|Ahead of print publication
A rare case report of transitional urothelial carcinoma metastasizing to isolated upper cervical lymph node diagnosed on cytology
Sumaira Qayoom, Mala Sagar, Divya Goel, Madhu Mati Goel
Department of Pathology, KGMU, Lucknow, Uttar Pradesh, India
Department of Pathology, KGMU, Lucknow - 226 003, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Transitional urothelial carcinoma frequently metastasizes to pelvic and retroperitoneal lymph nodes usually within 2 years of primary diagnosis but isolated metastasis to upper cervical lymph node after 5 years of primary diagnosis is extremely rare. We report here a case of a 53-year-old male who presented with Level II cervical node enlargement after 5 years of being diagnosed and treated for urothelial carcinoma. The diagnosis of cervical metastasis from urothelial carcinoma was suggested by fine-needle aspiration cytology and confirmed by immunocytochemistry.
Keywords: Cervical node, fine-needle aspiration cytology immunocytochemistry, urothelial carcinoma
|How to cite this URL:|
Qayoom S, Sagar M, Goel D, Goel MM. A rare case report of transitional urothelial carcinoma metastasizing to isolated upper cervical lymph node diagnosed on cytology. J Can Res Ther [Epub ahead of print] [cited 2019 Oct 14]. Available from: http://www.cancerjournal.net/preprintarticle.asp?id=264221
| > Introduction|| |
Head-and-neck cancers comprise 3.3% of all the cancers, with cervical lymph nodes being one of the most common sites for metastasis. Most common primary malignancy metastasizing to the cervical lymph node is epithelial malignancies of the upper aerodigestive tract. Rarely, metastasis from a cancer of remote organ presents with cervical lymphadenopathy, which constitutes <1% of all head-and-neck malignancies. The common sites of primary, in decreasing order of frequency, are the breast, lung, gastrointestinal tract, and genitourinary. Among the genitourinary regions, prostatic and renal cell carcinoma metastasizes frequently to cervical lymph nodes. Urothelial carcinoma of the bladder metastasizes very rarely to this location, and only scattered case reports have been published. As fine-needle aspiration cytology is less invasive with short turnaround time, it plays an important role in the diagnosis of metastatic lesions with known primary and when supplemented by immunocytochemistry (ICC) can confirm the primary site. Here, we present a diagnosed and treated case of urinary bladder carcinoma which presented with isolated cervical nodal metastasis after 5 years of treatment.
| > Case Report|| |
A 53-year-old male was diagnosed 5 years back with high-grade papillary transitional cell carcinoma, nonmuscle invasive type [Figure 1]. He underwent transurethral resection of bladder tumor followed by intravesical bacillus Calmette-Guerin therapy. Now, he presented with painless mass in the right cervical region for 1 month. There was no history of fever cough, dysphagia, or hoarseness of voice. On examination, single firm, nontender right cervical lymph node was noted measuring 2.5 cm × 2 cm. Fine-needle aspiration cytology revealed cellular smears with atypical epithelial cells in sheets and clusters [Figure 2]a. Individual tumor cells were pleomorphic with high N:C ratio, vesicular chromatin, prominent nucleoli, and scant cytoplasm. Brisk mitosis was also noted [Figure 2]b. As cytology did not reveal any finding specific for urothelial carcinoma such as cercariform cells, plasmacytoid forms, and glandular or squamous différentiation, immunocytochemistry was performed which revealed these cells to be strongly positive for cytokeratin 7 (CK7), CK20, and GATA-3 [Figure 3]. In view of above findings, a diagnosis of metastatic urothelial carcinoma was rendered. Further workup with imaging studies showed asymmetrically, heterogeneously enhancing circumferential mural thickening of urinary bladder measuring 33 mm in maximum dimension. The patient was put on platinum-based chemotherapy and was doing well with regression of the nodal size.
|Figure 1: Sections shows tumor-forming papillary structures lined by multilayered, pleomorphic cells (a: H and E, ×40). The muscle was not involved (b: H and E, ×40)|
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|Figure 2: Smear shows cellular fragments with atypical epithelial cells (a: H and E, ×4). Higher magnification shows pleomorphic tumor cells with high N:C ratio, vesicular chromatin, prominent nucleoli, and scant cytoplasm. Atypical mitotic figure is also seen (b: H and E, ×60)|
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|Figure 3: Tumor cells positive for cytokeratin 7, cytokeratin 20, and GATA-3 on immunocytochemistry|
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| > Discussion|| |
Cervical lymph nodes are one of the most common sites for metastasis. The distant primary constitutes <1% and commonly involves infraclavicular or supraclavicular lymph nodes and very rarely isolated higher level cervical lymph nodes. The metastasis usually occurs within 2 years of diagnosis and the presence of a late metastasis in isolated higher level cervical lymph node is uncommon. Genitourinary primaries, especially kidney and prostate cancers, metastasize to the cervical lymph nodes in significant number of patients. However, isolated metastasis from urinary bladder is very uncommon and has been reported only as a few case reports and case series.,,,,, A summary of all these cases is presented in [Table 1]. Hessan et al. reported three cases of urothelial cancer metastasizing to cervical lymph nodes out of 845 urogenital tract tumors with head-and-neck metastasis. Pusztaszeri et al. reported a cervical node metastasis of a micropapillary carcinoma of the bladder. Tunio et al. reported a case of transitional carcinoma of the urinary bladder metastasizing to the left supraclavicular lymph node. Kancharla et al. presented a case of urothelial carcinoma with generalized lymphadenopathy and closely mimicking clinically as lymphoma. The presence of isolated higher level cervical lymph nodal metastasis, after 5 years from a urothelial transitional cell carcinoma, makes the present case very unusual and worth reporting.
|Table 1: Summary of urothelial carcinoma cases with cervical metastasis reported in literature|
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Microscopically, urothelial carcinoma can closely resemble high-grade squamous cell carcinoma (SCC) and its rarity demands high index of suspicion supplemented by careful history and ancillary techniques like ICC. As our patient was elderly and incidence of SCC of the upper aerodigestive tract in our geographical area is very high, we applied CK7, CK20, and GATA-3 to confirm the primary of urothelial carcinoma and all three markers turned out to be positive in our case. GATA-3 is one of the most sensitive makers for urothelial carcinomas. Due to the advances in the management of the primary urothelial carcinoma, the survival of the patient has increased as a result of which probability of the patients presenting with late and distant metastasis has increased yet standardized treatment protocol is not available owing to very limited number of such cases reported in literature. However, identifying these metastasize is important as these patients may show prolonged survival when offered treatment in the form of chemotherapy, radiotherapy, or immunotherapy.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
| > Conclusion|| |
It is very uncommon for a metastatic urothelial carcinoma of the urinary bladder to present as isolated cervical lymphadenopathy. Identifying this entity is of utmost importance owing to a proper management of these cases.
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Conflicts of interest
There are no conflicts of interest.
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