Indian Journal of Cancer, Vol. 46, No. 1, January-March, 2009, pp. 71-72
Letter To Editor
Transitional cell carcinoma urinary bladder manifesting as second malignancy following radiotherapy for carcinoma cervix
Dey Subhajeet, Philipraj JosephSebestian, Shankarnarayanan
Department of Surgery, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok - 737 102, Sikkim
Code Number: cn09014
A 63-year-old lady presented in the month of October 2006, with a history of hematuria, moderate pain and discomfort in the right lower abdomen, and occasional dysuria and frequency of micturation for the last one month. On examination mild tenderness was found on the right lower abdomen, but the rest of the examination was unremarkable.
She underwent Wertheim′s hysterectomy in 1996, for Ca. Cervix Stage Ia (Large cell non keratinizing squamous cell carcinoma) followed by 27-day external beam radiotherapy.
Her routine hematological and biochemical investigations were within normal limits, urine microscopy showed numerous RBCs, culture was sterile and urine cytology for malignancy was negative in three consecutive freshly voided samples. Ultrasonography of the abdomen revealed thickening of the bladder wall, more so on the right lateral aspect, suggestive of radiation cystitis with no evidence of hydroureteronephrosis. She underwent diagnostic cystoscopy under spinal anesthesia, which revealed erythematous mucosa all over and a single polypoid lesion measuring about 1.5 cm on the right lateral wall. The effluxes from the ureters were clear. The polypoid lesion was resected and base biopsy was also done. Multiple mucosal biopsies were also taken from the rest of the bladder. Hemostasis was ensured. She was discharged on the 4 th post-operative day, advised a checkup cystoscopy four weeks later for deciding about further management. The histopathology of the polypoidal lesion revealed Grade-II superficial transitional cell carcinoma. The deeper biopsies were negative for malignancy [Figure - 1] and [Figure - 2]
The cold cup biopsies of the rest of the mucosa revealed changes consistent with radiation cystitis-the lamina propria shows inflammatory cells composed of neutrophils, lymphocytes and macrophages. Areas of fibrosis and congested blood vessels with endothelial proliferation were seen.
Second malignancies arising five years after radiation therapy are defined as being potentially associated with treatment.  Among the late complications of high-dosage pelvic radiotherapy for cervical cancer, anorectal and bladder malignancies are sporadically reported in the literature.  Histological variants of the second malignancy of urinary bladder can be not only TCC; malignant mixed mesodermal tumors composed of carcinomatous and sarcomatous elements have also been reported.  Average time between irradiation and development of bladder cancer was 14.6 years and 26.8 years, and all were invasive cancers. , Our case had an interval of 10 years between the radiotherapy and diagnosis of second malignancy; probably that is why it is of superficial variety. The frequent occurrence of cystitis, hematuria, and non-specific bowel and bladder symptoms in older women obscures identification of late neoplastic complications after pelvic irradiation. Recruiting women with history of previous radiotherapy for cervical cancer in a strict follow-up program (ultrasonography, cytology and endoscopy) is useful in making an early diagnosis of the new pelvic malignancy with a better possibility of treatment.
Copyright 2009 - Indian Journal of Cancer
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