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Curative surgery for solitary adrenal metastasis of pT1 G3 transitional cell carcinoma of the bladder
CASE REPORT
CURATIVE SURGERY FOR SOLITARY ADRENAL METASTASIS OF pT1 G3 TRANSITIONAL CELL CARCINOMA OF THE BLADDER S. F. WYLER, A. BACHMANN, R. CASELLA, C. TAPIA, T. C. GASSER,
AND
T. SULSER
ABSTRACT 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. UROLOGY 65: 388.e8–388.e9, 2005. © 2005 Elsevier Inc.
R
ecent reports have suggested a survival benefit to selected patients with metastatic transitional cell carcinoma (TCC) after postchemotherapy surgery,1 and curative surgery for solitary metastasis of TCC has become a subject of debate.
tent with TCC. Sequence analysis of p53 in exons 5 to 8 showed the same mutation in the primary tumor and metastasis in exon 6, codon 195, ATC to TTC, with genetically proven metastasis of primary TCC. Computed tomography 4 years after cystectomy (2 years after adrenalectomy) revealed no other site of metastasis.
CASE REPORT In a 63-year-old man, transurethral resection was performed for grade 3 pT1 TCC with carcinoma in situ, marker p53 positive, and 50% Ki-67 labeling, with residual tumor of the same stage on repeated transurethral resection (TUR). Preoperative computed tomography before cystectomy revealed a right adrenal tumor of 3.7 ⫻ 4 cm (Fig. 1). Computed tomography-guided biopsy revealed no malignancy, and cystectomy was performed. The specimen revealed no residual malignancy in the bladder with pN0. Two years postoperatively, computed tomography detected a growth of the adrenal tumor to 6.4 ⫻ 6.3 cm without other pathologic findings, and the tumor showed no hormonal activity. The patient was referred to our center for right adrenalectomy. The histologic findings were consisFrom the Department of Urology and Institute of Pathology, University Hospital Basel, Basel, Switzerland Address for correspondence: Stephen F. Wyler, M.D., Department of Urology, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland. E-mail: [email protected] Submitted: June 16, 2004, accepted (with revisions): August 25, 2004 © 2005 ELSEVIER INC. 388.e8
ALL RIGHTS RESERVED
COMMENT In our case, the TUR specimen was TCC pT1 grade 3 with carcinoma in situ (biopsy specimen rich in musculature). The cystectomy specimen revealed no residual tumor and was pN0. We, therefore, assume the pT1 stage was correct and excluded possible understaging. The molecular analysis of the subsequent adrenal gland tumor proved its metastatic origin from the bladder. Solitary bladder cancer metastases to the adrenals from superficial TCC have not previously been reported. The metastasis was present at the initial TUR. Therefore, tumor cell spilling by TUR, repeat TUR, or cystectomy could be excluded as the source of this metastasis. What was remarkable was not only the size of the metastasis at initial presentation and its growth with a high proliferative index (p53 positive, Ki-67 labeling index of 50%), but also the missing evidence of other metastases during 4 years of follow-up. Surgery for solitary metastasis of TCC as a curative treatment option is a new subject of debate. Investigators at Memorial Sloan-Kettering Cancer Center2 0090-4295/05/$30.00 doi:10.1016/j.urology.2004.08.047
and Stanford3 have reported on the addition of postchemotherapy surgery to achieve a complete response in selected patients with metastatic or initially unresectable TCC. Curative surgery for solitary metastasis of TCC of the bladder is a treatment option that needs to be discussed further.
FIGURE 1. Preoperative CT scan at cystectomy showing 3.7 ⫻ 4-cm right adrenal tumor.
UROLOGY 65 (2), 2005
REFERENCES 1. Siefker-Radtke AO, Walsh GL, Pister LL, et al: Is there a role for surgery in the management of metastatic urothelial cancer? The M. D. Anderson experience. J Urol 171: 145–148, 2004. 2. Dodd PM, McCaffrey JA, Herr J, et al: Outcome of postchemotherapy surgery after treatment with methotrexate, vinblastine, doxorubicin, and cisplatin in patients with unresectable or metastatic transitional cell carcinoma. J Clin Oncol 17: 2546 –2552, 1999. 3. Miller RS, Freiha FS, Reese JH, et al: Cisplatin, methotrexate and vinblastine plus surgical restaging for patients with advanced transitional cell carcinoma of the urothelium. J Urol 150: 65– 69, 1993.
388.e9
CURATIVE SURGERY FOR SOLITARY ADRENAL METASTASIS OF pT1 G3 TRANSITIONAL CELL CARCINOMA OF THE BLADDER S. F. WYLER, A. BACHMANN, R. CASELLA, C. TAPIA, T. C. GASSER,
AND
T. SULSER
ABSTRACT 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. UROLOGY 65: 388.e8–388.e9, 2005. © 2005 Elsevier Inc.
R
ecent reports have suggested a survival benefit to selected patients with metastatic transitional cell carcinoma (TCC) after postchemotherapy surgery,1 and curative surgery for solitary metastasis of TCC has become a subject of debate.
tent with TCC. Sequence analysis of p53 in exons 5 to 8 showed the same mutation in the primary tumor and metastasis in exon 6, codon 195, ATC to TTC, with genetically proven metastasis of primary TCC. Computed tomography 4 years after cystectomy (2 years after adrenalectomy) revealed no other site of metastasis.
CASE REPORT In a 63-year-old man, transurethral resection was performed for grade 3 pT1 TCC with carcinoma in situ, marker p53 positive, and 50% Ki-67 labeling, with residual tumor of the same stage on repeated transurethral resection (TUR). Preoperative computed tomography before cystectomy revealed a right adrenal tumor of 3.7 ⫻ 4 cm (Fig. 1). Computed tomography-guided biopsy revealed no malignancy, and cystectomy was performed. The specimen revealed no residual malignancy in the bladder with pN0. Two years postoperatively, computed tomography detected a growth of the adrenal tumor to 6.4 ⫻ 6.3 cm without other pathologic findings, and the tumor showed no hormonal activity. The patient was referred to our center for right adrenalectomy. The histologic findings were consisFrom the Department of Urology and Institute of Pathology, University Hospital Basel, Basel, Switzerland Address for correspondence: Stephen F. Wyler, M.D., Department of Urology, University Hospital Basel, Spitalstrasse 21, Basel 4031, Switzerland. E-mail: [email protected] Submitted: June 16, 2004, accepted (with revisions): August 25, 2004 © 2005 ELSEVIER INC. 388.e8
ALL RIGHTS RESERVED
COMMENT In our case, the TUR specimen was TCC pT1 grade 3 with carcinoma in situ (biopsy specimen rich in musculature). The cystectomy specimen revealed no residual tumor and was pN0. We, therefore, assume the pT1 stage was correct and excluded possible understaging. The molecular analysis of the subsequent adrenal gland tumor proved its metastatic origin from the bladder. Solitary bladder cancer metastases to the adrenals from superficial TCC have not previously been reported. The metastasis was present at the initial TUR. Therefore, tumor cell spilling by TUR, repeat TUR, or cystectomy could be excluded as the source of this metastasis. What was remarkable was not only the size of the metastasis at initial presentation and its growth with a high proliferative index (p53 positive, Ki-67 labeling index of 50%), but also the missing evidence of other metastases during 4 years of follow-up. Surgery for solitary metastasis of TCC as a curative treatment option is a new subject of debate. Investigators at Memorial Sloan-Kettering Cancer Center2 0090-4295/05/$30.00 doi:10.1016/j.urology.2004.08.047
and Stanford3 have reported on the addition of postchemotherapy surgery to achieve a complete response in selected patients with metastatic or initially unresectable TCC. Curative surgery for solitary metastasis of TCC of the bladder is a treatment option that needs to be discussed further.
FIGURE 1. Preoperative CT scan at cystectomy showing 3.7 ⫻ 4-cm right adrenal tumor.
UROLOGY 65 (2), 2005
REFERENCES 1. Siefker-Radtke AO, Walsh GL, Pister LL, et al: Is there a role for surgery in the management of metastatic urothelial cancer? The M. D. Anderson experience. J Urol 171: 145–148, 2004. 2. Dodd PM, McCaffrey JA, Herr J, et al: Outcome of postchemotherapy surgery after treatment with methotrexate, vinblastine, doxorubicin, and cisplatin in patients with unresectable or metastatic transitional cell carcinoma. J Clin Oncol 17: 2546 –2552, 1999. 3. Miller RS, Freiha FS, Reese JH, et al: Cisplatin, methotrexate and vinblastine plus surgical restaging for patients with advanced transitional cell carcinoma of the urothelium. J Urol 150: 65– 69, 1993.
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