Non-muscle invasive transitional cell carcinoma of the distal ureter and bladder with lung metastasis, "Beyond the Abstract," by Nkwam Nkwam, BSc (Hons), MBBS, MRCS (Eng)

BERKELEY, CA (UroToday.com) - The occurrence a lung metastasis in the case of non-muscle invasive transitional cell carcinoma (TCC) of the distal ureter and bladder is as exceedingly rare as it is interesting. This case report highlighted this finding in a 78-year old male diagnosed with Duke’s B, T4, N0, M0 adenocarcinoma of the caecum at emergency right hemicolectomy for bowel perforation. Staging CT scans in the immediate post-op period revealed left hydronephro-ureter with a filling defect in the left distal ureter. This was biopsied and the histology reported G2, pTa TCC. Following adjuvant chemotherapy he underwent left laparoscopic nephro-ureterectomy at 12 weeks post-op which confirmed the same histology.

As part of his dual cancer surveillance, he had 3-monthly check flexible cystoscopies and repeat staging CT scans. The former identifying 2 superficial bladder recurrences within 14 months, which were resected and treated with a course of intravesical mitomycin C, and the latter the emergence of a 8.5mm pulmonary nodule 3 years post-op which was not present on the first staging CT. This increased in size to 10.5mm 4 months later, so metastasectomy was performed.

Some may argue why defining the primary of the lung metastasis in this case was necessary as probability would dictate that since the primary TCC was non-muscle invasive and the adenocarcinoma was stage T4, the most likely histology would be an adenocarcinoma from the bowel primary. However, pulmonary metastasectomy in colorectal cancer is well documented and used in the management of stage IV and recurrent disease.[1, 2] Its purpose was as a therapeutic tool which inadvertently turned out to be a diagnostic one. Secondly, the chemotherapeutic pathways for the management of advanced or metastatic colon cancer and metastatic bladder cancer are slightly different and this unexpected histological finding changed his subsequent management. In the UK, the following drugs and drug combinations are used,[3, 4] and cisplatin-containing combination chemotherapy is first-line for bladder cancer in patients who are fit enough.[5]

 

 

COLON CANCER

 

 

BLADDER CANCER

 

Folinic acid, Fluorouracil, Oxaliplatin (FOLFOX)

Methotrexate, Vincristine, Doxorubicin, Cisplatin (MVAC)

Folinic acid, 5FU, Irinotecan (FOLFIRI)

Gemcitabine & Cisplatin
(GemCis)

Irinotecan

Gemcitabine & Carboplatin (Gemcarb)

Oxaliplatin & Capecitabine (XELOX)

Cisplatin, Methotrexate, Vinblastine (CMV)

Capecitabine

 

Fluorouracil (5FU)

 

Tegafur & Uracil

 

 

Lastly came the challenging issue of educating the patient with regards to the disease upstaging from a bladder cancer point-of-view and, hence, prognosis. We are used to dealing with metastatic bladder cancer in the presence of quite obvious muscle-invasive disease, and it is well known that it carries a poor prognosis. However, this situation is slightly different and evidence for how these patients fare is anecdotal at best. We will keep this patient under close review to find out.

References:

  1. Olmez OF, Cubukcu E, Bayram AS, Akcali U, Evrensel T, Gebitekin C. Clinical outcomes of lung metastasectomy in patients with colorectal cancer. World J Gastroenterol. 2012 February 21; 18(7): 662–665. Published online 2012 February 21. doi: 10.3748/wjg.v18.i7.662
  2. National Cancer Institute at the National Institutes of Health – Colon Cancer Treatment. Modified 2 Aug 2012. Cited 22 May 2013. Available from URL: http://www.cancer.gov/cancertopics/pdq/treatment/colon/HealthProfessional/page9
  3. Cancer Research UK – Chemotherapy after surgery for bowel cancer. Modified 9 Dec 2011. Cited 22 May 2013. Available from URL: www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/chemotherapy/chemotherapy-after-surgery-for-bowel-cancer
  4. Cancer Research UK – About chemotherapy for invasive bladder cancer. Modified 26 Apr 2012. Cited 22 May 2013. Available from URL: http://www.cancerresearchuk.org/cancer-help/type/bladder-cancer/treatment/invasive/chemotherapy/about-chemotherapy-for-invasive-bladder-cancer
  5. Dreicer R, Manola J, Roth BJ, et al. Phase III trial of methotrexate, vinblastine, doxorubicin, and cisplatin versus carboplatin and paclitaxel in patients with advanced carcinoma of the urothelium. Cancer 2004 Apr;100(8):1639-45.

 

Written by:
Nkwam Nkwam, BSc (Hons), MBBS, MRCS (Eng) as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.

Department of Urology, Worcestershire Acute Hospitals NHS Trust, West Midlands, United Kingdom

Non-muscle invasive transitional cell carcinoma of the distal ureter and bladder with lung metastasis: A case report & literature review - Abstract

More Information about Beyond the Abstract

 

 

 

email news signup