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Metastatic Melano-epithelioma of the Urinary Bladder: Report of A Case
THE JOURNAL OF UROLOGY
Vol. 67, No. 1, January 1952 Printed in U.S.A.
METASTATIC MELANO-EPITHELIOMA OF THE URINARY BLADDER: REPORT OF A CASE ROBERT P. MORROW, JR. Fellow in Urology, Mayo Foundation
LEWIS B. WOOLNER Section on Surgical Pathology AND
JOHN L. EMMETT
Section on Urology, Mayo Clinic, Rochester, Minn.
Metastatic neoplasms constitute a very small percentage of tumors of the urinary bladder. Metastatic involvement of the bladder by melano-epithelioma apparently is rare; we have encountered only 3 such cases in a cursory review of the literature. Way and Light reported a case of generalized melanosis in which necropsy revealed almost every organ of the body to be involved from a primary melanoepithelioma of the skin. The urinary bladder was described as showing extensive involvement. McComb and Smith reported a case in which tumor of the bladder was treated by segmental resection. Microscopic examination disclosed melano-epithelioma. A search was made for a primary lesion, but none could be found. The patient died 13 months after operation, and necropsy showed both adrenal glands to be involved with what was presumed to be the primary lesion. At this time, numerous subcutaneous metastatic lesions also were demonstrable. Wheelock reported 4 cases of sarcoma and 1 of malignant melanoma of the urinary bladder. The author included the case of melano-epithelioma because at the time it was believed that melanomas were of connective-tissue origin. The tumor was treated by suprapubic implantation of radon seeds, followed by deep roentgen therapy. The patient died 7 months after operation. Postmortem examination was not carried out and no primary lesion was demonstrated before death; therefore, the author speculated that this lesion may have been primary in the bladder, having its origin from an embryonic cell rest. In the case we are presenting here the diagnosis was suspected preoperatively and was confirmed by biopsy. Because of the rarity of such a lesion, we feel that it is worth while to report this case. REPORT OF CASE
A man 47 years old was first seen in the Mayo Clinic in October 1948. His chief complaint at this time was persistent drainage from the base of the nail of the right great toe. He stated that in July 1947, he had first noted a small amount of drainage from the base of the nail of this toe. There was no pain associated with the lesion. The patient consulted his physician; after a trial of local therapy, the nail was removed and the nail bed was cauterized. This was followed by 92
METASTATIC :V!ELANO-EPITHELIOMA OF l'RI1'ARY DLADDIDR
93
complete healing in 2 weeks, )Jo other symptoms ,rnre noted until a short time prior to his examination at the clinic, The family history and the patient's history were n011contributory, Physical examination disclosed a healthy man, 5 feet, 11 inches in height, weighing 171 pounds. The blood pressure, pulse, respiration and temperature were normal. The right great toe presented a granular-appearing lesion on the lateral aspect of the nail bed. The nail had been removed surgically, There ,nu, a slight amount of purul,mt drainage from the lesion, but the toe 1Yas not tender. There ,1·ere Hevernl enlarged, non tender nodes in the right inguinal region, The Pdge of the liver was palpable, hut was not tender. Results of physicaJ examination otherwise were negative. Laboratory studies revealed the urine and blood to be normal. The m·ythrocyte sedimentation rate was 30 mm, in one hour by the vVestergren method.
Fw. 1. :\fotastatic nwlano-epithelionm of urirrnn· bln.dder. Histologic section of lcsi011 bln.ddcr, showing highly anapla.stic tumor cells containing rneln.uin pigment (hcmai.ox,·lin and eosiw X 400).
i11
H.e:mlts of tests of hepatic funetiou all were ,Yithin normal limits, as was the re:mli. of the fiocc:ulation test for syphilis. Hoentgenologic examination of the right foot failed to show any pathologic lesion of the bones. A roentgenogra.rn of the· thorax 1:,howed nothing significant. A malignant lesion was suspected. For this reason, the right inguinal lymph nocles were removed and the right great toe was amputated. Pathologic examination revealed an ulcerating subungnal melano-epithelioma. involving the right great toe. :.Vfo:roscopic examination of the inguinal lymph nodes also showed metastatic melano-epithelioma. Approximately a year later (December l 949) the patient returned to the
94
R. P. MORROW, JR., L. B. WOOLNER AND J. L. EMMETT
clinic. Examination disclosed a metastatic lesion which involved the skin on the medial aspect of the right thigh. The lesion was excised and deep roentgen therapy was administered to the right thigh. On January 22, 1950, the patient was seen in urologic consultation because of terminal hematuria, which consisted of only one drop of blood on one occasion. He had no other symptoms referable to the urinary tract. Results of routine urinalysis were negative, except for microhematuria graded 1. Results of examination of the prostatic secretion were considered to be negative. On cystoscopic examination a small nodule 0.5 cm. in diameter was seen, high on the posterior wall of the bladder. It was noted that this lesion did not have the typical appearance of the usual tumor of the bladder, and that it was somewhat blue, containing several dark granules in its substance. Bimanual examination gave negative results. Bilateral pyelograms were considered to show nothing abnormal. Specimens were removed for microscopic examination, and the lesion was fulgurated. Microscopic examination of the excised specimen disclosed a malignant neoplasm in which melanin pigment was present in the tumor cells (fig. 1). The microscopic appearance was identical to that seen in sections obtained from the primary lesion of the great toe. A diagnosis was made of metastatic melanoepithelioma. SUMMARY
A cursory review of the literature reveals only 3 cases in which the urinary bladder has been secondarily involved with melano-epithelioma. In 1 case there was a necropsy report of generalized melanosis; in the other 2 there were primary vesical symptoms apparently caused by single melanomas of the bladder. The primary lesion in 1 case was located in the skin; in the second case, it was felt to be primary in the adrenal glands; in the third, no primary lesion was demonstrated. To the literature we have added an additional case in which the primary lesion was a melano-epithelioma of the great toe.
REFERENCES McCOMB, R. A. AND SMITH, D. B.: Melanotic sarcoma of the adrenal glands with a secondary tumour in the bladder. J. Urol., 30: 49-59, 1933. WAY, S. C. AND LIGHT, S. E.: Generalized melanosis; report of case, with necropsy. J.A. M.A., 94: 241-245, 1930. WHEELOCK, M. C.: Sarcoma of the urinary bladder. J. Urol., 48: 628-634, 1942.
Vol. 67, No. 1, January 1952 Printed in U.S.A.
METASTATIC MELANO-EPITHELIOMA OF THE URINARY BLADDER: REPORT OF A CASE ROBERT P. MORROW, JR. Fellow in Urology, Mayo Foundation
LEWIS B. WOOLNER Section on Surgical Pathology AND
JOHN L. EMMETT
Section on Urology, Mayo Clinic, Rochester, Minn.
Metastatic neoplasms constitute a very small percentage of tumors of the urinary bladder. Metastatic involvement of the bladder by melano-epithelioma apparently is rare; we have encountered only 3 such cases in a cursory review of the literature. Way and Light reported a case of generalized melanosis in which necropsy revealed almost every organ of the body to be involved from a primary melanoepithelioma of the skin. The urinary bladder was described as showing extensive involvement. McComb and Smith reported a case in which tumor of the bladder was treated by segmental resection. Microscopic examination disclosed melano-epithelioma. A search was made for a primary lesion, but none could be found. The patient died 13 months after operation, and necropsy showed both adrenal glands to be involved with what was presumed to be the primary lesion. At this time, numerous subcutaneous metastatic lesions also were demonstrable. Wheelock reported 4 cases of sarcoma and 1 of malignant melanoma of the urinary bladder. The author included the case of melano-epithelioma because at the time it was believed that melanomas were of connective-tissue origin. The tumor was treated by suprapubic implantation of radon seeds, followed by deep roentgen therapy. The patient died 7 months after operation. Postmortem examination was not carried out and no primary lesion was demonstrated before death; therefore, the author speculated that this lesion may have been primary in the bladder, having its origin from an embryonic cell rest. In the case we are presenting here the diagnosis was suspected preoperatively and was confirmed by biopsy. Because of the rarity of such a lesion, we feel that it is worth while to report this case. REPORT OF CASE
A man 47 years old was first seen in the Mayo Clinic in October 1948. His chief complaint at this time was persistent drainage from the base of the nail of the right great toe. He stated that in July 1947, he had first noted a small amount of drainage from the base of the nail of this toe. There was no pain associated with the lesion. The patient consulted his physician; after a trial of local therapy, the nail was removed and the nail bed was cauterized. This was followed by 92
METASTATIC :V!ELANO-EPITHELIOMA OF l'RI1'ARY DLADDIDR
93
complete healing in 2 weeks, )Jo other symptoms ,rnre noted until a short time prior to his examination at the clinic, The family history and the patient's history were n011contributory, Physical examination disclosed a healthy man, 5 feet, 11 inches in height, weighing 171 pounds. The blood pressure, pulse, respiration and temperature were normal. The right great toe presented a granular-appearing lesion on the lateral aspect of the nail bed. The nail had been removed surgically, There ,nu, a slight amount of purul,mt drainage from the lesion, but the toe 1Yas not tender. There ,1·ere Hevernl enlarged, non tender nodes in the right inguinal region, The Pdge of the liver was palpable, hut was not tender. Results of physicaJ examination otherwise were negative. Laboratory studies revealed the urine and blood to be normal. The m·ythrocyte sedimentation rate was 30 mm, in one hour by the vVestergren method.
Fw. 1. :\fotastatic nwlano-epithelionm of urirrnn· bln.dder. Histologic section of lcsi011 bln.ddcr, showing highly anapla.stic tumor cells containing rneln.uin pigment (hcmai.ox,·lin and eosiw X 400).
i11
H.e:mlts of tests of hepatic funetiou all were ,Yithin normal limits, as was the re:mli. of the fiocc:ulation test for syphilis. Hoentgenologic examination of the right foot failed to show any pathologic lesion of the bones. A roentgenogra.rn of the· thorax 1:,howed nothing significant. A malignant lesion was suspected. For this reason, the right inguinal lymph nocles were removed and the right great toe was amputated. Pathologic examination revealed an ulcerating subungnal melano-epithelioma. involving the right great toe. :.Vfo:roscopic examination of the inguinal lymph nodes also showed metastatic melano-epithelioma. Approximately a year later (December l 949) the patient returned to the
94
R. P. MORROW, JR., L. B. WOOLNER AND J. L. EMMETT
clinic. Examination disclosed a metastatic lesion which involved the skin on the medial aspect of the right thigh. The lesion was excised and deep roentgen therapy was administered to the right thigh. On January 22, 1950, the patient was seen in urologic consultation because of terminal hematuria, which consisted of only one drop of blood on one occasion. He had no other symptoms referable to the urinary tract. Results of routine urinalysis were negative, except for microhematuria graded 1. Results of examination of the prostatic secretion were considered to be negative. On cystoscopic examination a small nodule 0.5 cm. in diameter was seen, high on the posterior wall of the bladder. It was noted that this lesion did not have the typical appearance of the usual tumor of the bladder, and that it was somewhat blue, containing several dark granules in its substance. Bimanual examination gave negative results. Bilateral pyelograms were considered to show nothing abnormal. Specimens were removed for microscopic examination, and the lesion was fulgurated. Microscopic examination of the excised specimen disclosed a malignant neoplasm in which melanin pigment was present in the tumor cells (fig. 1). The microscopic appearance was identical to that seen in sections obtained from the primary lesion of the great toe. A diagnosis was made of metastatic melanoepithelioma. SUMMARY
A cursory review of the literature reveals only 3 cases in which the urinary bladder has been secondarily involved with melano-epithelioma. In 1 case there was a necropsy report of generalized melanosis; in the other 2 there were primary vesical symptoms apparently caused by single melanomas of the bladder. The primary lesion in 1 case was located in the skin; in the second case, it was felt to be primary in the adrenal glands; in the third, no primary lesion was demonstrated. To the literature we have added an additional case in which the primary lesion was a melano-epithelioma of the great toe.
REFERENCES McCOMB, R. A. AND SMITH, D. B.: Melanotic sarcoma of the adrenal glands with a secondary tumour in the bladder. J. Urol., 30: 49-59, 1933. WAY, S. C. AND LIGHT, S. E.: Generalized melanosis; report of case, with necropsy. J.A. M.A., 94: 241-245, 1930. WHEELOCK, M. C.: Sarcoma of the urinary bladder. J. Urol., 48: 628-634, 1942.