- Email: [email protected]
Skeletal Muscle Metastasis from Transitional Cell Carcinoma of the Urinary Bladder: Clinicoradiological Features
Clinical Radiology (2003) 58: 883–885 doi:10.1016/S0009-9260(03)00234-4, available online at www.sciencedirect.com
Skeletal Muscle Metastasis from Transitional Cell Carcinoma of the Urinary Bladder: Clinicoradiological Features G. NABI*, N. P. GUPTA†, D. GANDHI‡ *Academic Urology Unit, Department of Surgery, Medical School, University of Aberdeen, Scotland; Departments of †Urology, and ‡Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India Received: 21 January 2003
Revised: 11 April 2003 Accepted: 26 April 2003
AIM: To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder. MATERIALS AND METHODS: A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records. RESULTS: Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27 – 70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of lowdensity enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6 – 12 months). CONCLUSION: Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal. Nabi, G. et al. (2003). Clinical Radiology 58: 883–885. q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved. Key words: skeletal muscle, carcinoma, urinary bladder, metastasis.
INTRODUCTION
Despite the fact that skeletal muscle comprises 50% of total body mass and receives a large portion of cardiac output, haematogenous metastases to these areas rarely manifest clinically. This has been partly attributed to muscle movements, pH and ability of muscle to remove lactic acid [1,2]. Guarantor and correspondent: G. Nabi, Department of Surgery, Medical School, Polwarth Building, University of Aberdeen, Aberdeen, Scotland, UK. Tel: þ 44-1224-558989; Fax: þ 44-1224-551992; E-mail: [email protected] 0009-9260/03/$30.00/0
There are reports and small series in the literature describing clinical and radiological features of skeletal muscle metastasis from different primaries, for example, lung, breast, colon, renal and gastric malignancies [3 –6], but to our knowledge clinical and radiological features of transitional cell carcinoma of the urinary bladder metastasizing to skeletal muscles have not been described. Skeletal muscle metastases represented the only clinical manifestations at the time of presentation in our series. Localized masses in muscles in patients treated previously for transitional cell carcinoma should be considered to be metastases. Two typical appearances seen on contrastenhanced computed tomography (CT) of muscle are swelling
q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.
884
CLINICAL RADIOLOGY
with hypoattenuation or ring-enhancing lesions. Lack of clinical suspicion and unusual radiological features mimicking abscesses often delay diagnosis in these patients. We report clinicoradiological features of five histologically proven metastases from transitional cell carcinoma of urinary bladder.
PATIENTS AND METHODS
A retrospective review of all patients with biopsy-proven skeletal muscle metastasis between January 1999 to December 2001 at single tertiary radiological centre was carried out. Patients with radiological evidence of muscular metastases from transitional cell carcinoma of the urinary bladder were identified. Patients’ demographic data, clinical presentation, stage of disease, radiological features, treatment, and follow-up were recorded from hospital records.
RESULTS
Of 24 patients with biopsy-proven skeletal muscle metastasis from various malignancies, five patients had spread to these unusual sites from transitional cell carcinoma of the urinary bladder. Patients’ were aged between 27–70 years (mean 52 years) and all were males. They presented with localized swelling with or without accompanying pain in two patients, limp in two and back ache in one (Table 1). The muscles involved were psoas in three patients, adductor group of muscles in the thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). Mean duration from the time of initial treatment was 5 months (3 –8 months). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical CT, and two types of lesions were seen on imaging. Two patients with psoas metastasis had typical low-density enlargement of muscle suggestive of muscle oedema (Fig. 1). Patients with rectus abdominis and adductor group of the thigh muscle lesions had thick, ring-enhancing lesions mimicking abscesses (Fig. 2). The diagnosis was confirmed by fine-needle aspiration (FNA) in three patients and biopsy in two. The typical appearances of low-density enhancing lesions on CT
Fig. 1 – CECT scan of abdomen showing enlarged hypoattenuated left psoas muscle.
were mistaken for abscess in two patients, and these patients had incision and drainage with biopsies taken that later showed evidence of malignancy. All patients had palliative chemotherapy (mitomycin, vincristine, adriamycin and cyclophosphamide). Two patients with severe back ache had local palliative radiotherapy (3500 rads). Widespread metastatic disease appeared in all patients in a mean duration of 3.5 months. Mean survival was 8 months (range 6–12 months).
DISCUSSION
The rarity of muscular metastatic lesions has been attributed to multiple factors such as contractile activity, change in pH, the accumulation of metabolites, intramuscular blood pressure and local temperature [6–7]. In a recent series, previously documented trauma has been found to be risk factor for development of metastasis [8]. This is presumably due to changed local physiological and mechanical factors. Skeletal muscle metastasis is a rare clinical event, seen usually in advanced malignancies. Pretorius et al. [9] had 87% of patients with evidence of widespread metastatic disease at the time of detection of muscular lesions. Usually these were poorly differentiated tumours with no identifiable primaries.
Table 1 – Clinical and radiological features of patients with skeletal muscular metastasis No. Age Initial stage of disease
Initial treatment received
Clinical presentation
Radiological presentation
Treatment received
Follow-up
1
65
T3N0MO
Radical cystectomy with sigmoid neobladder
CECT showing ringenhancing lesion
Palliative chemotherapy
Died at 8 months
2
27
T3BN2MO
Radical cystectomy with ileal conduit
Localized swelling on medial aspect of thigh with pain Persistent back ache with limp
CECT showed enlarged swollen left psoas
Died at 6 months
3
62
T3ANOMO
Radical cystectomy with sigmoid neobladder
Palliative chemotherapy with localized radiotherapy Palliative chemotherapy
4
70
T3BN2M1
None
5
36
T3AN1MO
Radical cystectomy with ileal conduit
Painless swelling in anterior abdominal wall Left limp with backache Pain in back
CECT showed ringenhancing lesion in left rectus abdominis CECT showed enlarged swollen left psoas muscle CECT showed swollen left psoas with areas of low attenuations
Palliative chemotherapy with local radiotherapy Palliative chemotherapy
Died at 12 months Died at 8 months Died at 6 months
SKELETAL MUSCLE METASTASIS FROM TRANSITIONAL CELL CARCINOMA OF URINARY BLADDER: CLINICORADIOLOGICAL FEATURES
Fig. 2 – CECT of right thigh showing ring-enhancing lesion (arrow) on medial aspect.
Moreover, lesions seen on CT were neither palpable nor painful and majority of these were incidental findings on routine oncological imaging. Subclinically metastasis to skeletal muscle may be more common than thought, as it is impractical to image each muscle, or section it serially on autopsy [10,11]. In a large series, autopsy studies of 5298 patients who died of malignancy, 6% had involvement of anterior chest wall or abdominal wall muscles and 13% had diaphragmatic lesions. In contrast, the majority of our patients developed secondaries on follow-up and presented with symptomatic lesions. Commonly the clinical presentation included swelling with or without pain. One patient had a concomitant psoas abscess-like lesion and muscle-invasive transitional cell carcinoma of urinary bladder [12]. Dedicated imaging of these sites showed either lowdensity enlargement of muscles or ring-enhancing lesions. Two cases were mistaken for abscesses in the absence of evidence of metastasis elsewhere. These typical clinical and radiological appearances highlight the need for a strong clinical suspicion of metastatic lesions in patients previously treated for transitional cell carcinoma of urinary bladder in order to avoid unnecessary and unplanned incision and drainage. The latter is usually an emergency procedure carried out by less experienced surgeons. Two patients had enlarged muscles with decreased attenuation suggestive of muscular oedema on CT, similar to the one described by Schultz et al. [12] in their series (Fig. 1). Although magnetic resonance T2-weighted and short tau inversion recovery imaging is better in delineating muscular oedema, it was not carried out in present series. Three patients had typical
885
ring-enhancing intramuscular lesions with central hypoattenuation. A localized, painful swelling with such a CT appearance can easily be mistaken for an abscess. Metastasis should be considered in these lesions and proven by FNA or biopsy. Although muscular lesions represented a solitary site of metastasis at presentation, at follow-up the majority of patients subsequently developed widespread disease and died in a mean duration of 8 months. Effective palliation can be achieved with chemotherapy with or without addition of local radiotherapy as in this series; however, muscular metastases in transitional cell carcinoma carry a poor prognosis. In conclusion, localized swellings in muscles in patients of transitional cell carcinoma with or without pain and with CT appearances of muscle enlargement or ring-enhancing lesions with central hypoattenuation may guide lesion biopsy and appropriate treatment.
REFERENCES 1 Seely S. Possible reasons for the high resistance of muscle to cancer. Med Hypotheses, 1980;6:133 –137. 2 Nicholson GL, Poste G. Tumour implantation and invasion at metastatic sites. Int Rev Exp Pathol, 1981;25:77–81. 3 Suto Y, Yamagushi Y, Sugihara S. Skeletal muscle metastasis from lung carcinoma. MR findings. J Comput Assist Tomogr, 1997;21: 304– 305. 4 Sridhar KS, Rao RK, Kunhardt B. Skeletal muscle metastasis from lung cancer. Cancer, 1987;59:1530 –1534. 5 Araki K, Kobayashi M, Ogata T, Takuma K. Colorectal carcinoma metastatic to skeletal muscle. Hepatogastroenerology, 1994;41: 405– 408. 6 Mulsow FW. Metastatic carcinoma of skeletal muscles. Arch Pathol, 1943;35:112–114. 7 Herring CL, Harrelson JM, Scully SP. Metastatic carcinoma to skeletal muscles. Clinical Orthop, 1998;355:272 –281. 8 Magee T, Rosenthal H. Skeletal muscle metastasis at sites of documented trauma. AJR Am J Roentgenol, 2002;178:985 –988. 9 Pretorius ES, Fishman EK. Helical CT of skeletal muscle metastases from primary carcinoma. AJR Am J Roentgenol, 2000;174:401– 404. 10 Abualfia O, Sherer DM, Fultz PJ. Computed tomography detection of asymptomatic striated muscle metastasis from ovarian carcinoma. Am J Obstetric Gynecol, 1994;171:560 –561. 11 Pickren JW. Use and limitations of autopsy data, In: Weiss L, ed. Fundamental Aspects of Metastasis. Amersterdam: North Holland, 1976, 377–384. 12 Schultz SR, Bree RL, Schwab RE, Raiss G. CT detection of skeletal muscle metastasis. J Comput Assist Tomogr, 1986;10:81–83.
Skeletal Muscle Metastasis from Transitional Cell Carcinoma of the Urinary Bladder: Clinicoradiological Features G. NABI*, N. P. GUPTA†, D. GANDHI‡ *Academic Urology Unit, Department of Surgery, Medical School, University of Aberdeen, Scotland; Departments of †Urology, and ‡Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India Received: 21 January 2003
Revised: 11 April 2003 Accepted: 26 April 2003
AIM: To define the clinicoradiological characteristics of skeletal muscle metastasis from transitional cell carcinoma of the urinary bladder. MATERIALS AND METHODS: A retrospective review of all patients with skeletal muscle metastasis was undertaken between January 1999 to December 2001. Patients suspected of having a metastasis on radiological examinations, and subsequently proven to have metastatic disease on histological examination were included in study. The clinical presentation and radiological features of five patients with skeletal muscle metastasis from bladder tumours were reviewed from hospital records. RESULTS: Twenty-four patients had skeletal muscle metastasis from various primaries. Of these five patients had previous or concurrent primary tumours in the bladder. Patients were aged between 27 – 70 years (mean 52 years), and all had persistent, localized pain with or without accompanying swelling. The muscles involved were psoas in three patients, adductor muscles of thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical computed tomography (CT) before confirmation of diagnosis by fine-needle aspiration (FNA) or biopsy. The typical appearance of lowdensity enhancing lesions on CT was mistaken for abscess in two patients and failure to respond to conservative treatment led to suspicion of metastasis. Diagnosis was proven histologically in all patients (FNA in three and biopsy in two). All patients had palliative chemotherapy (Mitomycin, Vincristine, Adriamycin and Cyclophosphamide). Two patients had local palliative 3500 rad radiotherapy for persistent pain. Mean survival was 8 months (range 6 – 12 months). CONCLUSION: Muscular metastasis from urothelial tumours typically presents with persistent localized pain with or without swelling. The characteristic low-density, ring-enhancing lesions on CT in a patient with previous or concomitant urothelial tumours should raise the suspicion of metastasis until proven otherwise. Prognosis is dismal. Nabi, G. et al. (2003). Clinical Radiology 58: 883–885. q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved. Key words: skeletal muscle, carcinoma, urinary bladder, metastasis.
INTRODUCTION
Despite the fact that skeletal muscle comprises 50% of total body mass and receives a large portion of cardiac output, haematogenous metastases to these areas rarely manifest clinically. This has been partly attributed to muscle movements, pH and ability of muscle to remove lactic acid [1,2]. Guarantor and correspondent: G. Nabi, Department of Surgery, Medical School, Polwarth Building, University of Aberdeen, Aberdeen, Scotland, UK. Tel: þ 44-1224-558989; Fax: þ 44-1224-551992; E-mail: [email protected] 0009-9260/03/$30.00/0
There are reports and small series in the literature describing clinical and radiological features of skeletal muscle metastasis from different primaries, for example, lung, breast, colon, renal and gastric malignancies [3 –6], but to our knowledge clinical and radiological features of transitional cell carcinoma of the urinary bladder metastasizing to skeletal muscles have not been described. Skeletal muscle metastases represented the only clinical manifestations at the time of presentation in our series. Localized masses in muscles in patients treated previously for transitional cell carcinoma should be considered to be metastases. Two typical appearances seen on contrastenhanced computed tomography (CT) of muscle are swelling
q 2003 The Royal College of Radiologists. Published by Elsevier Science Ltd. All rights reserved.
884
CLINICAL RADIOLOGY
with hypoattenuation or ring-enhancing lesions. Lack of clinical suspicion and unusual radiological features mimicking abscesses often delay diagnosis in these patients. We report clinicoradiological features of five histologically proven metastases from transitional cell carcinoma of urinary bladder.
PATIENTS AND METHODS
A retrospective review of all patients with biopsy-proven skeletal muscle metastasis between January 1999 to December 2001 at single tertiary radiological centre was carried out. Patients with radiological evidence of muscular metastases from transitional cell carcinoma of the urinary bladder were identified. Patients’ demographic data, clinical presentation, stage of disease, radiological features, treatment, and follow-up were recorded from hospital records.
RESULTS
Of 24 patients with biopsy-proven skeletal muscle metastasis from various malignancies, five patients had spread to these unusual sites from transitional cell carcinoma of the urinary bladder. Patients’ were aged between 27–70 years (mean 52 years) and all were males. They presented with localized swelling with or without accompanying pain in two patients, limp in two and back ache in one (Table 1). The muscles involved were psoas in three patients, adductor group of muscles in the thigh in one and rectus abdominis in one. Four patients had radical cystectomy with urinary diversion (two ileal conduit and two orthotopic sigmoid neobladder). Mean duration from the time of initial treatment was 5 months (3 –8 months). One patient presented with bladder tumour and concomitant muscular metastasis. All patients underwent helical CT, and two types of lesions were seen on imaging. Two patients with psoas metastasis had typical low-density enlargement of muscle suggestive of muscle oedema (Fig. 1). Patients with rectus abdominis and adductor group of the thigh muscle lesions had thick, ring-enhancing lesions mimicking abscesses (Fig. 2). The diagnosis was confirmed by fine-needle aspiration (FNA) in three patients and biopsy in two. The typical appearances of low-density enhancing lesions on CT
Fig. 1 – CECT scan of abdomen showing enlarged hypoattenuated left psoas muscle.
were mistaken for abscess in two patients, and these patients had incision and drainage with biopsies taken that later showed evidence of malignancy. All patients had palliative chemotherapy (mitomycin, vincristine, adriamycin and cyclophosphamide). Two patients with severe back ache had local palliative radiotherapy (3500 rads). Widespread metastatic disease appeared in all patients in a mean duration of 3.5 months. Mean survival was 8 months (range 6–12 months).
DISCUSSION
The rarity of muscular metastatic lesions has been attributed to multiple factors such as contractile activity, change in pH, the accumulation of metabolites, intramuscular blood pressure and local temperature [6–7]. In a recent series, previously documented trauma has been found to be risk factor for development of metastasis [8]. This is presumably due to changed local physiological and mechanical factors. Skeletal muscle metastasis is a rare clinical event, seen usually in advanced malignancies. Pretorius et al. [9] had 87% of patients with evidence of widespread metastatic disease at the time of detection of muscular lesions. Usually these were poorly differentiated tumours with no identifiable primaries.
Table 1 – Clinical and radiological features of patients with skeletal muscular metastasis No. Age Initial stage of disease
Initial treatment received
Clinical presentation
Radiological presentation
Treatment received
Follow-up
1
65
T3N0MO
Radical cystectomy with sigmoid neobladder
CECT showing ringenhancing lesion
Palliative chemotherapy
Died at 8 months
2
27
T3BN2MO
Radical cystectomy with ileal conduit
Localized swelling on medial aspect of thigh with pain Persistent back ache with limp
CECT showed enlarged swollen left psoas
Died at 6 months
3
62
T3ANOMO
Radical cystectomy with sigmoid neobladder
Palliative chemotherapy with localized radiotherapy Palliative chemotherapy
4
70
T3BN2M1
None
5
36
T3AN1MO
Radical cystectomy with ileal conduit
Painless swelling in anterior abdominal wall Left limp with backache Pain in back
CECT showed ringenhancing lesion in left rectus abdominis CECT showed enlarged swollen left psoas muscle CECT showed swollen left psoas with areas of low attenuations
Palliative chemotherapy with local radiotherapy Palliative chemotherapy
Died at 12 months Died at 8 months Died at 6 months
SKELETAL MUSCLE METASTASIS FROM TRANSITIONAL CELL CARCINOMA OF URINARY BLADDER: CLINICORADIOLOGICAL FEATURES
Fig. 2 – CECT of right thigh showing ring-enhancing lesion (arrow) on medial aspect.
Moreover, lesions seen on CT were neither palpable nor painful and majority of these were incidental findings on routine oncological imaging. Subclinically metastasis to skeletal muscle may be more common than thought, as it is impractical to image each muscle, or section it serially on autopsy [10,11]. In a large series, autopsy studies of 5298 patients who died of malignancy, 6% had involvement of anterior chest wall or abdominal wall muscles and 13% had diaphragmatic lesions. In contrast, the majority of our patients developed secondaries on follow-up and presented with symptomatic lesions. Commonly the clinical presentation included swelling with or without pain. One patient had a concomitant psoas abscess-like lesion and muscle-invasive transitional cell carcinoma of urinary bladder [12]. Dedicated imaging of these sites showed either lowdensity enlargement of muscles or ring-enhancing lesions. Two cases were mistaken for abscesses in the absence of evidence of metastasis elsewhere. These typical clinical and radiological appearances highlight the need for a strong clinical suspicion of metastatic lesions in patients previously treated for transitional cell carcinoma of urinary bladder in order to avoid unnecessary and unplanned incision and drainage. The latter is usually an emergency procedure carried out by less experienced surgeons. Two patients had enlarged muscles with decreased attenuation suggestive of muscular oedema on CT, similar to the one described by Schultz et al. [12] in their series (Fig. 1). Although magnetic resonance T2-weighted and short tau inversion recovery imaging is better in delineating muscular oedema, it was not carried out in present series. Three patients had typical
885
ring-enhancing intramuscular lesions with central hypoattenuation. A localized, painful swelling with such a CT appearance can easily be mistaken for an abscess. Metastasis should be considered in these lesions and proven by FNA or biopsy. Although muscular lesions represented a solitary site of metastasis at presentation, at follow-up the majority of patients subsequently developed widespread disease and died in a mean duration of 8 months. Effective palliation can be achieved with chemotherapy with or without addition of local radiotherapy as in this series; however, muscular metastases in transitional cell carcinoma carry a poor prognosis. In conclusion, localized swellings in muscles in patients of transitional cell carcinoma with or without pain and with CT appearances of muscle enlargement or ring-enhancing lesions with central hypoattenuation may guide lesion biopsy and appropriate treatment.
REFERENCES 1 Seely S. Possible reasons for the high resistance of muscle to cancer. Med Hypotheses, 1980;6:133 –137. 2 Nicholson GL, Poste G. Tumour implantation and invasion at metastatic sites. Int Rev Exp Pathol, 1981;25:77–81. 3 Suto Y, Yamagushi Y, Sugihara S. Skeletal muscle metastasis from lung carcinoma. MR findings. J Comput Assist Tomogr, 1997;21: 304– 305. 4 Sridhar KS, Rao RK, Kunhardt B. Skeletal muscle metastasis from lung cancer. Cancer, 1987;59:1530 –1534. 5 Araki K, Kobayashi M, Ogata T, Takuma K. Colorectal carcinoma metastatic to skeletal muscle. Hepatogastroenerology, 1994;41: 405– 408. 6 Mulsow FW. Metastatic carcinoma of skeletal muscles. Arch Pathol, 1943;35:112–114. 7 Herring CL, Harrelson JM, Scully SP. Metastatic carcinoma to skeletal muscles. Clinical Orthop, 1998;355:272 –281. 8 Magee T, Rosenthal H. Skeletal muscle metastasis at sites of documented trauma. AJR Am J Roentgenol, 2002;178:985 –988. 9 Pretorius ES, Fishman EK. Helical CT of skeletal muscle metastases from primary carcinoma. AJR Am J Roentgenol, 2000;174:401– 404. 10 Abualfia O, Sherer DM, Fultz PJ. Computed tomography detection of asymptomatic striated muscle metastasis from ovarian carcinoma. Am J Obstetric Gynecol, 1994;171:560 –561. 11 Pickren JW. Use and limitations of autopsy data, In: Weiss L, ed. Fundamental Aspects of Metastasis. Amersterdam: North Holland, 1976, 377–384. 12 Schultz SR, Bree RL, Schwab RE, Raiss G. CT detection of skeletal muscle metastasis. J Comput Assist Tomogr, 1986;10:81–83.