Bladder Lymphoepithelioma-Like Carcinoma: Case Report and LiteratureReview

Urinary lymphoepithelioma-like carcinoma is a rare tumour. These tumours are classified according to lymphoepithelioma component as pure (100%), predominant (≥50%) or focal ( 50%. Neoadjuvant gemcitabine and platinium-based chemotherapy was carried out. The patient received four cycles with a good tolerance. After completed chemotherapy, the patient underwent a radical cystoprostatectomy with lymph nodes dissection and bricker urinary diversion. It’s difficult to define the optimal strategy, literature reporting only small series. Nevertheless, the benefits of chemotherapy is certain. The outcome is good in the pure and predominant forms and bad in focal subtypes.

We present here an original case of a 54 year-old man who was diagnosed with a LELC of the urinary bladder and discuss its management regarding the lake of data in the literature.

Case Report
A 54 year-old Caucasian man presented few weeks history of haematuria associated with urinary frequency and dysuria. He had no medical history. He underwent surgery for discal hernia and appendicectomy a long time ago. He was a smoker since he was 15 year-old and stopped for fifteen years.
He underwent transurethral resection for its bladder tumour.
The results of histological examination confirmed a highgrade T2 transitional cell carcinoma with LELC >50%. On immunohistochemical staining the CKAE1/AE3, p53, was positive and CK7 and CD20 were negative.
In order to classify this tumor, the patient got a CT scan of the chest and the abdomens as well as a bone scan showing no evidence of loco regional extension or metastases. Blood tests showed a moderate

Case Report
Bladder Lymphoepithelioma-Like Carcinoma: Case Report and Literature Review anemia and normal kidney and hepatic functions. The tumor was classified according TNM classification of urinary bladder cancer (2009) as a stage T2b, N0, M0.
After discussion of the case during a multidisciplinary GU round, treatment with neoadjuvant gemcitabine and platinium-based chemotherapy was carried out. The patient received four cycles with a good tolerance (no grade 3 or more toxicity).
After completed chemotherapy, the patient underwent a radical cystoprostatectomy with lymph nodes dissection and orthotopic urinary diversion.
The final pathological evaluation of the tumour was predominant transitional cell carcinoma with LELC, classified ypT2R0pN0 tumour, and a low-risk Gleason 6 prostate adenocarcinoma.
The patient is under close observation with regular clinical and radiologic follow-up. He is for now considering in remission for 6 months.

Discussion
Lymphoepithelioma-like carcinoma of the bladder is a rare variant, often manifesting in T2-T3 (usually muscle-invasive) stages and occurring in male patients of 60 year-old.
They are revealed most of the time by haematuria, generally accompanied with urgency.
These tumours have a favorable prognosis with a five-year survival of 59%, achieving 62% in the pure type, compared to transitional cell carcinoma [4].
They respond better to chemotherapy than transitional cell carcinoma. The exact pathogenesis of this tumour is not well Submit your Manuscript | www.austinpublishinggroup.com established. Epstein-Barr virus is frequently associated with Lymphoepithelioma of the nasopharynx but has not been found in the LELC of the urinary bladder. Abnormality of p53 regulation might be a part of the pathogenesis [5]. These tumours are characterized by a prominent lymphocytic infiltration. They may occur in an association with transitional cell carcinoma.
Kenichi et al. reported a case of LELC of the bladder and a review of the literature [6].
In their pooled analysis of 56 patients, Serrano et al. concluded that focal disease is more aggressive and requires a radical cystectomy; pure or predominant tumors could benefit from a bladder-preserving treatment [8].
The benefits of chemotherapy are recognized, especially in infiltrative disease. In the Serrano study, patients with pure/ predominant LELC who received chemotherapy followed by surgery showed a 100% disease-free survival, compared with 53% disease-free survival in those who did not (median follow up of 34 and 25 months respectively).
Platinium-based agents have shown promising outcomes. In fact, Dinney et al. used cisplatin as neoadjuvant chemotherapy for three patients with LELC. All patients remained free of recurrence after six years of follow-up [9].
Ziouziou et al. nevertheless described the case of a patient treated only by radical surgery for a LELC of bladder [10].
In our case the patient was treated with four cycles of neoadjuvant chemotherapy with cisplatin. The response was excellent after chemotherapy and the patient underwent surgery. No adjuvant treatment was delivered because of the N0, R0 status.
However it's difficult to define the optimal strategy, literature reporting only small series. The benefits of chemotherapy are certain. Multiple chemotherapy regimens have been used, but platinumbased agents have shown good outcomes. Differential diagnoses are: lymphoma or inflammatory lesions like chronic cystisis. Evidence suggests that transitional cell carcinoma have poorer prognosis than LELC. Focal LELC is expected to be more aggressive than pure form.
It can be explained by the immune response due to the lymphoid cells against the tumour.

Conclusion
In summary our case is an original report, it underlines many questions.
First of all the problem of differential diagnosis, which can need the help of experiences pathologists.
Then, no guidelines exist due to a few case-reports and studies.
Other studies are needed to better understand the pathology and help the management.
The outcome is good in the pure and predominant forms and bad in focal subtypes. That suggests that in the first case, patients could be treated with a sparing approach, while, and in the other case, cystectomy and systematic adjuvant treatment seem to be the best choice.