Isolated central nervous system metastasis from transitional cell carcinoma of the bladder: report of a case and review of the literature

Although systemic metastases from transitional cell carcinoma of the bladder occur frequently, involvement of the central nervous system is uncommon. We describe a patient with an isolated cerebral metastasis who had previously undergone resection of a Grade III, Stage B2 carcinoma of the bladder. We have been able to find only one previous case report of a solitary intracerebral metastasis from transitional cell carcinoma of the bladder without evidence of primary recurrence or additional sites of spread. Central nervous system metastasis from bladder carcinoma must be considered in the differential diagnosis of solitary intracerebral lesions.     

Brain metastases from transitional cell carcinoma of the bladder

We present our experience with 4 patients with transitional cell carcinoma of the bladder and brain metastases. In all 4 cases a solitary intracranial metastasis occurred. In 3 patients this represented the first site of recurrent disease following systemic chemotherapy. Aggressive therapy of the brain metastases was instituted in 3 patients, including external beam radiation and in 2 cases surgical resection. Although all patients died only 3 died as a result of metastatic transitional cell carcinoma, including 2 who died as a direct result of intracranial disease. A review of the literature suggests an increasing incidence of brain metastases from transitional cell carcinoma of the bladder with the advent of more aggressive therapy for bladder cancer, which includes radical surgery for high stage disease and combination chemotherapy. Aggressive intervention for solitary brain metastases from transitional cell carcinoma can relieve neurological dysfunction and may prolong survival.     

Large cerebellar lesion as original manifestation of transitional cell carcinoma of the bladder

Patients with transitional cell carcinoma of the bladder classically present with irritative voiding symptoms or painless hematuria. Common sites of vascular metastases include the liver (38%), lung (36%), bone (27%), adrenal glands (21%), and intestine (13%). Vascular metastasis to the brain, without a prior history of chemotherapy, is extremely rare. To our knowledge, this is the first report of a patient with bladder transitional cell carcinoma whose original presentation was from a symptomatic, metastatic, cerebellar lesion.     

Complete responses in metastatic transitional cell carcinoma of the prostate with cisplatin regimens

We describe 3 patients with metastatic transitional cell carcinoma of the prostate who achieved a complete response with regimens containing cisplatin. Two patients received cyclophosphamide and weekly cisplatin, and 1 was given cyclophosphamide, doxorubicin and cisplatin. All 3 patients had extensive pulmonary metastasis at initiation of chemotherapy. One patient, who also had massive local disease, suffered an isolated brain metastasis 9 months after completion of chemotherapy but he remains in systemic remission 5 months later. Another patient had bilateral brain metastases 3 months after achieving complete remission with chemotherapy, followed 4 months later by systemic relapse. The third patient, who also had bone and bone marrow metastasis, is free of disease 20 months after completion of chemotherapy. In contrast, none of 14 patients with transitional cell carcinoma of the bladder and other sites treated with the same regimens obtained a complete response. Advanced transitional cell carcinoma of the prostate must be recognized promptly, since it is nonresponsive to hormonal manipulation and complete responses have been achieved with cisplatin chemotherapy programs as used in our patients.     

Clinically isolated cerebellar metastasis of renal pelvic urothelial cancer

A 70-year-old man who had undergone radical surgery for renal pelvic transitional cell carcinoma 9 months previously developed solitary cerebellar metastasis. Despite neurosurgical removal, the patient died and post-mortem pathological examination revealed microscopic metastatic lesions within microvessels of the lung. No other lesion, including local residual cancer, was detected.     

Brain metastases from transitional cell carcinoma of urinary bladder.

Of 293 patients with transitional cell carcinoma of the bladder seen at our institution between April 1977 and December 1987, 9 patients were found to have brain metastasis. Seven of 9 patients were found to have a solitary brain lesion, and in 4 of these, no other site of metastatic disease was identified. Five patients received palliative whole brain irradiation, 3,000 cGy in 10 fractions, due to the presence of multiple lesions of the central nervous system (CNS) or metastases to other sites. The average survival for this group was seven weeks. One patient with a solitary brain metastasis and no other documented metastatic site was hospitalized at another institution, and was managed expectantly receiving only parenteral steroid therapy and survived four weeks. Three patients with solitary lesions and no evidence of other metastatic sites were treated with a combined surgical and radiotherapeutic approach receiving 4,000-5,000 cGy to the lesion site postoperatively. The average survival of that group was twenty-nine months, with one five-year survivor and 1 patient with no evidence of disease fourteen months after treatment. It appears that survival is longer in those patients with solitary lesions, perhaps due, at least in part, to a more aggressive therapeutic approach.     

Extrarenal manifestations of renal cell carcinoma: the primary metastatic lesion (author's transl)]

In 18 patients, histologic evaluation of a solitary distant metastasis with characteristic hypernephroid pattern subsequently led to the diagnosis of renal cell carcinoma. The metastatic lesion was treated surgically in 15 cases; 14 patients underwent radical surgery and one patient with a solitary kidney underwent partial nephrectomy. Osseous metastases were predominant (12 out of 18). There was an excellent morphologic agreement between metastatic and primary lesions: in no case were metastases less differentiated than the primary tumor. Therefore in all cases of metastases with hypernephroid structures an aggressive search for renal malignancy is required. Five-year survival was 5% and identical to a group of 61 patients with metastases and a symptomatic renal cell carcinoma at diagnosis. The poor prognosis was not influenced by surgical extirpation of the solitary metastasis.     

Twenty-three years of disease-free survival following cutaneous metastasis from a primary bladder transitional cell carcinoma

We present a case of cutaneous metastases from a primary bladder transitional cell carcinoma (TCC), with a prolonged survival of 23 years. Cutaneous metastases from primary bladder TCC are uncommon and, like all metastases, have a poor prognosis. The common modality of treatment of cutaneous metastases from a primary bladder cancer is wide local excision of the metastases followed by combination chemotherapy. Here, we present a case of a solitary cutaneous metastasis from a primary bladder TCC, which was treated with wide local excision and single agent chemotherapy. Twenty-three years on, the patient remains disease and recurrence free.     

Curative surgery for solitary adrenal metastasis of pT1 G3 transitional cell carcinoma of the bladder

A preoperative computed tomography scan in a patient undergoing radical cystectomy for pT1N0 grade 3 transitional cell carcinoma revealed a tumor in the adrenal gland. Biopsy was negative, but 2 years later computed tomography showed progression, and adrenalectomy was performed, revealing transitional cell carcinoma. Four years after cystectomy, the patient had no evidence of other metastases. We discuss surgery for solitary metastasis of transitional cell carcinoma as a curative treatment option.     

Ring-enhanced malignant meningioma mimicking a brain metastasis from a renal cell carcinoma

We report a case of ring-enhanced malignant meningioma mimicking a solitary brain metastasis in a patient with renal cell carcinoma. This misleading situation is rarely encountered and has not been documented previously. Considering the low incidence of brain metastases from a renal cell carcinoma staged T1-2 without systemic metastases, a clinical diagnosis requires circumspection, and both primary and metastatic tumors should be considered when a solitary brain lesion is encountered.     

Solitary brain metastasis from pT1, G3 bladder cancer

Abstract:   Brain metastasis from bladder cancer occurs rarely. Particularly, solitary brain metastasis is very rare in patients who have never received systemic chemotherapy. We encountered a patient who underwent transurethral resection of bladder tumor and bacillus Calmette-Guérin bladder instillation for pT1, G3 bladder cancer accompanied by carcinoma in situ , and subsequently revealed solitary brain metastasis after 34 months while neither cystoscopy nor urine cytology revealed abnormalities during this period. To our knowledge, our experience of solitary brain metastasis from pT1 bladder cancer is the second case in the world.     

Long-term results following thoracotomy for metastatic bladder cancer

Six patients, who had been treated for transitional cell carcinoma of the bladder and had no residual disease in the bladder or other evidence of malignancy, underwent thoracotomy and wedge resection for a solitary pulmonary metastasis. Five patients remain alive without disease at one, five, five, seven, and sixteen years, respectively. The median length of survival of these patients (five years), when contrasted to the median survival time of all patients with metastasis from bladder cancer (three months), emphasizes the importance of individualizing assessment and treatment.     

Solitary port-site metastasis after laparoscopic bilateral nephroureterctomy for transitional cell carcinoma in a renal transplant recipient

A renal transplant recipient with upper tract transitional cell carcinoma developed a solitary port-tract recurrence 8 months after a hand-assisted laparoscopic bilateral nephroureterectomy and was successfully managed by a local wide excision and adjuvant radiotherapy. Follow-up for 3 years after the salvage therapy showed no evidence of local recurrence or distant metastasis. This patient is the first one in the literature to have a solitary port-site metastasis of transitional cell carcinoma in renal transplant recipients.     

The perineal implantation of a bladder tumor through urethro-vasal reflux]

Perineal implantation of urinary bladder cancer in a 57-year-old male is reported. The patient had been suffering from incomplete paraplegia and neurogenic bladder for these 29 years because of accidental injury of lumbar spinal cord with episodes of bladder stones two times and right epididymitis three times, and presented urinary leakage from a perineal fistula. The fistula orifice was surrounded by a hard mass lesion. Bilateral swelling of inguinal lymph nodes was present. Fistulogram and voiding cysto-urethrography revealed reflux from posterior urethra to the fistula through right vas and epididymis. Histological diagnosis of resected perineal mass and biopsied left inguinal lymph node was transitional cell carcinoma with predominant metaplasia of squamous cell carcinoma. Tissues obtained by TUR-biopsy of a mass lesion at bladder wall was also histologically diagnosed transitional cell carcinoma with metaplasia of squamous cell carcinoma. The present case indicates implantation of a bladder tumor to perineum by urethero-vasal reflux and metastases to inguinal lymphnodes from the perineal lesion.     

Extensive cutaneous metastasis of transitional cell carcinoma of the bladder

Cutaneous metastasis of bladder carcinoma is extremely rare. Iatrogenic implantations have been the main cause in the majority of cases of transitional cell carcinoma with cutaneous metastasis. Otherwise, primary cutaneous metastasis is accepted as the late manifestation of systemic spread. The present paper describes a case of relatively early and extensive skin metastasis of transitional cell carcinoma in a 78-year-old man. The patient had a histopathological diagnosis of poorly differentiated (grade III) muscle invasive transitional cell carcinoma with a staging of T2NOMO 6 months prior to presenting. He presented to our outpatient clinic with a 3-month history of skin lesions as multiple, rubbery subcutaneous nodules. Radiological reinvestigation revealed no other metastatic site (including bone and lung), except for a metastatic nodule in the liver. The present paper reports an interesting and rare case of extensive skin metastasis of transitional cell carcinoma as the primary complaint.     

Cutaneous metastases from transitional cell carcinoma of the bladder

Two cases of transitional cell carcinoma of the bladder with cutaneous metastases are reported. In one patient, multiple nodular metastatic lesions appeared simultaneously with urethral recurrence after total cystectomy. In another patient, diffuse inflammatory metastatic lesion was generated after radiotherapy for pelvic lymph nodes. The pathways of metastatic dissemination from the transitional cell carcinoma of the bladder are discussed.     

Brain metastases from bladder carcinoma: presentation, treatment and survival

PURPOSE: We report the presentation of brain metastases from bladder carcinoma. We investigated the role of whole brain radiation therapy for treating this disease. MATERIALS AND METHODS: Between January 1982 and November 1999, 16 patients with brain metastases from bladder carcinoma were treated at our institution. We reviewed patient and tumor characteristics at the time of the primary diagnosis and the brain metastasis diagnosis. We analyzed treatment results in regard to survival and local metastasis control. RESULTS: Brain metastases from bladder carcinoma were commonly accompanied by uncontrolled systemic metastases. Multiple brain lesions developed in 14 of the 16 patients. Of the 16 patients 14 received radiation therapy with or without surgery, 1 was treated surgically and 1 did not receive any treatment. The 11 patients treated with whole brain radiation therapy had a median survival of only 2 months (range 0.5 to 11). A patient who received stereotactic radiosurgery survived 12 months after the brain metastasis diagnosis and 2 treated with radiation therapy after surgery survived 12.75 and 2.75 months, respectively (median 7.75). The patient treated with surgery alone survived 1.25 months after the brain metastasis diagnosis and 1 who received no treatment survived 1.75 months. Patients with multiple brain metastases had shorter survival than those with a single metastasis. CONCLUSIONS: Overall survival after brain metastasis development in patients with bladder carcinoma was poor. Although the number of patients in this study was small, results indicate that radiation therapy alone is inadequate treatment. Therefore, when possible, we advocate more effective treatment by combining radiation therapy with other treatment modalities, as recommended in ongoing clinical trials.     

Studies of biological malignancy in bladder cancer using two parameter DNA-RNA cytofluorometric analysis

An acridine orange cytofluorometric analysis was used to study the DNA-RNA contents of bladder washing exfoliated cells from 109 patients with transitional cell carcinoma of the urinary bladder. DNA and RNA measurements were performed in each of 200-300 cells/sample, and DNA index (DI) and RNA index (RI) were calculated from the distributions of these values. Presence of aneuploid stem cell line and/or increased mean DNA contents were observed in 83 (76.1%) of the 109 patients. Elevated RNA content in a diploid cell population, was of no additional diagnostic significance. Histologically diagnosed high grade and high stage bladder carcinoma apparently showed an aneuploid stem cell line with high DI and high RI. Thirty patients with superficial bladder cancer (Ta and Tl) who had tumor recurrence within 2 years after surgical interventions showed a significantly increased RI in contrast to 10 patients who had no recurrence for more than 2 years. RNA content measurement was thought to be useful for prediction of tumor recurrence after surgical interventions. Six patients who had a progression from superficial to invasive carcinoma were with high histological malignancy, lamina propria invasion, high DI and high RI. However, there was no significant difference in RI between the 6 patients and the other patients with superficial bladder cancer. Eight patients who had distant metastasis within one year after radical cystectomy also showed a significant increase in RI in contrast to 8 patients who had no metastasis for more than 1 year. Increased RI may be said to be an important risk factor in predicting the development of distant metastasis and recurrent tumor after surgical interventions.     

Metastasising carcinoma of the urinary bladder presenting as a retro-orbital mass. Case report

A 61-year-old man presented with macroscopic haematuria. Infiltrating transitional cell carcinoma of the urinary bladder was diagnosed after transurethral resection, and he was treated first with three doses of cisplatinum (100 mg/m2 at three week intervals) and then by radical cystectomy. Eleven months later he complained of progressive diplopia, which was found on computed tomography to be caused by a retro-orbital metastatic mass. There was no evidence of a space occupying lesion in the brain or of other metastases. The patient died four weeks later and permission for necropsy was refused. Despite the fact that carcinoma of the urinary bladder rarely metastasis in this way, urologists should be aware that it can happen.     

Renal cell carcinoma with solitary metachronous contralateral adrenal metastasis. Experience with 2 cases and review of the literature.

We report on 2 cases of renal cell carcinoma with solitary metachronous contralateral adrenal metastasis occurring up to four years after radical nephrectomy. Both patients were treated with adrenalectomy and steroid replacement. One patient died with distant metastases twenty-eight months after adrenalectomy and the other is alive with no evidence of disease four years postoperatively. Such a presentation of hypernephroma is rare, with only 1 such case having been found in the literature.