S4604 Beyond the Bladder: Metastatic Urothelial Carcinoma in the Major Papilla

Introduction: Urothelial carcinoma (UC) is a commonly diagnosed bladder tumor. The plasmacytoid variant of urothelial carcinoma tends to have an aggressive clinical course with nontraditional metastasis along peritoneal surfaces, tissue planes and the lymphatic system. Presented here is a rare case of plasmacytoid UC with isolated metastasis to the major papilla and duodenum following radical cystectomy. Case Description/Methods: The patient is a 70-year-old woman who presented with 2-months of dysuria and hematuria. She underwent transurethral resection of an identified mass in the bladder with pathology demonstrating UC, high grade plasmacytoid variant. Shortly after diagnosis she presented with obstructive acute kidney injury and bilateral hydronephrosis requiring placement of bilateral percutaneous nephrostomy tubes. After discussion with urology, she elected to undergo radical cystectomy with ileal conduit and end colostomy creation. Two weeks later, she re-presented to the emergency department due to abdominal pain, bilious emesis, and inability to tolerate oral intake. She had an nasogastric tube placed for decompression due to concern for post-op ileus and was started on total parenteral nutrition. A follow up computed tomography scan was obtained which revealed an obstructing polypoid mass in the duodenum. Gastroenterology was consulted and preformed upper endoscopy showing a non-traversable solitary mass at the major papilla and duodenum. Biopsies were positive for metastatic plasmacytoid UC. After multidisciplinary discussion the patient ultimately elected for palliative percutaneous endoscopic gastrostomy tube placement and was sent home under the care of hospice services. Discussion: UC accounts for approximately 90% of all bladder neoplasms with Plasmacytoid UC accounting for only 1-3% of invasive phenotypes. The estimated rate of incidence in females is 4 times higher than males with females presenting at higher clinical stages. Similar to this case, most patients with invasive UC undergo radical cystectomy. In those with plasmacytoid variant, it has been suggested that 33% have intraperitoneal spread and 20% have subsequent metastasis involving other serosal surfaces. Plasmacytoid UC is an aggressive variant with nontraditional, but characteristic metastatic patterns. Our patient demonstrated a rare presentation of isolated metastasis to the major papilla in the duodenum with only 3 similar cases reported in the literature. Further research must be done to determine plasmacytoid UC’s propensity for metastasis to the duodenum and its surrounding structures given the rarity of its occurrence.