A-90-year-old female presented in November 2003 with a history of nausea, vomiting and dysphagia, with hematuria. On admission her abdomen was slightly distended, tympanic, and slightly tender in the upper abdominal regions, with normal bowel sounds and no palpable mass. Blood tests revealed a white blood cell count of 6,100/mm3, c reactive protein (CRP) 6.01 mg/dl, carcinoma antigen (CA) 19-9 50.6 mg/dl and carcinoembryonic antigen (CEA) of 2.9 mg/dl. Pelvic computed tomography (CT) identified an abnormal thickness of the bladder wall with enhance effect in a diverticulum and it's origin from bladder (Figure. ). Another mass was seen in the antral portion of the stomach; however, pancreas and biliary tract were normal on computed tomography. There was not other lesion detected in other abdominal and pelvic organs.
Pelvic computed tomography revealed an abnormally thickened diverticulum of the bladder.
A gastroscopy was carried out which revealed type 3 pyloric stenosis. A biopsy of the stomach was taken which revealed well-differentiated tubular adenocarcinoma. Cystoscopy was performed which showed a lesion in the bladder diverticulum, a biopsy of the bladder wall revealed well-differentiated tubular adenocarcinoma metastasis from gastric carcinoma. At laparotomy, the pylorus segment of the stomach was viable with signs of edema, but no serosal invasion was identified. There were no sign of peritoneal dissemination in the intra-abdominal cavity. Peritoneal washings were negative for malignant cells. A palliative distal gastrectomy with gastrojejunostomy was performed to relieve pyloric obstruction.
However, cystectomy or diverticulectomy was not performed due to age of the patient and technical difficulties due to previous two surgeries performed for abnormal position of uterus and volvulus of intestine. The size of the macroscopic specimen was 3.0 × 2.5 cm (Figure. ). Histology revealed well differentiated tubular adenocarcinoma invading to the muscularis propria (MP), 3type, Infiltrative growth pattern (inf) β, int, ly3, v0 (Figure. , ), Similar to that of bladder tumor (Figure ). The patient recovered with no further symptoms, and was discharged on the 19th postoperative day. However, patient later developed pyelonephritis, bilateral hydronephrosis, disseminated intravascular coagulation (DIC) and died three months after the surgery.
Macroscopic specimens identified a type-3 tumor at the pylorus of the stomach.
Microscopic specimens demonstrated localization in the muscularis propria on the invasion index (T2) (Hematoxylin and Eosin ×10).
Figure 4 Photomicrograph of a) stomach showing well differentiated tubular adenocarcinoma (left). (Hematoxylin and Eosin ×400) and b) bladder biopsy specimen showing well differentiated tubular adenocarcinoma (right) (Hematoxylin and Eosin ×400). (more ...)