Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
CASE REPORT
Year : 2011  |  Volume : 7  |  Issue : 2  |  Page : 217-219

Cutaneous metastasis of transitional cell bladder carcinoma: A rare presentation and literature review


2nd Department of Surgery, Army General Hospital, Athens, Greece

Date of Web Publication12-Jul-2011

Correspondence Address:
Nikolaos S Salemis
19 Taxiarhon Str, 19014 Kapandriti, Athens
Greece
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.82940

Rights and Permissions
 > 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


How to cite this article:
Salemis NS, Gakis C, Zografidis A, Gourgiotis S. Cutaneous metastasis of transitional cell bladder carcinoma: A rare presentation and literature review. J Can Res Ther 2011;7:217-9

How to cite this URL:
Salemis NS, Gakis C, Zografidis A, Gourgiotis S. Cutaneous metastasis of transitional cell bladder carcinoma: A rare presentation and literature review. J Can Res Ther [serial online] 2011 [cited 2019 Nov 13];7:217-9. Available from: http://www.cancerjournal.net/text.asp?2011/7/2/217/82940


 > Introduction Top


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 Top


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.
Figure 1: Contrast-enhanced computed tomography scan of the abdomen showing the subcutaneous nodule (arrow) and a soft tissue mass in contact with the anterior abdominal wall (star)

Click here to view
Figure 2: Contrast-enhanced computed tomography scan of the abdomen showing a soft tissue mass (arrows) extending to the anterior abdominal wall along the ureters' course

Click here to view
Figure 3: Histology showing extensive skin infiltration from a high-grade urothelial carcinoma (H– E stain, ×25)

Click here to view


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 Top


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 Top


The authors would like to thank Dr. Nakos G. of the Pathology Department for providing the histology slide.

 
 > References Top

1.Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin 2009;59:225-49.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Jakse G, Stockle M, Lehmann J, Otto T, Krege S, Rubben H. Metastatic bladder carcinoma. Dtsch Arztebl 2007;104:A1024-8.  Back to cited text no. 2
    
3.Vom Dorp F, Börgermann C, Rübben H. Palliative therapy concepts for patients with urothelial cancer of the urinary bladder. Urologe A 2007;46:54-5.  Back to cited text no. 3
    
4.Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: A meta-analysis of data. South Med J 2003;96:164-7.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Mueller TJ, Wu H, Greenberg RE, Hudes G, Topham N, Lessin SR, et al. Cutaneous metastases from genitourinary malignancies. Urology 2004;63:1021-6.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Block CA, Dahmoush L, Konety BR. Cutaneous metastases from transitional cell carcinoma of the bladder. Urology 2006;67:846.e15-7.  Back to cited text no. 6
    
7.Atmaca AF, Akbulut Z, Demirci A, Belenli O, Alici S, Balbay DM. Multiple subcutaneous nodular metastases from transitional cell carcinoma of the bladder. Pathol Oncol Res 2007;13:70-2.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Akman Y, Cam K, Kavak A, Alper M. Extensive cutaneous metastasis of transitional cell carcinoma of the bladder. Int J Urol 2003;10:103-4.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Messing EM, Catalona W. Urothelial tumors of the bladder. In: Wein AJ, editor. Campbell-Walsh urology. 9 th ed. Philadelphia: W.B. Saunders; 2007. p. 2407-46.  Back to cited text no. 9
    
10.Siefker-Radtke AO, Walsh GL, Pisters LL, Shen Y, Swanson DA, Logothetis CJ, et al. Is there a role for surgery in the management of metastatic urothelial cancer? The M. D. Anderson experience. J Urol 2004;171:145-8.  Back to cited text no. 10
    
11.Otto T, Krege S, Suhr J, Rübben H. Impact of surgical resection of bladder cancer metastases refractory to systemic therapy on performance score: A phase II trial. Urology 2001;57:55-9.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Abstract>Introduction>Case Report>Discussion>Acknowledgment>Article Figures
  In this article
>References

 Article Access Statistics
    Viewed4060    
    Printed156    
    Emailed2    
    PDF Downloaded324    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]