Lymphoepithelioma like Carcinoma of the Bladder – “A Case” Revisited

Lymphoepitheliomas are a type of undifferentiated carcinomas primarily described in the nasopharyngeal cavity.


Introduction
Lymphoepitheliomas are a type of undifferentiated carcinomas primarily described in the nasopharyngeal cavity.
In the urinary tract, they are typically, but uncommonly seen in the urinary bladder, although occasional cases have been We report the case of an 82 year old gentleman, who presented with a bladder mass, which on post surgical histopathology examination was diagnosed to be a Lymphoepithelioma like carcinoma.

Case report
An 82 year old gentleman presented to our outpatient The partial cystectomy and bilateral pelvic lymph node dissection was performed without event and he was discharged on his 5 th post operative day.
Tumour had infi ltrated the perivesical fat microscopically and there was no nodal metastasis-giving the following staging: pT3aN0M0.
In lieu of his age, as well as caveats in literature as regards further management strategies, the MDT decided not to offer adjuvant chemotherapy and keep him on active surveillance.
A surveillance fl exible cystoscopy at 1 year, post procedure was normal, along with no clinic-radiological evidence of recurrence.

Discussion
Lymphoepithelioma like tumors of the urinary bladder (LELCB) are a rare entity with an incidence of about 1% of all bladder tumors [1,2]. Due to this rarity, there are currently no standardized treatment guidelines for LELCB. It is commonly accepted that hematuria is the most common presenting feature [1,3]. Currently with the development of Immunohistochemistry (IHC), the diagnosis is much easier than it was in 1991 when it was fi rst noticed [4] and it is known that LELCB is usually muscle invasive at diagnosis but not metastatic, as with other bladder cancers [5]. But there are reports that LELCB can occur in a background of Transitional Cell Carcinoma (TCC) and these behave more aggressively. Lopez, et al. in their series found that patients with LELCB in a background of high-grade TCC died of the disease 3-30 months from diagnosis [5].
Thus, presently there is still confusion regarding the long term aggressiveness of the disease and thus the role for adjuvant therapy is still debated. Generally they are considered sensitive to radiotherapy and chemotherapy [6,7], while some Japanese centers advocate adjuvant chemoradiotherapy [2].
Williamson, et al. suggest that for pure or predominant LELCB a transurethral resection and adjuvant chemotherapy is adequate. [9] While Kozyrakis, et al. would prefer radiotherapy or radical cystectomy to high risk patients [3] Tamas in their series of 28 patients found that 47% of them were associated with urothelial cancers with high propensity for multifocality, so they favor radical cystectomy over partial cystectomy [10]. Procaro, et al. gives a reasonable suggestion of performing TURBT with or without chemotherapy for pure or predominant LELCB and radical surgery with chemotherapy for focal muscle invasive LELCB [7].
Since LELCB was initially described in the nasopharynx and has been associated with Epstein Barr virus, some authors suggest that one should exclude a primary tumor occurrence in the nasopharynx [3].

Conclusion
Lymphoepithelioma like carcinomas of the bladder are a clinical rarity, with no set management protocols. On account of this, reports of this disease re-visited, akin to ours, would help to add to the caveats in literature and help clinicians to plan appropriate treatment strategies.