Abstract
Muscle-invasive bladder cancer (MIBC) with cardiac metastasis typically carries a very poor prognosis. A Black woman in her 70s developed high-grade urothelial carcinoma with squamous differentiation invading the bladder muscle. Despite chemotherapy, radiation, and nephrostomy, the disease progressed. Six months after diagnosis, imaging revealed metastases to the heart and liver with biopsy showing a rare p63-positive, CK7-negative phenotype. Following a single dose of pembrolizumab, she died within three weeks, likely from cardiogenic shock. In CK7-negative variant urothelial carcinoma, early cardiac imaging and expanded immunohistochemical panels may improve detection of atypical metastases.