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The patient declined surgery and received chemoradiation with EBRT and brachytherapy plus capecitabine, followed by stereotactic body radiation therapy for a suspicious mesorectal lymph node, with post-treatment imaging showing a 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Miller3  \n1School of Medicine, Wayne State University, Detroit, Michigan, USA  \n2Oncology, Wayne State University, Detroit, Michigan, USA  \n3Radiation Oncology, Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA  \nCorrespondence to  \nSteven Raymond Miller; [srmiller@med.wayne.edu](srmiller@med.wayne.edu)  \nAccepted 11 July 2023  \n© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.  \nTo cite: Wang P, Joiner M, Dzul S, et al. BMJ Case Rep 2023;16:e252747 . doi:10 . 1136/bcr-2022- 252747  \nSUMMARY  \nA man in his 70s previously diagnosed with anadenocarcinoma of the prostate, received external beam radiation therapy (EBRT) and brachytherapy  \n11 years ago. Ten years later, he developed urinary symptoms and a cystoscopy identified a bladder neck tumour. A transurethral resection of a bladder tumour was performed, and pathology revealed a high-grade adenocarcinoma consistent with a colorectal primary. A colonoscopy was unremarkable, and imaging studies showed tumour involving the bladder and prostate. Tumour markers and a CARIS genomic prevalence score also favoured a colorectal cancer primary.  \nThe patient refused surgery and underwent chemoradiation with a combination of EBRT and brachytherapy with concurrent capecitabine. Imaging studies obtained 6 months after reirradiation revealed an enlarged left-sided mesorectal lymph node concerning for disease recurrence. The lymph node was treated with Stereotactic Body Radiation Therapy and his posttreatment imaging revealed a response to treatment with no other evidence of disease.  \nBACKGROUND  \nThe human body is composed of ~30 trillion cells of varying types,1 each with the potential for malignant transformation. This huge number of cells (each with multiple mechanisms of oncogenesis) has resulted in over 150 types of cancer,2 with countless more subtypes and variants. Thus, each malignancy is unique and cancer patients need tobe evaluated on a case-by-case basis. To address this challenge, clinical oncologists use various classification schemes to group cancer patients into a framework via which educated treatment decisions can be made. The most used standardised classification system is from the American Joint Committee on Cancer (AJCC) which considers a cancer’s histology, location and extent of involvement which groups each patient’s cancer into a specific type and stage.3 Once a patient has been appropriately staged, national guidelines exist for best standard of care practices allowing standardisation of treatment.  \nDespite our best efforts to classify the vast diversity of cancers, however, there remain challenging cases which do not fit this traditional model. These unique cancers present challenging clinical situations foroncologic healthcare providers, as there are rarely, if ever, clinical studies that directly apply. Best practice in these unique situations is for multidisciplinary (and in this case, multisite) evaluation by an experienced and diverse group of healthcare providers.  \nCASE PRESENTATION  \nA man in his 70s previously diagnosed with a high risk adenocarcinoma of the prostate, with an initial  \nProstate Specific Antigen (PSA) as high as 88 ng/mLand Gleason grade group 4 disease, received definitive treatment with external beam radiation therapy and low-dose rate (LDR) brachytherapy 11 years ago. In his primary course of radiation, he received 45 Gy in 25 fractions to the prostate and pelvic lymph nodes followed by an LDR brachytherapy boost to the prostate for an additional 110 Gy delivered via 125I seed implantation. He did well for the following 10 years until he developed lower urinary tract symptoms which prompted him to be evaluated via cystoscopy which identified a necrotic tumour involving the posterior bladder wall and bladder neck. He","cbCaieDbmBb84Jxq","https://ap.wps.com/l/cbCaieDbmBb84Jxq","pdf",479060,"English","# Summary\n# Background\n# Case presentation","[{\"question\":\"What initial treatments were given for the patient’s prostate adenocarcinoma?\",\"answer\":\"He received definitive external beam radiation therapy and low-dose rate (LDR) brachytherapy 11 years earlier, including prostate and pelvic nodal irradiation followed by an LDR brachytherapy boost to the prostate.\"},{\"question\":\"How was the bladder tumour characterized after transurethral resection?\",\"answer\":\"Pathology showed high-grade adenocarcinoma consistent with a colorectal primary, supported by immunohistochemical positivity for markers such as GDX2, CEA, SATB2, Villin, and CK20 and negativity for CK7, NKX3-1, PAP, and PSA.\"},{\"question\":\"What treatment was chosen after the patient refused surgery?\",\"answer\":\"He underwent chemoradiation combining EBRT and brachytherapy with concurrent capecitabine, and later received stereotactic body radiation therapy to a suspicious mesorectal lymph node.\"}]","Adenocarcinoma involving the urinary bladder - Case report | PDF",1790222623,13]