S3912 A Rare Presentation of Transitional Cell Carcinoma

Introduction: Transitional cell carcinoma (TCC) is the most common type of bladder cancer. Typically, presentation includes urinary frequency, dysuria, and/or hematuria. Here we present a case TCC diagnosed after presentation with persistent diarrhea and rectal pain, with magnetic resonance imaging negative for a discrete mass. Case Description/Methods: A 71-year-old woman with past medical history of hypertension and type 2 diabetes presented to the hospital with 1 month of profuse, watery, non-bloody diarrhea, associated with perianal discomfort. Initial labs were concerning for acute kidney injury. Computed tomography of the abdomen and pelvis (CT A/P) was significant for diffuse wall thickening in the distal colon and rectum, diffuse bladder wall thickening, and left sided hydroureteronephrosis. Stool studies were negative for infectious etiology. Due to worsening abdominal pain, CT A/P was repeated showing increased diffuse colonic distension most prominent in the transverse colon measuring up to 5.5 cm with fluid and feculent material, persistent severe bladder wall thickening up to 2.6 cm, and persistent moderate distal sigmoid and rectal wall thickening. Due to significant distension, nasogastric tube (NGT) was placed to suction. With improved bowel movements, sigmoidoscopy was performed with findings notable for hyperplastic thickened sigmoid folds, rectal polyp, and hemorrhoids. Patient was discharged, saw her primary care provider for follow-up visit, and was promptly referred to the emergency room after being found to have electrolyte abnormalities. While there, she was also evaluated by general surgery for anal pain. She underwent repeat sigmoidoscopy notable for stricture in anal canal and anal mass with ulcerations. Pelvic magnetic resonance imaging (MRI) was significant for intense enhancement of entire rectum, anus, and urinary bladder without discrete mass. Pathology from sigmoidoscopy was significant for poorly-differentiated carcinoma involving submucosa favoring metastatic carcinoma of urothelial origin. She unfortunately expired after a cardiac arrest prior to further imaging or initiation of therapy. Discussion: TCC accounts for 90% of all bladder cancers. Metastatic TCC impacts the colon in less than 1% of cases. When there is colonic impact, the most common presentation is hematochezia. Endoscopy typically shows a fixed mass in the rectum or thickened rectal wall. This case highlights the importance of thorough evaluation with physical examination, imaging, and endoscopy.