2016 classification of World Health Organization tumors. We provide modified criteria for diagnosing urachal adenocarcinomas, which remains a clinico-pathologic exercise. The role of ancillary diagnostic methodology and issues pertaining to staging and prognostication are presented.