A 59-year-old male presented with painless hematuria. Cystoscopy revealed a 6 cm solid lesion on the bladder wall. Transurethral resection of the mass showed a pT2 G3 transitional cell carcinoma (TCC). Staging computed tomography demonstrated a solitary left adrenal metastasis that was confirmed on fine-needle aspiration. He then underwent 6 cycles of gemcitabine and cisplatin. Postchemotherapy positron emission tomography demonstrated no glucose-avid areas. Left adrenalectomy and radical cystectomy were performed. There is no evidence of disease recurrence 62 months after the procedure. In metastatic TCC, postchemotherapy surgery is controversial but may provide significant survival benefit to patients with limited systemic disease that responds well to chemotherapy. This report adds to the growing body of evidence that supports a more aggressive multimodal approach to metastatic TCC in select patients. Other patient selection criteria are discussed.
Shuo Liu,1 Vincent Tse,1 Martin Stockler,2 Betty Lin3
1 Department of Urology, Concord Repatriation General Hospital, Sydney, Australia
2 Department of Medical Oncology, Concord Repatriation General Hospital, Sydney, Australia
3 Department of Anatomical Pathology, Concord Repatriation General Hospital, Sydney, Australia
Submitted August 17, 2010 - Accepted for Publication September 10, 2010
KEYWORDS: Adrenal; Bladder cancer; Metastasis; Survival
CORRESPONDENCE: Dr. Shuo Liu, Department of Urology, Concord Repatriation General Hospital, Hospital Road, Concord, Sydney NSW 2139, Australia ().
CITATION: UroToday Int J. 2010 Oct;3(5). doi:10.3834/uij.1944-5784.2010.10.09
ABBREVIATIONS AND ACRONYMS: CT, computed tomography; GC, gemcitabine and cisplatin; PET, positron emission tomography; TCC, transitional cell carcinoma.
The optimal management of invasive transitional cell carcinoma (TCC) of the bladder with solitary distal metastasis has been a subject of intense debate. The general recommendation for metastatic TCC has been medical treatment with systemic chemotherapy; surgery should only be offered in the form of palliation . Long-term survival is extremely rare. We present a case of a patient with synchronous adrenal metastasis secondary to bladder TCC. Five-year disease-free survival was achieved after a combined treatment approach consisting of standard chemotherapy and radical surgery.
In May 2004, a 59-year-old male was referred to our center with a 2-month history of painless hematuria. He was otherwise healthy. He stopped smoking more than 20 years ago and had no other risk factors.
Transurethral resection was performed for a 6 cm solid mass on the left posterolateral wall of the bladder. Pathological findings were consistent with high-grade muscle-invasive TCC (pT2 G3; Figure 1). No other urothelial lesions were identified on cystoscopy.
Subsequent staging computed tomography (CT) revealed a solitary left adrenal lesion that was later confirmed by fine-needle aspiration to be a metastasis (Figure 2). In view of his advanced disease, no further surgery was planned at the time. He received 6 cycles of gemcitabine and cisplatin (GC) over a 4-month period. Upon completion of chemotherapy, shrinkage of his left adrenal metastasis was noted on the progress CT. The maximal transverse diameter of the lesion was reduced from 5.5 cm to 4.5 cm (Figure 3). In addition, positron emission tomography (PET) did not reveal any markedly glucose-avid foci suggestive of residual or recurrent TCC.
After extensive discussion regarding risks and benefits associated with available management options, the patient elected to undergo radical surgery with curative intent. The surgery consisted of left adrenalectomy, radical cystoprostatectomy with ileal conduit formation, and bilateral pelvic lymph node dissection. All surgical specimens were free of viable tumor cells on histopathology (Figure 4).
Postoperatively, the patient had an uneventful recovery. He has been followed regularly with chest x-ray and abdominal and pelvic CT. There is no evidence of disease recurrence 62 months after the procedure.
Stage 4 TCC is generally associated with a very poor prognosis. The adrenal glands are among the most commonly involved distant organs [2,3]. In the past few years, survival benefit derived from thoracotomy for patients with solitary pulmonary metastasis has gained wider recognition [4,5,6]. In 1998, Kim et al  reported prolonged survival in patients who underwent adrenalectomy for isolated metastasis from nonbladder primary tumors. By contrast, extended disease-free survival has not been previously reported in patients who presented with synchronous adrenal metastasis from muscle-invasive TCC.
Systemic chemotherapy regimens of either GC or methotrexate vinblastine doxorubicin cisplatin (M-VAC) are now being regarded as the mainstay treatment modality in metastatic TCC. Initial response rates are up to 70%. However this response is often transient and recurrence is common, especially at the responding sites of the disease . In the present case, both the PET and the postoperative pathological examination revealed no viable disease after chemotherapy.
The role of radical extirpative surgery in metastatic TCC remains controversial. Most advocates of metastasectomy admit that only a subgroup of patients is likely to benefit from surgical treatment, and few characteristics of this subgroup have ever been described. Therefore, there is no consensus for selection criteria [9,10,11]. Some recent papers and case reports suggest that surgery of curative intent should be offered to patients that have shown evidence of: (1) good response to chemotherapy, (2) solitary and/or relatively indolent metastatic disease, and (3) tumors that are suitable for complete resection [4,5,6,7,9,11].
Given the uncertainties, it is particularly important for clinicians to acknowledge treatment controversy and to facilitate the process of shared decision-making with the patients. For our patient, the absence of major medical comorbidities, limited nature of his metastatic disease, and complete response to chemotherapy agents encouraged him to pursue more active treatment. This report adds to the growing body of evidence that supports a more aggressive multimodal approach to metastatic TCC in select patients.
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