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Journal of Cancer Research and Therapeutics, Vol. 7, No. 2, April-June, 2011, pp. 217-219 Case Report Cutaneous metastasis of transitional cell bladder carcinoma: A rare presentation and literature review Nikolaos S Salemis, Christos Gakis, Andreas Zografidis, Stavros Gourgiotis 2nd Department of Surgery, Army General Hospital, Athens, Greece Code Number: cr11054 PMID: 21768720 Abstract Cutaneous metastasis from transitional cell bladder carcinoma is a rare clinical entity associated with poor prognosis. We present a case of cutaneous metastasis arising from a transitional cell bladder carcinoma in a male patient who had undergone a radical cystectomy and bilateral ureterostomy 17 months previously. The cutaneous metastasis became evident 3 months before the manifestations of generalized recurrent disease. An awareness of this rare clinical entity and high index of suspicion is needed to rule out metastatic spread in patients with a previous history of transitional cell bladder carcinoma presenting with cutaneous nodules. Definitive diagnosis requires a histological confirmation, but prognosis is generally poor. Keywords: Bladder cancer, cutaneous metastasis, transitional cell Introduction Bladder cancer is the fourth most common cancer among men and the tenth most common cancer among women, with 70,980 new patients and 14,330 deaths in 2009 in the United States. [1] Approximately 50% of the patients will develop local recurrence and/or metastatic disease after radical cystectomy, [2] whereas in 30% of the cases the tumor has invaded the bladder′s muscle layer at the time of diagnosis. [2],[3] Cutaneous metastasis of transitional cell bladder carcinoma is a rare clinical entity. We describe here a case of cutaneous metastasis of a high-grade transitional cell bladder carcinoma as an early sign of a generalized recurrent disease with an uncommon spread. Case Report A 68-year-old white male presented with a 3-month history of a palpable nodule in his left lower abdomen. His past medical history included a radical cystectomy and bilateral ureterostomy that he had undergone 17 months previously at another institution, due to a high-grade transitional cell bladder carcinoma. He denied any recent symptoms. On physical examination, a hard nontender nodule measuring 1 × 2 cm was palpated in his left lower abdomen. There was no abdominal pain or tenderness but a mass was palpable very close to the ureterostomy site. Laboratory studies revealed anemia with a hematocrit of 23.8% and a hemoglobin level of 7.6 g/dL. Biochemical investigations revealed increased levels of C-reactive protein 161 mg/L (reference range < 5), alkaline phosphatase 175 U/L (reference range, 45-140) and erythrocyte sedimentation rate (ESR) of 137 mm/h. Evaluation of tumor markers revealed elevated levels of carcinoembryonic antigen (CEA) 133.86 ng/mL (reference range, 0-10) and carbohydrate antigen 19-9 (CA 19-9) 213 U/mL (reference range, 0-37). Urinalysis revealed marked microscopic hematuria with 53 red blood cells per high power field. Contrast-enhanced computed tomography (CT) scan of the abdomen revealed the cutaneous nodule [Figure - 1] and a soft tissue mass, which was extending to the anterior abdominal wall along the ureters′ course [Figure - 2]. Excisional biopsy of the cutaneous nodule revealed extensive infiltration from a high-grade transitional cell bladder carcinoma [Figure - 3] with tumor emboli in small veins. Due to the presence of advanced disease and patient′s poor performance status supportive treatment was only administered. The disease run an aggressive clinical course and the patient unfortunately died 2 months after the diagnosis of cutaneous metastasis. Discussion Cutaneous metastasis from internal malignancies is a rare clinical entity and it may be the first sign of an advanced disease. In a meta-analysis performed by Krathen et al., it was found that the overall incidence of cutaneous metastases was 5.3% among 20,380 cancer patients. [4] Breast cancer was the most common origin of cutaneous metastases, whereas the most commonly affected sites were the chest and the abdomen. Cutaneous spread from primary urologic malignancies has been reported in 1.3% of the patients. [5] Mueller et al. [5] found that the incidence of cutaneous metastases from bladder cancer was 0.84%. Metastatic infiltration of the skin or subcutaneous tissues can occur due to direct tumor invasion, hematogeneous or lymphatic spread, or as a result of iatrogenic implantation of tumor cells. [5] Gross appearance of cutaneous metastases is not distinctive and may mimic many common dermatologic disorders. [4],[6] These lesions can have a nodular, inflammatory, or fibrotic appearance [5] and can be solitary or multiple. [7],[8] Urologic malignancies most commonly metastasize to regional lymph nodes, liver, lung, and bones. [5],[7] An iatrogenic implantation is considered the main cause of cutaneous spread in the majority of the patients with transitional cell bladder carcinoma. [8] In our patient the solitary cutaneous metastasis was a very early sign as it became clinically evident 3 months before the onset of symptoms of generalized disease. The extension of the tumor to the anterior abdominal wall along the ureters′ course was very unusual. We believe that this type of spread was likely the result of iatrogenic seeding of tumor cells during radical cystectomy and bilateral ureterostomy that was performed 17 months earlier. Since the patient was obese, the mass extending to the abdominal wall close to the ureterostomy site was hardly palpable, making therefore the cutaneous nodule the first sign of the disease. Implantation of bladder cancer cells occurs most commonly with high-grade tumors and may affect abdominal wounds, denuded urothelium, resected prostatic fossa, or traumatized urethra. [9] It can occur after inadvertent bladder perforation during transurethral resection (TUR), laparoscopic biopsy of bladder cancer, or during partial or total cystectomy. The implantation of bladder cancer into the abdominal wall, as seen in our patient, is a very rare occurrence. Prognosis of patients with cutaneous spread of bladder cancer is generally poor and the median survival is less than 12 months. [6] However, very rare cases with extended survival have been reported. [8] Due to the limited number of patients with cutaneous metastases of bladder cancer and their subsequent poor survival, management strategies have not been clearly defined. [7] Treatment options are often limited and palliative due to the patients′ advanced age and disease stage, resulting in poor prognosis. [3],[5] The treatment of choice for metastatic bladder cancer is chemotherapy, which however is rarely curative. [10] Currently, the combination of gemcitabine and cisplatin and the MVAC scheme (methotrexate, vinblastine, doxorubicin, and cisplatin) are established treatments with reported tumor remission rates up to 70%. Survival, however, does not exceed 14 months. [2] The role of surgery in the metastatic bladder cancer has not been fully investigated. [2] Surgical resection can be performed in cases with persistent or recurrent disease that is resectable [10] Siefker-Radtke et al. [10] reported a 5-year survival rate of 33% in 31 patients who underwent resection of the metastases. Median survival from the diagnosis of metastases was 31 months, whereas the median survival after metastasectomy was 23 months. The authors suggested that resection of metastases is feasible and may benefit selected patients, especially in combination with chemotherapy. In a prospective trial where 70 patients with bladder cancer metastases refractory to chemotherapy were enrolled, a median survival of 7 months was found, whereas 1- and 2-year survival rates were 30% and 19%, respectively. [11] Symptomatic patients benefited from surgical resection of metastases in terms of tumor-related symptoms and performance status. However, asymptomatic patients complained for a negative impact on quality of life, whereas no prolongation of survival was observed. [11] Palliative therapy includes supportive treatment, whereas selective arterial embolization can be used for the management of gross and intractable hematuria. The use of pelvic irradiation for palliation has not been fully investigated. [3] In conclusion, we presented a rare case of cutaneous metastasis of transitional bladder cell carcinoma, which became clinically evident 3 months before the onset of symptoms of advanced disease. The patient was on an aggressive clinical course. Metastatic disease should always be considered in the differential diagnosis in patients with a previous history of bladder cancer who present with cutaneous nodules. Due to the advanced stage of the disease in many cases treatment is mainly supportive and prognosis is poor. Acknowledgment The authors would like to thank Dr. Nakos G. of the Pathology Department for providing the histology slide. References
Copyright 2011 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr11054f3.jpg] [cr11054f2.jpg] [cr11054f1.jpg] |
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