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Renal cell carcinoma with solitary metachronous metastasis to the urinary bladder
CASE REPORT
RENAL CELL CARCINOMA WITH SOLITARY METACHRONOUS METASTASIS TO THE URINARY BLADDER MANABU MATSUO, SHIGEHIKO KOGA, MASAHARU NISHIKIDO, MITSURU NOGUCHI, MIKI SAKAGUCHI, KOICHIRO NOMATA, NAOKI MARUTA, TOMAYOSHI HAYASHI, AND HIROSHI KANETAKE
ABSTRACT We report a case of renal cell carcinoma with solitary metachronous metastasis to the urinary bladder occurring 6 years after radical nephrectomy. The patient was treated with partial cystectomy and survived for 60 months. Other cases like this one were reviewed in published reports, and the 3-year survival rate for patients with this type of cancer with solitary metastasis to the urinary bladder was found to be 80%. The follow-up duration of our case was the longest in the published studies. We suggest that urinary bladder metastasis of renal cell carcinoma should be resected because no effective treatment for metastatic renal cell carcinoma is available. A good prognosis may be expected, especially in patients with solitary metastasis to the urinary bladder. UROLOGY 60: 911xiii–911xiv, 2002. © 2002, Elsevier Science Inc.
R
enal cell carcinoma frequently presents with distant metastasis. However, involvement of the urinary bladder is rarely diagnosed during life, and few studies have reported the survival rate of patients with renal cell carcinoma with metastasis to the urinary bladder. We present a case of solitary metachronous metastasis to the urinary bladder and review the associated published data to evaluate the prognosis of surgical management.
mography (Fig. 1) revealed a solid mass in the anterior bladder wall. Resection biopsies revealed metastatic renal cell carcinoma in the bladder wall. No other metastases were evident. She underwent partial cystectomy. The histologic examination of the tumor confirmed metastatic renal cell carcinoma occurring from the bladder wall (Fig. 2). The tumor was identical to the renal cell carcinoma in the right kidney. This patient was free of recurrent disease at 60 months of follow-up.
CASE REPORT A 77-year-old woman presented with painless gross hematuria. The computed tomography results suggested a right renal tumor. Metastasis to the urinary bladder or any other metastases was not evident. Bone scans showed negative findings. Right radical nephrectomy was performed, and the pathologic examination revealed renal cell carcinoma (clear cell, grade 1, pT2N0M0). The tumor penetrated the renal pelvis. She again presented with painless gross hematuria 6 years after the radical nephrectomy. Cystoscopy and computed toFrom the Department of Urology, Nagasaki University School of Medicine; and Department of Pathology, Nagasaki University Hospital, Nagasaki City, Nagasaki, Japan Address for correspondence: Shigehiko Koga, M.D., Department of Urology, Nagasaki University School of Medicine, Nagasaki City, Nagasaki 852-8501, Japan Submitted: April 15, 2002, accepted (with revisions): June 17, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
COMMENT Urinary bladder metastasis from renal cell carcinoma is rarely diagnosed during life. To our knowledge, 27 cases have been reported in detail.1–7 Ten of them were Japanese cases. Our case brings the total to 28, which form the basis of this discussion. These 28 cases consisted of 20 males and 8 females. Their age ranged from 12 to 86 years (median 58). The diagnosis of urinary bladder metastasis was made within 6 months of nephrectomy in 10 cases (synchronous metastasis) and more than 6 months after nephrectomy in 18 cases (metachronous metastasis). The follow-up duration of our case was the longest of the published cases. The 3-year survival rate was 80% for solitary urinary bladder metastasis (n ⫽ 13) and 20% for multiple metastases (more than two metastases, including urinary bladder metastasis; n ⫽ 15). The difference between the survival rates was statisti0090-4295/02/$22.00 PII S0090-4295(02)01900-3 911xiii
FIGURE 1. Computed tomography scan showing a mass in the urinary bladder wall (arrow).
FIGURE 2. Tumor showing clear cell pattern identical histologically to previous renal cell carcinoma. Note bladder mucosa in lower left corner. Hematoxylin-eosin stain, reduced from ⫻150.
cally significant (log-rank test, P ⫽ 0.026). One half of the patients with multiple metastases, including urinary bladder metastasis, died within 1 year. The mean duration from nephrectomy to detection of the urinary bladder metastasis was 28 months (range 0 to 131). The mean survival time was 17.5 months (range 4 to 36) for synchronous urinary bladder metastasis and 15.8 months (range 4 to 60) for metachronous urinary bladder metastasis. The survival rates were not significantly different for patients with synchronous and those with metachronous urinary bladder metastasis (log-rank test, P ⫽ 0.7). These results suggest that the prognosis is not related to the interval between nephrectomy and the appearance of urinary bladder metastasis. The mechanism of spread to the urinary bladder is controversial. Several investigators have proposed direct extension and implantation.8,9 Shaw10 and Abeshouse11 suggested that metastases to the urinary bladder occurred by way of retrograde ve-
911xiv
nous embolism of tumor cells from the renal vein into the numerous venous connections to the left renal vein. Their theory was supported by several reports of left-sided renal tumors leading to the bladder. We reviewed the side of the primary tumor and found 11 tumors on the left and 17 tumors on the right. These findings do not support the above theory. It is possible that lymphatic spread accounts for the metastasis to the urinary bladder.9 Swanson and Liles12 recommended that cystoscopy should be performed in patients with renal cell carcinoma and hematuria. We agree with their careful evaluation of the urinary bladder. All 28 patients reviewed in published studies underwent surgical treatment of the metastatic bladder lesion, including transurethral resection in 20, partial cystectomy in 6, total cystectomy in 1, and fulguration in 1. Urinary bladder metastasis of renal cell carcinoma should be surgically resected, because no effective treatment of metastatic renal cell carcinoma is available. A good prognosis may then be expected, especially in patients with solitary urinary bladder metastasis. REFERENCES 1. Tanikawa K, and Matsushita K: Bladder metastasis from renal cell carcinoma three years after nephrectomy. Hinyokika Kiyo 36: 927–929, 1990. 2. Gelister JSK, Falzon M, Crawford R, et al: Urinary tract metastasis from renal carcinoma. Br J Urol 69: 250 –252, 1992. 3. Uygur MC, Ozen HA, Sungur A, et al: A solitary and synchronous metastasis of renal cell carcinoma to the bladder. Int Urol Nephrol 26: 529 –533, 1994. 4. Takatama K, Rin M, Hosokawa H, et al: Bladder metastasis of renal cell carcinoma: a case report. Hinyokigeka 7: 63–65, 1994. 5. Chinegwundoh FI, Khor T, and Leedham PW: Bladder metastasis from renal cell carcinoma. Br J Urol 79: 650 –651, 1997. 6. Sim SJ, Ro JY, Ordonez NG, et al: Metastatic renal cell carcinoma to the bladder: a clinicopathologic and immunohistochemical study. Mod Pathol 12: 351–355, 1999. 7. Takahashi E, Ikegami S, Sumitomo M, et al: Bladder metastasis of renal cell carcinoma: a case report. Rinsho Hinyokika 55: 489 –491, 2001. 8. Heslin JE, Milner WA, and Garlick WB: Lower urinary tract implants or metastases from clear cell carcinoma of the kidney. J Urol 72: 39 –46, 1955. 9. Remis RE, and Halverstadt DB: Metastatic renal cell carcinoma to the bladder: case report and review of the literature. J Urol 136: 1294 –1296, 1986. 10. Shaw RE: Metastasis to the bladder from carcinoma of the kidney. Br J Surg 48: 420 –422, 1961. 11. Abeshouse BS: Metastasis to ureters and urinary bladder from renal cell carcinoma: report of 2 cases. J Intern Coll Surg 25: 117–126, 1958. 12. Swanson DA, and Liles A: Bladder metastasis: a rare cause of hematuria in renal cell carcinoma. J Surg Oncol 20: 80 –82, 1982.
UROLOGY 60 (5), 2002
RENAL CELL CARCINOMA WITH SOLITARY METACHRONOUS METASTASIS TO THE URINARY BLADDER MANABU MATSUO, SHIGEHIKO KOGA, MASAHARU NISHIKIDO, MITSURU NOGUCHI, MIKI SAKAGUCHI, KOICHIRO NOMATA, NAOKI MARUTA, TOMAYOSHI HAYASHI, AND HIROSHI KANETAKE
ABSTRACT We report a case of renal cell carcinoma with solitary metachronous metastasis to the urinary bladder occurring 6 years after radical nephrectomy. The patient was treated with partial cystectomy and survived for 60 months. Other cases like this one were reviewed in published reports, and the 3-year survival rate for patients with this type of cancer with solitary metastasis to the urinary bladder was found to be 80%. The follow-up duration of our case was the longest in the published studies. We suggest that urinary bladder metastasis of renal cell carcinoma should be resected because no effective treatment for metastatic renal cell carcinoma is available. A good prognosis may be expected, especially in patients with solitary metastasis to the urinary bladder. UROLOGY 60: 911xiii–911xiv, 2002. © 2002, Elsevier Science Inc.
R
enal cell carcinoma frequently presents with distant metastasis. However, involvement of the urinary bladder is rarely diagnosed during life, and few studies have reported the survival rate of patients with renal cell carcinoma with metastasis to the urinary bladder. We present a case of solitary metachronous metastasis to the urinary bladder and review the associated published data to evaluate the prognosis of surgical management.
mography (Fig. 1) revealed a solid mass in the anterior bladder wall. Resection biopsies revealed metastatic renal cell carcinoma in the bladder wall. No other metastases were evident. She underwent partial cystectomy. The histologic examination of the tumor confirmed metastatic renal cell carcinoma occurring from the bladder wall (Fig. 2). The tumor was identical to the renal cell carcinoma in the right kidney. This patient was free of recurrent disease at 60 months of follow-up.
CASE REPORT A 77-year-old woman presented with painless gross hematuria. The computed tomography results suggested a right renal tumor. Metastasis to the urinary bladder or any other metastases was not evident. Bone scans showed negative findings. Right radical nephrectomy was performed, and the pathologic examination revealed renal cell carcinoma (clear cell, grade 1, pT2N0M0). The tumor penetrated the renal pelvis. She again presented with painless gross hematuria 6 years after the radical nephrectomy. Cystoscopy and computed toFrom the Department of Urology, Nagasaki University School of Medicine; and Department of Pathology, Nagasaki University Hospital, Nagasaki City, Nagasaki, Japan Address for correspondence: Shigehiko Koga, M.D., Department of Urology, Nagasaki University School of Medicine, Nagasaki City, Nagasaki 852-8501, Japan Submitted: April 15, 2002, accepted (with revisions): June 17, 2002 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
COMMENT Urinary bladder metastasis from renal cell carcinoma is rarely diagnosed during life. To our knowledge, 27 cases have been reported in detail.1–7 Ten of them were Japanese cases. Our case brings the total to 28, which form the basis of this discussion. These 28 cases consisted of 20 males and 8 females. Their age ranged from 12 to 86 years (median 58). The diagnosis of urinary bladder metastasis was made within 6 months of nephrectomy in 10 cases (synchronous metastasis) and more than 6 months after nephrectomy in 18 cases (metachronous metastasis). The follow-up duration of our case was the longest of the published cases. The 3-year survival rate was 80% for solitary urinary bladder metastasis (n ⫽ 13) and 20% for multiple metastases (more than two metastases, including urinary bladder metastasis; n ⫽ 15). The difference between the survival rates was statisti0090-4295/02/$22.00 PII S0090-4295(02)01900-3 911xiii
FIGURE 1. Computed tomography scan showing a mass in the urinary bladder wall (arrow).
FIGURE 2. Tumor showing clear cell pattern identical histologically to previous renal cell carcinoma. Note bladder mucosa in lower left corner. Hematoxylin-eosin stain, reduced from ⫻150.
cally significant (log-rank test, P ⫽ 0.026). One half of the patients with multiple metastases, including urinary bladder metastasis, died within 1 year. The mean duration from nephrectomy to detection of the urinary bladder metastasis was 28 months (range 0 to 131). The mean survival time was 17.5 months (range 4 to 36) for synchronous urinary bladder metastasis and 15.8 months (range 4 to 60) for metachronous urinary bladder metastasis. The survival rates were not significantly different for patients with synchronous and those with metachronous urinary bladder metastasis (log-rank test, P ⫽ 0.7). These results suggest that the prognosis is not related to the interval between nephrectomy and the appearance of urinary bladder metastasis. The mechanism of spread to the urinary bladder is controversial. Several investigators have proposed direct extension and implantation.8,9 Shaw10 and Abeshouse11 suggested that metastases to the urinary bladder occurred by way of retrograde ve-
911xiv
nous embolism of tumor cells from the renal vein into the numerous venous connections to the left renal vein. Their theory was supported by several reports of left-sided renal tumors leading to the bladder. We reviewed the side of the primary tumor and found 11 tumors on the left and 17 tumors on the right. These findings do not support the above theory. It is possible that lymphatic spread accounts for the metastasis to the urinary bladder.9 Swanson and Liles12 recommended that cystoscopy should be performed in patients with renal cell carcinoma and hematuria. We agree with their careful evaluation of the urinary bladder. All 28 patients reviewed in published studies underwent surgical treatment of the metastatic bladder lesion, including transurethral resection in 20, partial cystectomy in 6, total cystectomy in 1, and fulguration in 1. Urinary bladder metastasis of renal cell carcinoma should be surgically resected, because no effective treatment of metastatic renal cell carcinoma is available. A good prognosis may then be expected, especially in patients with solitary urinary bladder metastasis. REFERENCES 1. Tanikawa K, and Matsushita K: Bladder metastasis from renal cell carcinoma three years after nephrectomy. Hinyokika Kiyo 36: 927–929, 1990. 2. Gelister JSK, Falzon M, Crawford R, et al: Urinary tract metastasis from renal carcinoma. Br J Urol 69: 250 –252, 1992. 3. Uygur MC, Ozen HA, Sungur A, et al: A solitary and synchronous metastasis of renal cell carcinoma to the bladder. Int Urol Nephrol 26: 529 –533, 1994. 4. Takatama K, Rin M, Hosokawa H, et al: Bladder metastasis of renal cell carcinoma: a case report. Hinyokigeka 7: 63–65, 1994. 5. Chinegwundoh FI, Khor T, and Leedham PW: Bladder metastasis from renal cell carcinoma. Br J Urol 79: 650 –651, 1997. 6. Sim SJ, Ro JY, Ordonez NG, et al: Metastatic renal cell carcinoma to the bladder: a clinicopathologic and immunohistochemical study. Mod Pathol 12: 351–355, 1999. 7. Takahashi E, Ikegami S, Sumitomo M, et al: Bladder metastasis of renal cell carcinoma: a case report. Rinsho Hinyokika 55: 489 –491, 2001. 8. Heslin JE, Milner WA, and Garlick WB: Lower urinary tract implants or metastases from clear cell carcinoma of the kidney. J Urol 72: 39 –46, 1955. 9. Remis RE, and Halverstadt DB: Metastatic renal cell carcinoma to the bladder: case report and review of the literature. J Urol 136: 1294 –1296, 1986. 10. Shaw RE: Metastasis to the bladder from carcinoma of the kidney. Br J Surg 48: 420 –422, 1961. 11. Abeshouse BS: Metastasis to ureters and urinary bladder from renal cell carcinoma: report of 2 cases. J Intern Coll Surg 25: 117–126, 1958. 12. Swanson DA, and Liles A: Bladder metastasis: a rare cause of hematuria in renal cell carcinoma. J Surg Oncol 20: 80 –82, 1982.
UROLOGY 60 (5), 2002