PMC10257781_01
Anterior bladder mass with heterogeneous enhancement measuring 35x36 mm, extending beyond the bladder contour and with slight infiltration of peripheral fat: yellow arrow, computed tomography (CT) scan image.
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F1
On the CT scan images, the bladder tumor seemed to exceed beyond the bladder contour (Figure 1). 
Bulky aspect of the bladder tumor situated at the anterior wall of the bladder: intraoperative image.
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F2
Papillary structures on the surface of the tumor (A) are lined by cells which showed obvious cytological and atypical architecture, whereas the invasive component was constituted by irregularly shaped nests of tumor cells (B). Hematoxylin-Eosin (HE) staining: (A) x100; (B) x200.
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F3
Multiple fragments of the muscularis propria were identified, but none was invaded by the tumor (Figure 3A and 3B).
The second bladder resection specimen revealed the infiltration of the lamina propria by a high-grade transitional carcinoma constituted by nests of highly pleomorphic cells. HE staining, x200.
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F4
The second-look transurethral resection was performed at the site of the previous resection and the histological examination of the tissue revealed the same invasive HG papillary transitional carcinoma of the bladder, with lamina propria invasion and nests of highly pleomorphic cells, but no muscle invasion (pT1 HG according to the UICC 8th edition) (Figure 4).
Speculated lesion of the upper right lobe of the lung: yellow arrow, CT scan image.
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F5
During the follow-up, a thoraco-abdominal CT scan was performed and a nodule in the upper right lobe of the lung was discovered (Figure 5).
Positron emission tomography (PET)/CT scan image of high metabolic activity at the level of the lung's nodule: yellow arrow.
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F6
The positron emission tomography (PET)/CT scan showed a high metabolic activity at the level of the lung's nodule (Figure 6).
The primitive lung acinar adenocarcinoma was composed of glands and cribriform structures lined by tumor cells with a high nuclear-cytoplasmic ratio and pleomorphic nuclei (A). Immunohistochemistry revealed a diffuse expression of TTF-1 in the nuclei of tumor cells (B), which did not express GATA3 (C). HE staining: (A) x200. Anti-TTF-1 antibody immunomarking: (B) x200. Anti-GATA3 antibody immunomarking: (C) x200. GATA3: GATA binding protein 3; TTF-1: Thyroid transcription factor-1.
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F7
Consequently, the patient underwent an upper lobectomy in October 2018 and the histological examination confirmed the lung acinar adenocarcinoma (pT1cN0 according to the UICC 8th edition) (Figure 7A,7B,7C).
Massive bladder tumor: (A) Axial CT scan; (B) Coronal CT scan.
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F8
An extension of the tumor to the proximal sigmoid could not be excluded (Figure 8A and 8B). 
Tumor bladder after chemotherapy: (A) Axial CT scan; (B) Coronal CT scan.
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F9
An abdominal CT scan was performed to evaluate the efficiency of the chemotherapy and it showed an impressive regression of the bladder tumor and complete remission of the hydronephrosis (Figure 9A and 9B). 
Secondary lesion of 33 mm located at the right lateral part of the base of the penis widely invading the right cavernous body and more discreetly the left cavernous body: (A) Axial magnetic resonance imaging (MRI); (B) Coronal MRI.
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F10
A magnetic resonance imaging (MRI) of the pelvis was performed and a lesion of about 30x20x20 mm was spotted at the base of the penis (Figure 10A and 10B).
Secondary lesion measured about 28 mm of long axis, it was located under the right iliopubic branch and invaded the anteroinferior part of the acetabulum: (A) Axial MRI; (B) Coronal MRI.
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F11
Another suspect lesion was described under the right iliopubic branch of the coxal bone that invades the anterior and inferior part of the acetabulum (Figure 11A and 11B).
Pathological examination of the penectomy specimen revealed a high-grade carcinoma whose morphological aspects were very similar to the urothelial carcinoma of the bladder, with fused and irregular nests composed of highly pleomorphic tumor cells (A), which expressed, in immunohistochemistry, HMWCKs (B) as well as CK7 (C). HE staining: (A) x200. Anti-HMWCK antibody (clone CK34betaE12) immunomarking: (B) x200. Anti-CK7 antibody immunomarking: (C) x200. CK7: Cytokeratin 7; HMWCK: High molecular weight cytokeratin.
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F12
IHC investigations confirmed a urothelial phenotype, with no arguments in favor of a lung metastasis: a diffuse and intense positivity was observed with cytokeratin 7 (CK7) and high molecular weight cytokeratin (HMWCK, clone CK34betaE12) whereas thyroid transcription factor-1 (TTF-1) and Napsin A were not expressed by the tumor cells (Figure 12A,12B,12C). 
PET/CT scan images: (A) Common iliac lymph nodes (LNs); (B) Multiple right external iliac and bilateral inguinal positive LNs.
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F13
Metastasis of the obturator foramen and of the right peritoneal flank were observed as well (Figure 13A, 13B). 