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Cutaneous Metastasis from a Carcinoma of the Bladder: Report of a Case
'l'tu; .JOCHNA.L OF U.ROLOGT
Vol. 75, No. 4, April 1956 Printed /n U.S.A.
CUTANEOUS lVIETASTASIS FIWJVI A CARCINOMA OF TJIE BLADDER: REPORT OF A CASE DUNCAN C. WORIVIER, WILLIAM ,L MARTIN, .JOHN L. El\L\IETT \NI) KENNETH D. DEVINE From Sections of Medici'ne, Urology and Plasi'l:c Surgery rtnd Larynyo/ogy, 111.ayo Clinic and Mayo Fonndat.'ion, Roche.~ter, Jifrin.
Cutaneous metastasis from carcinoma of the urinary bladder has not, been reported frequently. We are presenting data on a patient. seen recently, uot only because of its uncommon occurrence but because the unusual appearance and location of this cutaneous metastasis initially presn1ted a diagnostic problem. UJiJPORT OF CASJL
A white man, aged 88 years, was admitted to the Mayo Clinic .January 7, 19f>i'i, because of a large, plum-colored, boggy, cystic mass involving the left, c:heek and the left periorbital tis:,,ues (fig. 1). He had first noted a small "red spot" on his left cheek about I year prior to admission. This had enlarged progressively and painlessly, Roentgen therapy had been tried elsewhere without improvement. Numerous needle aspirations 01' r,he boggy mass had been attempted elsewhere without establishing a diagnosi:,:. Ten days prior t.o admission, surgical drainage had been attempted elsmvhere. This had resulted in au alarming increase of edmna ·which closed hi,; left eye. Continuous serosanguineom, drainage from the surgical wound was evidenL The patient's past medical history revealed that a laryngeal carcinomR had been removed elsewhere J 5 years previously. Residual hoarseness was evident,. Followup examinations had not revealed any recurrence. Cy.~toscopy had alr-,o been performed elsewhere 2 years previously because of gross hcmaturia but ,vith ostensibly negative results. Review of systems, aside from nocturia of four to six times and mild urinary urgency which had been present for a "long time," was not revealing. Physical examination revealed the patient's left cheek and periorbital ti,sc;ues to be involved in an extensive boggy lesion as shown in figure l, except that a~; this time there was cousiderably more edema and closure of the left eye 1,han shown in the figure. On auscultation there was noted a moderately loud, harsh, aortic, systolic rnurmur which was transmitted into the neck ves,s;c]s and ow,r the entire precordiurrL There were a few inspiratory subc:repitant rales at the lung bases. The results of the remainder of the physical examination were within normal lirnits. Laboratory data included results of urinalyses, noteworthy features of which were a positive reaction (grade 2) for albumin, and the demonstration of n1icrot;copic hematuria (grade 2). The concentration of hemoglobin, the erythrm;yte count, the platelet count and the leukocyte count were normal: the result. of the Kline test was norrrul, and estimations of t.he bleeding time, coagulation tirne, prothromhin time and clot retraction Lime were within normal limits Thero were 68 rng. of un)a per 100 cc of blood. After 5 mg. of sulfobromophthalein per Accepted for publication November I, 1955, 697
698
WORMER, MARTIN, EMMETT AND DEVINE
Fm. 1 Fm. 2 Fm. 1. Metastatic carcinoma involving the left cheek and the left periorbital tissues. Photograph taken on January 19, 1955. FIG. 2. Excretory urogrnm showing marked irregularity of the right side of the bladder.
kilogram of body weight had been given intravenously, there was no retention of the dye in the serum at the end of 1 hour. There was no residual urine. Roentgenograms and fluoroscopy of the thorax revealed calcification in the region of the annulus fibrosus and in the aortic valve. Roentgenograms of the head, cranial sinuses, lumbar segment of the spinal column and pelvis were within normal limits. An excretory urogram was obtained because of the microhematuria, albuminuria, azotemia, and history of gross hematuria 2 years previously. The urogram revealed a nonfunctioning right kidney and a marked irregularity of the right side of the bladder (fig. 2). Cystoscopy revealed a solid infiltrating carcinoma of the right lateral wall of the bladder adjacent to and involving the vesical neck and prostatic urethra. Because of the intense inflammatory nature of the facial lesion, it was decided to withhold surgical treatment temporarily and the area was treated symptomatically. On January 15, 1955, the bladder tumor was resected transurethrally, the resection being carried as deeply as possible into the wall of the bladder. It was necessary to remove a few pieces of prostatic tissue to gain better access to the tumor. The right ureteral orifice could not be identified. The results of bimanual examination were essentially negative. At the same time, several specimens for biopsy were removed from the tumor on the left cheek by Dr. Devine through a small transverse incision. Histologic examination of the specimens from the bladder (fig. 3, a) showed an undifferentiated carcinoma, grade 4. The specimen from the cheek (fig. 3, b) also showed an undifferentiated carcinoma, ·which was felt to be metastatic. On January 18, 1955, 39 radon seeds totaling 75.66 microcuries were implanted transurethrally in the base of the resected vesical tumor. The patient received a total of 3,700 roentgens by roentgen therapy, in 12 divided doses over a period of 2 weeks, to the cutaneous metastasis.
CUTANEOUS METASTASIS FROM BLADDER CARCINOMA
699
FIG. 3. Anaplastic carcinoma. a, Primary in the urinary bladder (hematoxylin and eosin; X 100). b, Metastasis to the skin (hematoxylin and eosin; X 100).
The weeping and edema of the cheek lesion gradually subsided, as can be observed in figure 1. The patient was dismissed February 3, 1955. COMMENT
Subsequent to Higgins and Hausfeld's1 plea in 1948 for additional case reports of cutaneous metastasis from carcinoma of the bladder "in order to help 1 Higgins, C. C. and Hausfeld, K. F.: Cutaneous metastases from carcinoma of the urinary bladder: Report of two cases. J. Urol., 59: 879~886, 1948.
700
WORMER, MARTIN, EMMETT AND DEVINE
evaluate carcinoma of the bladder more properly," several case reports have been added to the literature. McDonald, Heckel and Kretschmer2 reviewed their data on 1,114 patients with primary carcinoma of the bladder and could find only 2 patients with cutaneous metastasis. They added these two to 10 other cases recorded in the literature for a total of 12. Nearly simultaneously, Hamer and N ourse3 reported a case of cutaneous metastasis. They also reviewed the literature, finding 11 previously reported cases. Mantell and Hamilton4 have since added data on another case of cutaneous metastasis secondary to a transitional cell carcinoma of the renal pelvis and bladder. The fact that our patient's facial lesion appeared some 12 months prior to admission would seem to indicate that the appearance of a cutaneous metastasis with carcinoma of the bladder does not necessarily imply a fulminating course with death in the immediate future. Review of the literature indicates that a cutaneous metastasis from carcinoma of the urinary bladder is not common. 2 McDonald, J. H., Heckel, N. J. and Kretschmer, H. L.: Cutaneous metastases secondary to carcinoma of urinary bladder: Report of 2 cases and review of literature. Arch. Dermat. & Syph., 61: 276-284, 1950. 3 Hamer, H. G. and Nourse, M. H.: Cutaneous metastasis from carcinoma of bladder. Tr. Am. A. Genito-Urin. Surg., 42: 63-65, 1950. 4 Mantell, L. K. and Hamilton, G. R.: Cutaneous metastases from transitional cell carcinoma of the renal pelvis and bladder. J. Urol., 65: 386-388, 1951.
Vol. 75, No. 4, April 1956 Printed /n U.S.A.
CUTANEOUS lVIETASTASIS FIWJVI A CARCINOMA OF TJIE BLADDER: REPORT OF A CASE DUNCAN C. WORIVIER, WILLIAM ,L MARTIN, .JOHN L. El\L\IETT \NI) KENNETH D. DEVINE From Sections of Medici'ne, Urology and Plasi'l:c Surgery rtnd Larynyo/ogy, 111.ayo Clinic and Mayo Fonndat.'ion, Roche.~ter, Jifrin.
Cutaneous metastasis from carcinoma of the urinary bladder has not, been reported frequently. We are presenting data on a patient. seen recently, uot only because of its uncommon occurrence but because the unusual appearance and location of this cutaneous metastasis initially presn1ted a diagnostic problem. UJiJPORT OF CASJL
A white man, aged 88 years, was admitted to the Mayo Clinic .January 7, 19f>i'i, because of a large, plum-colored, boggy, cystic mass involving the left, c:heek and the left periorbital tis:,,ues (fig. 1). He had first noted a small "red spot" on his left cheek about I year prior to admission. This had enlarged progressively and painlessly, Roentgen therapy had been tried elsewhere without improvement. Numerous needle aspirations 01' r,he boggy mass had been attempted elsewhere without establishing a diagnosi:,:. Ten days prior t.o admission, surgical drainage had been attempted elsmvhere. This had resulted in au alarming increase of edmna ·which closed hi,; left eye. Continuous serosanguineom, drainage from the surgical wound was evidenL The patient's past medical history revealed that a laryngeal carcinomR had been removed elsewhere J 5 years previously. Residual hoarseness was evident,. Followup examinations had not revealed any recurrence. Cy.~toscopy had alr-,o been performed elsewhere 2 years previously because of gross hcmaturia but ,vith ostensibly negative results. Review of systems, aside from nocturia of four to six times and mild urinary urgency which had been present for a "long time," was not revealing. Physical examination revealed the patient's left cheek and periorbital ti,sc;ues to be involved in an extensive boggy lesion as shown in figure l, except that a~; this time there was cousiderably more edema and closure of the left eye 1,han shown in the figure. On auscultation there was noted a moderately loud, harsh, aortic, systolic rnurmur which was transmitted into the neck ves,s;c]s and ow,r the entire precordiurrL There were a few inspiratory subc:repitant rales at the lung bases. The results of the remainder of the physical examination were within normal lirnits. Laboratory data included results of urinalyses, noteworthy features of which were a positive reaction (grade 2) for albumin, and the demonstration of n1icrot;copic hematuria (grade 2). The concentration of hemoglobin, the erythrm;yte count, the platelet count and the leukocyte count were normal: the result. of the Kline test was norrrul, and estimations of t.he bleeding time, coagulation tirne, prothromhin time and clot retraction Lime were within normal limits Thero were 68 rng. of un)a per 100 cc of blood. After 5 mg. of sulfobromophthalein per Accepted for publication November I, 1955, 697
698
WORMER, MARTIN, EMMETT AND DEVINE
Fm. 1 Fm. 2 Fm. 1. Metastatic carcinoma involving the left cheek and the left periorbital tissues. Photograph taken on January 19, 1955. FIG. 2. Excretory urogrnm showing marked irregularity of the right side of the bladder.
kilogram of body weight had been given intravenously, there was no retention of the dye in the serum at the end of 1 hour. There was no residual urine. Roentgenograms and fluoroscopy of the thorax revealed calcification in the region of the annulus fibrosus and in the aortic valve. Roentgenograms of the head, cranial sinuses, lumbar segment of the spinal column and pelvis were within normal limits. An excretory urogram was obtained because of the microhematuria, albuminuria, azotemia, and history of gross hematuria 2 years previously. The urogram revealed a nonfunctioning right kidney and a marked irregularity of the right side of the bladder (fig. 2). Cystoscopy revealed a solid infiltrating carcinoma of the right lateral wall of the bladder adjacent to and involving the vesical neck and prostatic urethra. Because of the intense inflammatory nature of the facial lesion, it was decided to withhold surgical treatment temporarily and the area was treated symptomatically. On January 15, 1955, the bladder tumor was resected transurethrally, the resection being carried as deeply as possible into the wall of the bladder. It was necessary to remove a few pieces of prostatic tissue to gain better access to the tumor. The right ureteral orifice could not be identified. The results of bimanual examination were essentially negative. At the same time, several specimens for biopsy were removed from the tumor on the left cheek by Dr. Devine through a small transverse incision. Histologic examination of the specimens from the bladder (fig. 3, a) showed an undifferentiated carcinoma, grade 4. The specimen from the cheek (fig. 3, b) also showed an undifferentiated carcinoma, ·which was felt to be metastatic. On January 18, 1955, 39 radon seeds totaling 75.66 microcuries were implanted transurethrally in the base of the resected vesical tumor. The patient received a total of 3,700 roentgens by roentgen therapy, in 12 divided doses over a period of 2 weeks, to the cutaneous metastasis.
CUTANEOUS METASTASIS FROM BLADDER CARCINOMA
699
FIG. 3. Anaplastic carcinoma. a, Primary in the urinary bladder (hematoxylin and eosin; X 100). b, Metastasis to the skin (hematoxylin and eosin; X 100).
The weeping and edema of the cheek lesion gradually subsided, as can be observed in figure 1. The patient was dismissed February 3, 1955. COMMENT
Subsequent to Higgins and Hausfeld's1 plea in 1948 for additional case reports of cutaneous metastasis from carcinoma of the bladder "in order to help 1 Higgins, C. C. and Hausfeld, K. F.: Cutaneous metastases from carcinoma of the urinary bladder: Report of two cases. J. Urol., 59: 879~886, 1948.
700
WORMER, MARTIN, EMMETT AND DEVINE
evaluate carcinoma of the bladder more properly," several case reports have been added to the literature. McDonald, Heckel and Kretschmer2 reviewed their data on 1,114 patients with primary carcinoma of the bladder and could find only 2 patients with cutaneous metastasis. They added these two to 10 other cases recorded in the literature for a total of 12. Nearly simultaneously, Hamer and N ourse3 reported a case of cutaneous metastasis. They also reviewed the literature, finding 11 previously reported cases. Mantell and Hamilton4 have since added data on another case of cutaneous metastasis secondary to a transitional cell carcinoma of the renal pelvis and bladder. The fact that our patient's facial lesion appeared some 12 months prior to admission would seem to indicate that the appearance of a cutaneous metastasis with carcinoma of the bladder does not necessarily imply a fulminating course with death in the immediate future. Review of the literature indicates that a cutaneous metastasis from carcinoma of the urinary bladder is not common. 2 McDonald, J. H., Heckel, N. J. and Kretschmer, H. L.: Cutaneous metastases secondary to carcinoma of urinary bladder: Report of 2 cases and review of literature. Arch. Dermat. & Syph., 61: 276-284, 1950. 3 Hamer, H. G. and Nourse, M. H.: Cutaneous metastasis from carcinoma of bladder. Tr. Am. A. Genito-Urin. Surg., 42: 63-65, 1950. 4 Mantell, L. K. and Hamilton, G. R.: Cutaneous metastases from transitional cell carcinoma of the renal pelvis and bladder. J. Urol., 65: 386-388, 1951.