Multiple metachronous brain metastases from primary ureteral carcinoma

Transitional cell carcinoma (TCC) of the ureter is an uncommon urologic malignancy, with approximately 150 cases diagnosed annually. Metastatic brain disease from ureteral TCC is exceedingly rare. To our knowledge, our case report represents only the second report of brain metastasis from ureteral TCC and the only reported patient to undergo resection of their TCC brain metastasis.

[Bladder cancer with skin metastasis: a case report]

Bladder carcinoma with skin metastasis is extremely rare. We herein report a case of a bladder tumor with skin metastasis. A 68-year-old man was referred to our hospital with macroscopic hematuria. Cystoscopy revealed a trigone papillary tumor. Transurethral resection of bladder tumor (TURBT) was performed and the pathological diagnosis was transitional cell carcinoma (TCC), pT1, G3. Thereafter, he received several courses of TURBT, intravesical chemotherapy (pirarubicin, bacillus Calmette-Guerin and mitomycin C) and intra-arterial chemotherapy because of recurrence. Thirteen years later, he underwent total cystoprostatectomy with neobladder formation. Histological examination revealed muscle-invasive bladder cancer with a staging of T3bNOM0. Two years and three months later, multiple firm nodules with eruptions appeared on the skin in several regions; they were resected and the histological findings revealed TCC. This indicated metastatic spread from the primary bladder TCC. He received only supportive treatment during this period due to renal dysfunction. He died four months after the manifestation of the skin metastasis due to multiple metastases.

Significance of muscularis mucosae in metastasis involvement of urinary bladder transitional cell carcinoma

OBJECTIVE

To assess the significance of muscularis mucosae involvement in metastasis of urinary bladder transitional cell carcinoma.

MATERIAL AND METHOD

This was a retrospective cohort study of superficial urothelial carcinoma (transitional cell carcinoma). Histopathology and patient records of 192 patients were collected from 1990 to 2004. There were 115 males and 77 females, their age ranged from 43 to 83 years old with an average of 60 +/- 5 years. One hundred cases did not invade muscularis mucosae layer (group A) and 92 cases invaded the muscularis mucosae layer (group B). The histopathology of biopsy or cystectomy specimens for recurrence, progression of the disease and the number of vessels above and below the muscularis mucosae layer of bladder cancer specimens were compared by light microscopic examination with Hematoxylin and Eosin (H&E) and followed by immunoperoxidase desmin stain.

RESULTS

The amount per high power field of the blood and lymphatic vessels below muscularis mucosae layer, 9 (6-12), was significantly higher than that above muscularis mucosae layer, 7 (5-10) (p < 0.05). The cancer high grade (grade 3) in group B had also significantly higher percentage than that in group A, 30.4:5.0 (p < 0.05). Moreover, the recurrent rate (recurrent > 2) in group B had also a significantly higher percentage than that in group A, 21.4:4.0 (p < 0.05).

CONCLUSION

The present study has confirmed previous findings that not all muscularis mucosae layers (about 50%) were found in the biopsy specimens. The findings of superficial urothelial cancer (no invasion to muscularis propria) invading the muscularis mucosae are a warning sign for invasive tumor that needs more aggressive treatment.

Isolated cerebellar metastasis in a patient with organ-confined, lymph node negative bladder cancer

The majority of bladder cancer patients who develop brain metastasis have widely disseminated disease. Isolated cerebellar metastasis in patients with transional cell carcinoma (TCC) of the bladder is a rare event. We present the case of a patient with organ-confined bladder cancer who developed isolated cerebellar metastasis.

Metastasis to the Orbit from Transitional Cell Carcinoma of the Bladder

PURPOSE

To demonstrate the pathological features of the extremely rare metastatic transitional cell carcinoma (TCC) from the bladder to the orbit, and to review the literature on metastatic TCC to the orbit.

METHODS

A 74-year-old man experienced 2 weeks of red eye, proptosis, diplopia, pain, and visual loss in the right eye. Three years previous to the current presentation, the patient had undergone a transurethral resection for superficial and moderately differentiated TCC of the bladder. A transseptal anterior orbitotomy was performed.

RESULTS

Histopathological examination of the orbital lesion revealed nests of carcinomatous cells. Atypical pleomorphic cells with vacuolated cytoplasm were evident. The cellular morphology of the orbital lesion was identical to that of the primary TCC. There have been 12 previously reported cases of metastases to the orbit from TCC of the bladder, with the time from onset of primary TCC to observation of ocular symptoms ranging from 3 weeks to 11 years. Mean survival after orbital metastasis developed from TCC was 3.0 months.

CONCLUSION

This study presents a detailed description of the pathological features of metastatic TCC in the orbit. In cases of orbital metastasis from TCC, patient prognosis is very poor.

A novel method for gene expression mapping of metastatic competence in human bladder cancer

Expression profiling by DNA microarray analysis has provided insights into molecular alterations that underpin cancer progression and metastasis. Although differential expression of microarray-defined probes can be related to numerical or structural chromosomal alterations, it is unclear if such changes are also clustered in distinct chromosomes or genomic regions and whether chromosomal alterations always reflect changes in gene expression. Here we apply the dChip algorithm and a novel technique to test the hypothesis that expression changes occurring as a function of tumor progression and metastasis are nonrandomly distributed. Expression profiling of a human xenograft model of lung metastasis phenotype indicates that chromosomes 2, 11, and 20 contain higher percentages of differentially expressed genes (P < .05). Furthermore, we show that a number of differentially expressed probes mapped to chromosome 17q, defining the existence of an expression "hot spot" corresponding to an area of gain determined by comparative genomic hybridization (CGH). Interestingly, other areas of gains detected by CGH were not associated with expression hot spots. In summary, we show that gene expression changes during bladder cancer lung metastasis occur nonrandomly in specific chromosomes and intrachromosomal locations.

Postoperative Nomogram Predicting Risk of Recurrence After Radical Cystectomy for Bladder Cancer

Purpose

Radical cystectomy and pelvic lymphadenectomy (PLND) remains the standard treatment for localized and regionally advanced invasive bladder cancers. We have constructed an international bladder cancer database from centers of excellence in the management of bladder cancer consisting of patients treated with radical cystectomy and PLND. The goal of this study was the development of a prognostic outcomes nomogram to predict the 5-year disease recurrence risk after radical cystectomy.

Patients and Methods

Institutional radical cystectomy databases containing detailed information on bladder cancer patients were obtained from 12 centers of excellence worldwide. Data were collected on more than 9,000 postoperative patients and combined into a relational database formatted with patient characteristics, pathologic details of the pre- and postcystectomy specimens, and recurrence and survival status. Patients with available information for all selected study criteria were included in the formation of the final prognostic nomogram designed to predict 5-year progression-free probability.

Results

The final nomogram included information on patient age, sex, time from diagnosis to surgery, pathologic tumor stage and grade, tumor histologic subtype, and regional lymph node status. The predictive accuracy of the constructed international nomogram (concordance index, 0.75) was significantly better than standard American Joint Committee on Cancer TNM (concordance index, 0.68; P < .001) or standard pathologic subgroupings (concordance index, 0.62; P < .001).

Conclusion

We have developed an international bladder cancer nomogram predicting recurrence risk after radical cystectomy for bladder cancer. The nomogram outperformed prognostic models that use standard pathologic subgroupings and should improve our ability to provide accurate risk assessments to patients after the surgical management of bladder cancer.

Possibility of spontaneous seeding of transitional cell carcinoma of the ureter in renal tubules: another mechanism of transitional cell carcinoma dissemination

Cancer cell seeding inside the urinary tract always has been considered one possible mechanism of the multicentric origin of transitional cell carcinoma (TCC). However, there is still no direct clinical evidence to prove that the natural seeding of TCC is a real event. To our knowledge, we report the first case of spontaneous seeding of TCC of the ureter in the renal tubules of a hydronephrotic kidney. The TCC nature of the intratubular tumor cells has been confirmed by the morphological appearance of them after hematoxylin and eosin staining and positive p53 immunohistochemical staining.

[Abscopal effect on metastatic tumor induced by oncolytic virus of H101 combining with local heating]

BACKGROUND & OBJECTIVE

The abscopal effect on the tumors is a distant antitumor activity induced by local treatments. The study was to observe the induction of abscopal effect by the combination of H101 oncolytic virotherapy with local heating.

METHODS

Five patients with histologically confirmed, surgically unresectable metastatic malignant tumors (2 nasopharyngeal carcinomas, 1 pulmonary carcinoma, 1 parosteal sarcoma and 1 bladder carcinoma) that had definitely failed to the conventional chemotherapy and radiotherapy or refused these therapies were enrolled in this experimental therapy. All patients were treated with local intra tumor injection of H101 (5x10(11) - 15x10(11) VP) combined with 60-min heating at 42 degrees C.

RESULTS

Two patients were cured with complete regressions of both injected and non-injected tumors and have survived for a long period up to date. Three patients responded to the novel therapy variously and eventually died from the disease, who survived 29, 15 and 13 months, respectively.

CONCLUSION

The abscopal antitumor effect could be induced by the combination of H101 local intratumoral injection with heating.

Testicular metastasis of transitional cell carcinoma of the urinary bladder: An unusual site

We present a 74-year-old man with a testicular metastasis originating from a transitional cell carcinoma of the urinary bladder. Initially, radical cystectomy and ileal-conduit urinary diversion were performed. Three years later, he presented with a tumor in the left testicle, proved to harbor transitional cell carcinoma.

Long-term survival under maintenance gemcitabine chemotherapy for metastatic transitional cell carcinoma

We report a case of a 74-year-old patient who received 41 courses of maintenance therapy with gemcitabine over a length of 28 months for metastatic transitional cell carcinoma. One year earlier the patient had received three cycles of adjuvant cisplatin-based combination chemotherapy after nephro-ureterectomy for a locally advanced urothelial cancer of the right renal pelvis. This case demonstrates a paradigm shift in the palliative treatment of advanced urothelial cancer, with the implementation of more tolerable agents such as gemcitabine. Even elderly patients with impaired renal function may benefit in terms of tumor reduction and survival from systemic chemotherapy, which may be applied over a prolonged period of time.

[A case of pulmonary tumor embolism presenting with an initial manifestation of urothelial carcinoma]

A 64-year-old man presented with fever, chest pain, and bloody sputum. Chest computed tomography showed multiple, irregularly shaped infiltrative shadows in the subpleural regions of both lung fields. Out of the 6 sputum cytology specimens, only one specimen suggested malignancy. Furthermore, no malignant cells were detected in the bronchoalveolar lavage fluid. A video-assisted lung biopsy yielded a diagnosis of pulmonary tumor embolism was made. The primary lesion of this pulmonary metastatic cancer was urothelial carcinoma, which was not detected by contrast-enhanced computed tomography of the abdomen. This case is particularly unusual because it is difficult to establish an ante-mortem diagnosis of pulmonary tumor embolism, and there have been only a few previous reports regarding pulmonary tumor embolism from a urothelial tumor.

Adjuvant systemic chemotherapy in the treatment of patients with invasive transitional cell carcinoma of the upper urinary tract

OBJECTIVES

To evaluate the efficacy of adjuvant systemic chemotherapy in conjunction with surgery in patients with invasive transitional cell carcinoma of the upper urinary tract.

METHODS

From January 1991 to May 2001, 36 men and 7 women had invasive (Stage pT2 or worse), but not metastatic, disease and were the subjects of this study. Their median age was 59 years (range 36 to 72). Of these 43 patients, 32 were scheduled to receive more than four courses of cisplatin-based chemotherapy. The median follow-up period of all the evaluated patients was 30.7 months (range 4.7 to 98.8).

RESULTS

Recurrence was observed in 12 patients (37.5%) who underwent chemotherapy and 7 (63.6%) who did not (P = 0.170). The disease-free survival was lower in the nonchemotherapy group than in the chemotherapy group (P = 0.0439). During the follow-up period, 9 patients (28.1%) in the chemotherapy group died and 9 patients (81.8%) in the nonchemotherapy group died (P = 0.004). Multivariate Cox proportional hazard model analysis revealed that the use of adjuvant chemotherapy (P = 0.006, relative risk = 9.19) and node-positive status (P = 0.008, relative risk = 8.28) were strongly associated with overall survival. In the chemotherapy group, 24 (75%) had side effects due to the treatment; however, fever and gastrointestinal symptoms were the chief adverse effects and were well tolerated.

CONCLUSIONS

Our results have indicated that adjuvant systemic chemotherapy may provide therapeutic benefit in patients with invasive transitional cell carcinoma of the upper urinary tract.

Durable and complete remission of a metastatic bladder sarcomatoid carcinoma with chemotherapic and surgical treatments

The sarcomatoid carcinoma of the urinary bladder is a rare variant of transitional carcinomas with an extremely aggressive clinical course and dismal prognosis regardless therapies. The diagnosis of a bladder sarcomatoid carcinoma involving perivesical tissues with limphnodal, hepatic and lung metastasis was done in a 34-years old male. The disease underwent complete remission after neoadjuvant chemotherapy with adriblastine and ifosfamide, radical surgery and adjuvant chemotherapy with the same drugs, as confirmed by CT, vesical biopsies during chemotherapy and by the findings detected on the surgical specimen. Follow-up is negative for relapses at 72 months. The sarcomatoid bladder carcinoma is a rare variant of transitional carcinoma (0.31%), usually diagnosed in the late decades of life, with a survival time of a few months for metastatic patients regardless of any adopted therapies. The case presented is remarkable due to the young age of the patient but, overall, for the complete and durable regression of the disease achieved applying a chemotherapic scheme commonly adopted to treat pure sarcomatous mesenchimal neoplasms. Due to the rarity of the disease and the consequent unfeasibility of randomized studies, in our opinion these results, even if obtained in a single case, suggest a viable therapeutic option.

Intraperitoneal Chemotherapy for the Prevention of Transitional Cell Carcinoma Implantation

PURPOSE

Tumor spillage from bladder perforation during transurethral resection of a bladder tumor or during cystectomy risks seeding the peritoneum with TCC. Current therapy is irrigation with sterile water with an unknown extent of clinical benefit. Intraperitoneal chemotherapy for other human cancers has demonstrable benefit but to our knowledge it has never been investigated for TCC. We investigated whether intraperitoneal chemotherapy can prevent TCC implantation in a murine model of tumor spillage and whether water irrigation is beneficial.

MATERIALS AND METHODS

Laparotomy was performed in 28 Fischer 344 rats (National Cancer Institute, Frederick, Maryland) to instill 1 x 10 AY-27 TCC cells. Mitomycin (10 mg/m) was instilled in 9 rats and saline was used in the control group. A third group underwent lavage with sterile water. At sacrifice after 2 weeks tumors were measured in mm and weighed. A followup experiment of 4-week survival used 5 mg/m mitomycin and added a fourth group treated with water lavage plus mitomycin.

RESULTS

All 9 rats in the saline control group had gross tumors at the laparotomy site as well as gross carcinomatosis. The 10 water lavage rats also demonstrated gross tumors but of smaller size (p = 0.02). All rats treated with mitomycin had no gross or microscopic evidence of tumor growth anywhere in the peritoneum. In experiment 2 none of the rats treated with lower dose mitomycin had gross or microscopic tumors regardless of water lavage.

CONCLUSIONS

Intraperitoneal chemotherapy prevents TCC implantation in a murine model of tumor spillage. Water lavage decreases the tumor burden but it cannot effectively sterilize the peritoneum of tumor.

Cardiac metastasis from a transitional cell carcinoma diagnosed by two-dimensional echocardiography

We report a rare case of symptomatic cardiac metastasis from a transitional cell carcinoma of the renal pelvis. A 57-year-old man presented with severe anemia, inflammation, hypoxemia and disseminated intravascular coagulation. Computed tomography revealed a large tumor in the left renal pelvis with multiple lymph node metastases. Two-dimensional echocardiography revealed large tumors in the right ventricle. The patient suddenly died because of the obstructive mass of the right ventricular outflow tract. Histopathological examination showed high-grade transitional cell carcinoma in the left renal pelvis and the right ventricle. There are only three cases of cardiac metastases from a transitional cell carcinoma reported in the literature.

A phase II study of vinflunine in bladder cancer patients progressing after first-line platinum-containing regimen

A multicentre phase II trial to determine the efficacy of vinflunine as second-line therapy in patients with advanced transitional cell carcinoma (TCC) of the bladder; secondary objectives were to assess duration of response, progression-free survival (PFS) and overall survival (OS), and to evaluate the toxicity associated with this treatment. Patients had tumours that failed or progressed after first-line platinum-containing regimens for advanced or metastatic disease, or had progressive disease after platinum-containing chemotherapy given with adjuvant or neoadjuvant intent. Response and adverse events were assessed according to WHO criteria and NCI-CTC (version 2), respectively. Out of 51 patients treated with 320 mg m(-2) of vinflunine, nine patients responded to the therapy yielding an overall response rate of 18% (95% CI: 8.4-30.9%), and 67% (95%CI: 52.1-79.3%) achieved disease control (PR+SD). Of note, responses were seen in patients with relatively poor prognostic factors such as a short (<12 months) interval from prior platinum therapy (19%, including an 11% response rate in those progressing <3 months after platinum treatment), prior treatment for metastatic disease (24%), prior treatment with vinca alkaloids (14%) and visceral involvement (20%). The median duration of response was 9.1 months (95% CI: 4.2-15.0) and the median PFS was 3.0 months (95% CI: 2.4-3.8). The median OS was 6.6 months (95% CI: 4.8-7.6). The main haematological toxicity was grade 3-4 neutropenia, observed in 67% of patients (42% of cycles). Febrile neutropenia was observed in five patients (10%) and among them two were fatal. Constipation was frequently observed (but was manageable and noncumulative) and was grade 3-4 in only 8% of patients. The incidence of grade 3 nausea and vomiting was very low (4 and 6% of patients, respectively). Neither grade 3-4 sensory neuropathy nor severe venous irritation was observed. Moreover, and of importance in this particular study population, no grade 3-4 renal function impairment was observed. Vinflunine is an active agent for the treatment of platinum-pretreated bladder cancer, and these results warrant further investigation in phase III trials, either as monotherapy or in combination with other agents as treatment of advanced/metastatic TCC of the bladder.

Phase II study of MTX-HSA in combination with Cisplatin as first line treatment in patients with advanced or metastatic transitional cell carcinoma

PURPOSE

To assess the efficacy, tolerability and safety of MTX-HSA (methotrexate (MTX) covalently linked to human serum albumin (HSA)) combined with cisplatin as first line therapy for advanced bladder cancer.

METHODS

Patients (pat) were treated with a loading dose of 110 mg/m(2) of MTX-HSA followed by a weekly dose of 40 mg/m(2) starting on day 8. Cisplatin was given on day 2 of each 28 day cycle at a dose of 75 mg/m(2).

RESULTS

Tumor response evaluation was possible in 7 patients. Complete response (CR) and partial response (PR) was observed in 1 patient each (overall response rate: 29%). Key toxicities included CTC Grade (G) 3/4 stomatitis in 6 patients, vomiting G3 in 1 patient, fatigue G3 in 1 patient and thrombocytopenia G3 in 3 patients.

CONCLUSION

The combination of MTX-HSA with cisplatin is feasible and shows antitumor activity against urothelial carcinomas combined with an acceptable toxicity profile.

Phase I/II study of a combined gemcitabine, etoposide, and cisplatin chemotherapy regimen for metastatic urothelial carcinoma

BACKGROUND

The authors attempted to determine the maximum tolerated dose (MTD) of gemcitabine in combination with etoposide and cisplatin as a chemotherapy regimen and investigated the safety and antitumor activity with the recommended doses of gemcitabine with etoposide and cisplatin for patients with metastatic urothelial carcinoma.

METHODS

Patients age 75 years or younger with measurable lesions, creatinine clearance>or=50 mL per minute, and adequate bone marrow and hepatic function were studied. Etoposide and cisplatin were given on Days 1 through 3 at fixed doses of 75 mg/m2 and 25 mg/m2, respectively, and gemcitabine was given on Days 1, 8, and 15. In the Phase I component, gemcitabine was administered at increasing doses from 600 mg/m2. Cycles were repeated every 28 days unless progressive disease was encountered.

RESULTS

In Phase I, with the initially fixed doses of etoposide and cisplatin, the MTD of gemcitabine could not be determined because of the occurrence of dose-limiting toxicity at Level 1 in all 3 patients. When the doses of etoposide and cisplatin were modified to 60 mg/m2 and 20 mg/m2, respectively, the MTD of gemcitabine was 1000 mg/m2. Next, 19 additional patients were entered into Phase II with the recommended gemcitabine dose of 800 mg/m2, and 20 patients in all were treated at this dose level. The main toxicity was bone marrow suppression, with Grade 3 or 4 neutropenia and thrombocytopenia recognized in 20 patients (100%) and 14 patients (70%), respectively, although no toxic deaths occurred. In total, all 31 patients at all dose levels had an assessable response, with 6 complete responses and 15 partial responses observed, for an overall response rate of 67.7%. Patients who had visceral metastasis had a significantly worse response rate than patients who had lymph node metastasis alone (50.0% vs. 78.9%; P=.042). The response rate (66.7%) for 21 patients who received prior chemotherapy was not different from that for 10 chemotherapy-naive patients. The median survival for all patients was 13.1 months, and 4 patients survived for >2 years with no evidence of disease. Patients younger than age 65 years had significantly better survival than patients age 65 years or older (P=.026).

CONCLUSIONS

Although bone marrow toxicity was considerable, combination chemotherapy with gemcitabine, etoposide, and cisplatin appeared to be very active in patients with urothelial carcinoma and may be especially promising for younger patients, although further study is warranted.

[Tansitional vesical cell carcinoma metastatizing to the sphenoid sinus]

Secundary tumors of the paranasal sinus are very uncommon with only one hundred cases reported in the literature up to 2001. The commonest site of the primary tumor is the kidney. The maxillary sinus is most often involved. The Sphenoid sinus is the rarest site. We report a rare case of metastasis to the sphenoid sinces from a transitional cell bladder tumor in a 69-year-old man who died after treatment with chemotherapy and we also review the liteature.

Cutaneous metastases from transitional cell carcinoma of the bladder

Cutaneous metastases from primary genitourinary malignancies are rare and usually represent a poor prognostic sign. Very few cases of skin metastases from urothelial carcinoma have been reported in the past, and most of them were treated with chemotherapy. We report a patient with transitional cell carcinoma of the bladder who developed skin metastases after cystectomy. The lesions did not respond to systemic chemotherapy but resolved with local radiation therapy. We discuss the need to have a high index of suspicion to identify these lesions and the treatment approaches.

Nested variant of urothelial carcinoma: A rare presentation

We report a rare presentation of a nested variant of urothelial carcinoma with liver and bone metastases in a 74-year-old man admitted to the hospital with bilateral hydronephrosis and acute renal failure. At cystoscopy, both ureters were obstructed, with the right ureter narrowed along its entire length. Subsequent histopathologic examination from the ureteral resection revealed nested variant of urothelial carcinoma. Bilateral stents were placed, and the patient survived 12 months with a good partial response to chemotherapy. A total of 76 cases of nested variant of urothelial carcinoma have been reported worldwide. Our patient was the first, to our knowledge, to present with bilateral hydronephrosis and tumor extension along one ureter.

Krukenberg Tumor of Renal Pelvic Origin: Report of a Case With Selected Comments on Ovarian Tumors Metastatic From the Urinary Tract

Metastatic tumors to the ovary are infrequently of urinary tract origin. In approximate descending order of frequency, this subset of secondary ovarian neoplasms includes renal cell carcinoma, transitional cell carcinoma of the urinary bladder, and urachal adenocarcinomas. These tumors usually raise a differential in turn of primary ovarian clear cell, transitional cell, or mucinous carcinomas. Only rare metastatic signet-ring adenocarcinomas of the bladder have shown the features of a Krukenberg tumor. We report the case of a 74-year old woman with bilateral Krukenberg tumors metastatic from a primary renal pelvic transitional cell carcinoma with glandular and signet-ring cell differentiation. This unique case reinforces that tumors with signet-ring cell morphology have a propensity to metastasize to the ovary, and indicates that renal pelvic carcinoma rarely may be the source of Krukenberg tumors.

Implants of noninvasive papillary urothelial carcinoma in peritoneum and ileocolonic neobladder: Support for “seed and soil” hypothesis of bladder recurrence

OBJECTIVES

To explore the underlying mechanism of tumor regrowth in cases of noninvasive urothelial carcinoma that recur in unusual anatomic locations.

METHODS

The pathology files of our institution and the consult service of one of us were searched for cases of noninvasive nonmetastatic urothelial carcinoma with involvement of unusual anatomic sites. Cases in which the mode of spread included direct spread to the adjacent tissue and lymphovascular metastases were excluded. Medical history, including presenting symptoms, and follow-up data were obtained.

RESULTS

Two cases of noninvasive urothelial carcinoma were identified. One had presented as an implant in the peritoneal investment of the bladder dome and the other as multiple implants growing on the benign surface of the colonic mucosa of an orthotopic neobladder distant from the anastomosis site. Both cases had initially presented as noninvasive papillary urothelial carcinoma of the renal pelvis. Although the urinary bladder was free of neoplastic changes at nephroureterectomy, both patients also developed several papillary tumors within the bladder shortly after the removal of the kidney.

CONCLUSIONS

After clinicopathologic correlation, the mode of tumor spread in these cases was best explained by the "seeding/implantation" theory. The urothelial tumor cells in each of these cases demonstrated the ability to implant themselves not only in the urothelium of the bladder but also in the colonic mucosa of a constructed neobladder and on the peritoneal surface.

Inguinal metastasis of a bladder mixed carcinoma with predominant adenocarcinoma component

We report a case of urinary bladder mixed carcinoma with inguinal metastasis. Histological examination of the transurethral resection specimens revealed adenocarcinoma with small foci of squamous and transitional cell carcinomas. A right inguinal metastasis occurred 1 year after radical cystourethrectomy. Chemotherapy and radiotherapy were performed but the metastatic tumor remained unchanged.

Port site metastases after robot-assisted laparoscopic radical cystectomy

Laparoscopy has become a well-established alternative to open surgery for the management of many urologic tumors. Metastases at one of the port sites is not a common complication, though there are some reports of port site metastases after laparoscopic management for renal tumors and pelvicaliceal tumors, as well as after laparoscopic lymphadenectomy. Herein, we report a case of port site metastases after robot-assisted laparoscopic radical cystectomy for muscle-invasive bladder cancer. To the best of our knowledge this is the first case of such pathology to be reported. Although rare, the laparoscopic surgeon should be aware of such complications when dealing with malignant masses.

[Inguinal lymph node metastasis of bladder carcinoma ten years after cystourethrectomy: a case report]

A 79-year-old man had undergone radical cystourethrectomy for bladder carcinoma in January, 1989. Pathological report was Small cell carcinoma (SCC) >> transitional cell carcinoma (TCC), G2 > G3, pT4 (prostate), ew (-). Ten years later, follow-up computed tomography (CT) revealed swollen left inguinal lymph node in October 1998 and lymph node dissection was performed in January, 2000. The pathological report showed TCC, G2. Left inguinal lymph node metastases appeared again in January, 2001. Chest X-ray films showed multiple lung metastases in March, 2001. Three couses of MVAC (methotrexate, vinblastine, doxorubicin cisplatinum) chemotherapy had been performed since September, 2001 but were in effective. Papillary tumor was observed at external urethral meatus in September, 2002 and the biopsied specimens showed TCC, G1 > G2, pathologically. Finally he died of respiratory insufficiency in January, 2003. It is suggested that the recurrent TCC tumor in the urethral remnants might metastasize into the inguinal lymph nodes.

Clitoral metastasis from transitional cell carcinoma of the renal pelvis: CT and MRI findings

Metastatic tumors of the clitoris are extremely rare. We report a case of clitoral metastasis in a 75-year-old woman who was treated for transitional cell carcinoma of renal pelvis 2 years ago. The computed tomography and magnetic resonance imaging findings are presented with a short review of the literature. To the best of our knowledge, clitoral metastasis originating from transitional cell carcinoma of the renal pelvis has not been reported in the English language literature.

[Synchronous renal clear-cell carcinoma and ipsilateral transitional-cell carcinoma: case report and bibliographic review]

OBJECTIVES

We report a new case of simultaneous renal cell adenocarcinoma and ipsilateral multifocal transitional cell carcinoma.

METHODS

73-year-old man with initial diagnosis of transitional cell carcinoma of the urinary tract whose pathological report showed a asynchronous renal cell carcinoma.

RESULTS

We present microphotographs of both tumors after radical surgery.

CONCLUSIONS

The presentation of both tumors in the same kidney is unusual, although there are around 47 cases in the bibliography worldwide, 8 of them in Spanish. Presentation of both tumors altogether does not worsen prognosis.

[A case report of sarcomatoid carcinoma of the bladder with metastasis to small intestine]

A 67-year-old male presented to our clinic with gross hematuria. Cystoscopic examination revealed a broad-based tumor of 2.5 cm in diameter on the lateral side of the right ureteral orifice. Under the clinical diagnosis of TCC G2 > G3, T3bNOM0, radical cystectomy with orthotopic bladder substitution was performed. Pathological diagnosis was TCC G3 with sarcomatoid carcinoma, pT2pR0pL1 pVlpN0. Adjuvant chemotherapy was not performed because of his transient poor conditions. Lung metastasis was observed 6 months postoperatively. Despite of M-VAC therapy and radiation therapy, additional metastases to brain and liver were observed. One month later, partial ileectomy specimen for occlusive ileum revealed the same histologic findings, TCC G3 with sarcomatoid carcinoma. He died 9 months postoperatively. To our knowledge, this is the first case of sarcomatoid carcinoma of the bladder with metastasis to small intestine, although 6 cases of transitional cell carcinoma of the bladder with metastasis to small intestine has been reported in Japan.

Transitional Cell Carcinoma With Metastases to Spermatic Vein and Spermatic Cord: PET/CT Imaging

Transitional cell carcinoma of the kidney with venous tumor thrombus is uncommon with only a limited number of cases published in the medical literature. The authors present a case of renal urothelial carcinoma with PET/CT imaging. PET, in addition to the demonstration of tumor thrombus in the left renal vein and inferior vena cava, showed a thrombosed left spermatic vein with metastases to the left spermatic cord and epidydimis.

Metastatic umbilical mass from transitional cell carcinoma of the bladder

We present the case of an 83-year-old female presenting with an umbilical mass measuring 2 cm x 3 cm. This patient had an extensive prior history of transitional cell carcinoma of the bladder. A fine needle aspiration of this umbilical mass confirmed this to be metastatic transitional cell carcinoma and the diagnostic workup demonstrated the presence of invasive bladder cancer with metastatic liver lesions.

Lymphovascular Invasion Is Independently Associated With Overall Survival, Cause-Specific Survival, and Local and Distant Recurrence in Patients With Negative Lymph Nodes at Radical Cystectomy

Purpose

We hypothesized that bladder cancer patients with associated lymphovascular invasion (LVI) are at increased risk of occult metastases.

Methods

A multi-institutional group (University of Texas Southwestern [Dallas, TX], Baylor College of Medicine [Houston, TX], Johns Hopkins University [Baltimore, MD]) carried out a retrospective study of 958 patients who underwent cystectomy for bladder cancer between 1984 and 2003. Of patients with transitional-cell carcinoma (n = 776), LVI status was available for 750. LVI was defined as the presence of tumor cells within an endothelium-lined space.

Results

LVI was present in 36.4% (273 of 750) overall, involving 26% (151 of 581) and 72% (122 of 169) of node-negative and node-positive patients, respectively. Prevalence of LVI increased with higher pathologic stage (9.0%, 23%, 60%, and 78%, for T1, T2, T3, and T4, respectively; P < .001). Using multivariate Cox regression analyses including age, stage, grade, and number of pelvic lymph nodes removed, LVI was an independent predictor of local (HR = 2.03, P = .049), distant (HR = 2.60, P = .0011), and overall (HR = 2.02, P = .0003) recurrence in node-negative patients. LVI was an independent predictor of overall (HR = 1.84, P = .0002) and cause-specific (HR = 2.07, P = .0012) survival in node-negative patients. LVI maintained its independent predictor status in competing risks regression models (P = .013), where other-cause mortality was considered as a competing risk. LVI was not a predictor of recurrence or survival in node-positive patients.

Conclusion

LVI is an independent predictor of recurrence and decreased cause-specific and overall survival in patients who undergo cystectomy for invasive bladder cancer and are node-negative. These patients represent a high risk group that may benefit from integrated therapy with cystectomy and perioperative systemic chemotherapy.

Epithelioid cellular chordoma of the sacrum: a potential diagnostic problem

We describe a sacral chordoma composed of solid nests of epithelioid cells. The tumor originated in the presacral area. Extensive clinical workup did not reveal any other lesion in the patient. In contrast to typical chordomas, this tumor contained only rare physaliferous cells, had no myxoid stroma, and was immunohistochemically unreactive with the antibody to S-100. The diagnosis of chordoma was supported by electron microscopy, which showed that the tumor cells contained numerous mitochondria surrounded by profiles of rough endoplasmic reticulum. The abundance of mitochondria, the narrow intercellular spaces, combined with a lack of glycogen, and a lack of extracellular myxoid material accounted for the epithelioid appearance of the tumor. We report this case to point out that the cellular chordomas can appear epithelioid in the sacrum and they may resemble metastatic squamous or transitional cell carcinomas.

[Ureteral cancer producing granulocyte colony-stimulating factor: a case report]

A 60-year-old man who underwent radical nephroureterectomy due to left ureteral cancer 22 months before (transitional cell carcinoma, pT4pN0Mx, grade 2, INF beta), was admitted to the hospital with the chief compliant of anorexia and body weight loss. The patient had severe leukocytosis and elevation of C-reactive protein, with no obvious focus of infection. Abdominal plain computed tomographic scan revealed left external ileac lymph node swelling. Positron emission tomography demonstrated left external ileac lymph node recurrence. Enzyme immunoassay of the serum demonstrated a markedly high concentration of granulocyte colony-stimulating factor (G-CSF; 790 pg/ml). Immunohistochemical examination of ureteral cancer cells with anti-G-CSF monoclonal antibody demonstrated G-CSF production in cancer cells. After diagnosed as lymph node recurrence of ureteral cancer producing G-CSF, the patient underwent radiotherapy (total 4000 Gy). CT after radiotherapy showed the complete disappearance of the lymph node swelling. To our knowledge, this is the second report of ureteral cancer proven to produce G-CSF in Japan.

[Recurrence of bladder cancer in fossa navicularis 17 months after cystourethrectomy: a case report]

We report a case of bladder cancer recurrence in fossa navicularis of urethra 17 months after cystourethrectomy for bladder cancer. A 75-year-old man had undergone cystourethrectomy preserving between fossa navicularis and external meatus, and ileal conduit urinary diversion for advanced bladder cancer on June 24, 2002. Histopathological findings showed urothelial carcinoma, G2>G3, pT1N0. The patient had been followed regularly for 17 months without evidence of recurrence until he suffered the onset of hemorrhagic urethral discharge. Endoscopic examination of the residual urethra showed multiple, papillary sessile tumors which almost filled the fossa navicularis. He was admitted to our hospital on December 15, 2003. The urethral wash cytology revealed urothelial carcinoma. Since computed tomography, magnetic resonance imaging, and bone scintigraphy showed no evidence of lymph node and distant metastasis, partial penectomy was performed. Histopathological findings showed urothelial carcinoma pTa, G2>G3, which was identical to primary tumor. Tumor had not invaded the corpus cavernosum. Careful follow-up of the patients with preservation of fossa navicularis is important.

[Small cell carcinoma of the bladder: a case report]

A 61-year-old man was referred to our hospital with a complaint of gross hematuria and lower abdominal discomfort. Ultrasonography, magnetic resonance imaging and cystoscopy revealed a nodular invasive tumor in urinary bladder. The histopathological findings of transurethral-biopsy specimen was the small cell carcinoma and transitional cell carcinoma of the bladder infiltrating into smooth muscle layer. Total cystectomy with ileal conduit was performed following 1 course of neoadjuvant chemotherapy (M-VAC). Computed tomography (CT) before adjuvant chemotherapy revealed tiny lung metastasis in left peripheral lung area. As postoperative adjuvant therapy, 4 courses of chemotherapy (etoposide and calboplatin) were performed with 50 Gy of extra beam radiotherapy to the lung metastasis. Follow up CT revealed disapperance of lung metastasis, and the patient has been free from disease for one year after chemotherapy.

Methotrexate-paclitaxel-epirubicin-carboplatin (M-TEC) combination chemotherapy in patients with advanced bladder cancer: an open label phase II study

The present phase II study aimed to define the application of a novel regimen incorporating methotrexate, paclitaxel, epirubicin, and carboplatin (M-TEC) in advanced bladder cancer, essentially as an M-VAC-like regimen, by substitution of cisplatin by carboplatin, doxorubicin by epirubicin and vinblastine by paclitaxel. Forty patients with advanced bladder cancer entered the study; 34 males/6 females, median age: 68 (range, 59-76), median PS (Karnovsky): 80, without receiving prior chemotherapy. Disease extention was as follows; 11/40 had local recurrence, 6/40 liver metastases, 14/40 lung metastases, bone and lymph node 8/40, bones-lymph node-lung metastases 4, lymph node and liver 4/40, lymph node-liver and lung metastases 2/40. Drug schedule and doses were as follows: paclitaxel 180 mg/m2, carboplatin AUC = 5 (according to creatinine clearance, based on Calvert's formula), and epirubicin 40 mg/m2 were administered during day 1, whereas methotrexate 30 mg/m2 and epirubicin 40 mg/m2 were administered on day 14. All patients were evaluable for response with 24/40 responding [response rate (RR) 60%]; 10/40 (25%) CR, 14/40 (35%) PR, 9/40 (22.5%) SD, and 7/40 (17.5%) PD. Symptomatic improvement was observed in 50% of patients. The median duration of response was 22 (14-32) weeks, median time-to-progression (TTP) 33 (12-44) weeks, and median survival was 56 (20-84) weeks. Toxicity was well accepted and was mainly neutropenia > grade 3: 17%, anemia >grade 3: 16%, thrombocytopenia > grade 2: 6%, nausea & vomiting mainly > grade 2: 31%, according to the administered chemotherapy cycles, whereas fatigue grade 2-3: 19%, neurotoxicity grade 1-2 13% of patients, and alopecia grade 2 was observed in all patients. The present pilot study indicates the feasibility of the M-TEC combination for bladder cancer with acceptable toxicity.

Estrogen receptor expression in papillary urothelial carcinoma of the bladder and ovarian transitional cell carcinoma

CONTEXT

Relatively little is known about estrogen receptor (ER) expression in papillary urothelial carcinoma (PUC) of the bladder. Greater understanding of this feature of PUCs could aid with the treatment and identification of the origin of metastases, particularly with relation to the morphologically similar entity of ovarian transitional cell carcinoma (TCC).

OBJECTIVE

To assess the presence of ERs in PUC of the bladder, its metastases, and ovarian TCC.

DESIGN

Formalin-fixed, paraffin-embedded archival tissue from 92 primary bladder PUCs, 11 PUC metastases, and 11 primary or metastatic ovarian TCCs was immunostained with a monoclonal antibody against the human ER beta-molecule. The ER-positive and ER-negative tumors were compared by the patients' sex and age, tumor grade, and the presence or absence of invasion. Statistical analysis was performed on the PUC results, first defining a positive result as staining of at least 10% of nuclei and then repeated using any percentage of staining as a positive result.

RESULTS

By the 10% criterion, 11% of PUCs of the bladder were ER positive. Invasive PUCs were more likely to be ER positive (P = .10). Women with ER-positive PUCs were older than their male counterparts (P = .03). By the second criterion, 22% of all PUCs were ER positive, and both higher grade and the presence of invasion were significantly associated with ER expression (P = .004 and .01, respectively). All 11 PUC metastases were totally ER negative. Ten of the 11 ovarian TCC cases exhibited strong and diffuse ER expression.

CONCLUSION

Depending on the criterion used, up to 22% of bladder PUCs were ER positive. Higher grade and the presence of invasion were significantly associated with ER expression in these bladder carcinomas. In contrast, almost all of the ovarian TCCs marked strongly for ERs, a characteristic that may help differentiate these lesions from PUCs metastatic to the ovary.

[An unusual cause of multiple hepatic cysts]

A metastatic hepatic process, generally arising from a primary tumor of the gastrointestinal tract, is a common cause of multinodular and/or multicystic liver. If the primary tumor remains unknown in spite of complete and exhaustive explorations, it might be useful to re-evaluate the benign nature of previously resected tumors. We report the case of a 37 year-old woman who presented a multicystic metastatic liver related to a nasal cylindrical cell carcinoma resected 4 years earlier and diagnosed initially "inverted papilloma". Cylindrical cell carcinoma also called "transitional carcinoma" or "schneiderian carcinoma" is rare with only a few cases reported in the literature. Metastases occur generally in the lungs and no previous reported cases mention secondary hepatic location.