- Email: [email protected]
Transitional cell carcinoma associated with marijuana: Case report and review of the literature
CASE REPORT
TRANSITIONAL CELL CARCINOMA ASSOCIATED WITH MARIJUANA: CASE REPORT AND REVIEW OF THE LITERATURE ALAN M. NIEDER, MICHAEL C. LIPKE,
AND
SHAHAR MADJAR
ABSTRACT Transitional cell carcinoma of the bladder tends to occur in older patients with a history of tobacco use. We recently evaluated and treated a 45-year-old man with a history of heavy marijuana use. The patient’s only risk factor for transitional cell carcinoma was the inhalation of up to five marijuana cigarettes daily for more than 30 years. We present our case and review the literature. UROLOGY 67: 200.e5–200.e6, 2006. © 2006 Elsevier Inc.
T
ransitional cell carcinoma (TCC) of the bladder will affect approximately 60,000 Americans in 2005.1 The most significant risk factor for TCC is tobacco use.2 Other risk factors include occupational and chemical exposures. Furthermore, TCC tends to develop in older patients who have smoked for a significant number of years. Marijuana smoking has not yet been reported in association with TCC of the bladder in the English literature. We report the first such case. CASE REPORT An otherwise healthy 45-year-old man, employed as an electrical contractor, presented with gross painless hematuria of 2 months’ duration. The patient denied any history of tobacco use, chemical exposure, or family history of TCC. However, he reported smoking up to five marijuana cigarettes daily for 30 years. Computed tomography of the abdomen and pelvis demonstrated a 7-cm enhancing bladder mass suspicious for a bladder tumor. Cystoscopy revealed a large papillary lesion along the right lateral wall, with a few smaller papillary lesions. Transurethral resection of the bladder tumor was performed, and the pathologic examination demonstrated a high-grade Stage T1 From the Department of Urology, State University of New York at Stony Brook, Stony Brook, New York Address for correspondence: Alan M. Nieder, M.D., Department of Urology, University of Miami Miller School of Medicine, P.O. Box 016960 (M814), Miami, FL 33101. E-mail: [email protected] Submitted: May 18, 2005, accepted (with revisions): August 3, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
TCC, without any evidence of muscle invasion. He subsequently received 6 weeks of intravesical bacille Calmette-Guérin therapy. The cystoscopy and cytology findings were normal at the 3-month surveillance visit. The patient also stopped smoking marijuana. COMMENT Zeegers et al. performed a meta-analysis evaluating the risk factors for TCC. They reported that cigarette smokers have an approximately threefold greater risk of TCC than nonsmokers.3 They also found that a positive dose-response relationship exists between the number of cigarettes smoked per day and the number of years smoked. In a more comprehensive meta-analysis, Zeegers et al.2 reported on a weaker association between bladder cancer and cigar and pipe smoking. Pitard et al.4 similarly concluded that cigar and pipe smoking is carcinogenic to the bladder; however, the risk is less than for cigarette smoking. Marijuana use has been associated with other cancers, such as squamous cell carcinoma of the head and neck5 and carcinoma of the tongue.6 Men who smoke marijuana have also been noted to have an increased risk of prostate cancer.7 The carcinogenic effects of marijuana are secondary to cannabis smoke rather than a direct effect of the principal psychoactive agent tetrahydrocannabinol.8 Cannabis contains many of the same carcinogens found in tobacco, and cancers caused by smoking are most likely to develop in organs that receive long-term exposure to those carcinogens, such as the lung, upper airway tract, and bladder.9 These carcinogens include vinyl 3
0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.006 200.e5
chlorides, nitrosamines, phenols, and reactive oxygen species. Roth et al.8 demonstrated that marijuana smoke upregulated the carcinogen-metabolizing enzyme cytochrome P4501A1 (CYP1A1), an inducible enzyme linked to carcinogenesis. Furthermore, marijuana smoke was more potent than tobacco smoke in increasing the expression of CYP1A1. Wu et al.9 reported that marijuana produces a greater level of tar and carcinogenic agents compared with tobacco, secondary to the marijuana smoking habits, which include filterless products, deeper inhalation, and breath-holding. There has been only one report in the nonEnglish literature indicating a cause-and-effect relationship between marijuana and TCC. Moiche Bokobo et al.10 reported on a case of an upper tract TCC in a young, heavy marijuana user. Their patient was 36 years old and reportedly smoked up to 10 marijuana cigarettes a day for over 14 years. Should marijuana smokers with bladder cancer be encouraged to stop smoking? Only suggestive evidence is available that cigarette smokers who quit smoking have more favorable outcomes than those who continue to smoke.11,12 Nevertheless, quitting cigarette smoking is beneficial on numerous health levels. However, for the occasional, recreational marijuana smoker, little evidence is available to support smoking cessation to reduce the risk of bladder cancer. In fact, many patients may assume marijuana is safe because a preponderance of proposals have been generated to legalize marijuana for medical reasons. CONCLUSIONS We report the first case in the English literature of a case of bladder cancer associated with heavy marijuana smoking in a young man. Urologists should be encouraged to obtain a history, not only of cigarette smoking, but also of marijuana use.
200.e6
Additional epidemiologic studies are warranted to assess the association of bladder cancer and marijuana use. REFERENCES 1. Jemal A, Tiwari RC, Murray T, et al: Cancer statistics, 2004. CA Cancer J Clin 54: 8 –29, 2004. 2. Zeegers MP, Kellen E, Buntinx F, et al: The association between smoking, beverage consumption, diet and bladder cancer: a systematic literature review. World J Urol 21: 392– 401, 2004. 3. Zeegers MP, Goldbohm RA, and van den Brandt PA: A prospective study on active and environmental tobacco smoking and bladder cancer risk (The Netherlands). Cancer Causes Control 13: 83–90, 2002. 4. Pitard A, Brennan P, Clavel J, et al: Cigar, pipe, and cigarette smoking and bladder cancer risk in European men. Cancer Causes Control 12: 551–556, 2001. 5. Zhang ZF, Morgenstern H, Spitz MR, et al: Marijuana use and increased risk of squamous cell carcinoma of the head and neck. Cancer Epidemiol Biomarkers Prev 8: 1071– 1078, 1999. 6. Almadori G, Paludetti G, Cerullo M, et al: Marijuana smoking as a possible cause of tongue carcinoma in young patients. J Laryngol Otol 104: 896 – 899, 1990. 7. Sidney S, Quesenberry CP Jr, Friedman GD, et al: Marijuana use and cancer incidence (California, United States). Cancer Causes Control 8: 722–728, 1997. 8. Roth MD, Marques-Magallanes JA, Yuan M, et al: Induction and regulation of the carcinogen-metabolizing enzyme CYP1A1 by marijuana smoke and delta (9)-tetrahydrocannabinol. Am J Respir Cell Mol Biol 24: 339 –344, 2001. 9. Wu TC, Tashkin DP, Djahed B, et al: Pulmonary hazards of smoking marijuana as compared with tobacco. N Engl J Med 318: 347–351, 1988. 10. Moiche Bokobo P, Atxa de la Presa MA, and Cuesta Angulo J: [Transitional cell carcinoma in a young heavy marijuana smoker]. Arch Esp Urol 54: 165–167, 2001. 11. Fleshner N, Garland J, Moadel A, et al: Influence of smoking status on the disease-related outcomes of patients with tobacco-associated superficial transitional cell carcinoma of the bladder. Cancer 86: 2337–2345, 1999. 12. Aveyard P, Adab P, Cheng KK, et al: Does smoking status influence the prognosis of bladder cancer? A systematic review. BJU Int 90: 228 –239, 2002.
UROLOGY 67 (1), 2006
TRANSITIONAL CELL CARCINOMA ASSOCIATED WITH MARIJUANA: CASE REPORT AND REVIEW OF THE LITERATURE ALAN M. NIEDER, MICHAEL C. LIPKE,
AND
SHAHAR MADJAR
ABSTRACT Transitional cell carcinoma of the bladder tends to occur in older patients with a history of tobacco use. We recently evaluated and treated a 45-year-old man with a history of heavy marijuana use. The patient’s only risk factor for transitional cell carcinoma was the inhalation of up to five marijuana cigarettes daily for more than 30 years. We present our case and review the literature. UROLOGY 67: 200.e5–200.e6, 2006. © 2006 Elsevier Inc.
T
ransitional cell carcinoma (TCC) of the bladder will affect approximately 60,000 Americans in 2005.1 The most significant risk factor for TCC is tobacco use.2 Other risk factors include occupational and chemical exposures. Furthermore, TCC tends to develop in older patients who have smoked for a significant number of years. Marijuana smoking has not yet been reported in association with TCC of the bladder in the English literature. We report the first such case. CASE REPORT An otherwise healthy 45-year-old man, employed as an electrical contractor, presented with gross painless hematuria of 2 months’ duration. The patient denied any history of tobacco use, chemical exposure, or family history of TCC. However, he reported smoking up to five marijuana cigarettes daily for 30 years. Computed tomography of the abdomen and pelvis demonstrated a 7-cm enhancing bladder mass suspicious for a bladder tumor. Cystoscopy revealed a large papillary lesion along the right lateral wall, with a few smaller papillary lesions. Transurethral resection of the bladder tumor was performed, and the pathologic examination demonstrated a high-grade Stage T1 From the Department of Urology, State University of New York at Stony Brook, Stony Brook, New York Address for correspondence: Alan M. Nieder, M.D., Department of Urology, University of Miami Miller School of Medicine, P.O. Box 016960 (M814), Miami, FL 33101. E-mail: [email protected] Submitted: May 18, 2005, accepted (with revisions): August 3, 2005 © 2006 ELSEVIER INC. ALL RIGHTS RESERVED
TCC, without any evidence of muscle invasion. He subsequently received 6 weeks of intravesical bacille Calmette-Guérin therapy. The cystoscopy and cytology findings were normal at the 3-month surveillance visit. The patient also stopped smoking marijuana. COMMENT Zeegers et al. performed a meta-analysis evaluating the risk factors for TCC. They reported that cigarette smokers have an approximately threefold greater risk of TCC than nonsmokers.3 They also found that a positive dose-response relationship exists between the number of cigarettes smoked per day and the number of years smoked. In a more comprehensive meta-analysis, Zeegers et al.2 reported on a weaker association between bladder cancer and cigar and pipe smoking. Pitard et al.4 similarly concluded that cigar and pipe smoking is carcinogenic to the bladder; however, the risk is less than for cigarette smoking. Marijuana use has been associated with other cancers, such as squamous cell carcinoma of the head and neck5 and carcinoma of the tongue.6 Men who smoke marijuana have also been noted to have an increased risk of prostate cancer.7 The carcinogenic effects of marijuana are secondary to cannabis smoke rather than a direct effect of the principal psychoactive agent tetrahydrocannabinol.8 Cannabis contains many of the same carcinogens found in tobacco, and cancers caused by smoking are most likely to develop in organs that receive long-term exposure to those carcinogens, such as the lung, upper airway tract, and bladder.9 These carcinogens include vinyl 3
0090-4295/06/$32.00 doi:10.1016/j.urology.2005.08.006 200.e5
chlorides, nitrosamines, phenols, and reactive oxygen species. Roth et al.8 demonstrated that marijuana smoke upregulated the carcinogen-metabolizing enzyme cytochrome P4501A1 (CYP1A1), an inducible enzyme linked to carcinogenesis. Furthermore, marijuana smoke was more potent than tobacco smoke in increasing the expression of CYP1A1. Wu et al.9 reported that marijuana produces a greater level of tar and carcinogenic agents compared with tobacco, secondary to the marijuana smoking habits, which include filterless products, deeper inhalation, and breath-holding. There has been only one report in the nonEnglish literature indicating a cause-and-effect relationship between marijuana and TCC. Moiche Bokobo et al.10 reported on a case of an upper tract TCC in a young, heavy marijuana user. Their patient was 36 years old and reportedly smoked up to 10 marijuana cigarettes a day for over 14 years. Should marijuana smokers with bladder cancer be encouraged to stop smoking? Only suggestive evidence is available that cigarette smokers who quit smoking have more favorable outcomes than those who continue to smoke.11,12 Nevertheless, quitting cigarette smoking is beneficial on numerous health levels. However, for the occasional, recreational marijuana smoker, little evidence is available to support smoking cessation to reduce the risk of bladder cancer. In fact, many patients may assume marijuana is safe because a preponderance of proposals have been generated to legalize marijuana for medical reasons. CONCLUSIONS We report the first case in the English literature of a case of bladder cancer associated with heavy marijuana smoking in a young man. Urologists should be encouraged to obtain a history, not only of cigarette smoking, but also of marijuana use.
200.e6
Additional epidemiologic studies are warranted to assess the association of bladder cancer and marijuana use. REFERENCES 1. Jemal A, Tiwari RC, Murray T, et al: Cancer statistics, 2004. CA Cancer J Clin 54: 8 –29, 2004. 2. Zeegers MP, Kellen E, Buntinx F, et al: The association between smoking, beverage consumption, diet and bladder cancer: a systematic literature review. World J Urol 21: 392– 401, 2004. 3. Zeegers MP, Goldbohm RA, and van den Brandt PA: A prospective study on active and environmental tobacco smoking and bladder cancer risk (The Netherlands). Cancer Causes Control 13: 83–90, 2002. 4. Pitard A, Brennan P, Clavel J, et al: Cigar, pipe, and cigarette smoking and bladder cancer risk in European men. Cancer Causes Control 12: 551–556, 2001. 5. Zhang ZF, Morgenstern H, Spitz MR, et al: Marijuana use and increased risk of squamous cell carcinoma of the head and neck. Cancer Epidemiol Biomarkers Prev 8: 1071– 1078, 1999. 6. Almadori G, Paludetti G, Cerullo M, et al: Marijuana smoking as a possible cause of tongue carcinoma in young patients. J Laryngol Otol 104: 896 – 899, 1990. 7. Sidney S, Quesenberry CP Jr, Friedman GD, et al: Marijuana use and cancer incidence (California, United States). Cancer Causes Control 8: 722–728, 1997. 8. Roth MD, Marques-Magallanes JA, Yuan M, et al: Induction and regulation of the carcinogen-metabolizing enzyme CYP1A1 by marijuana smoke and delta (9)-tetrahydrocannabinol. Am J Respir Cell Mol Biol 24: 339 –344, 2001. 9. Wu TC, Tashkin DP, Djahed B, et al: Pulmonary hazards of smoking marijuana as compared with tobacco. N Engl J Med 318: 347–351, 1988. 10. Moiche Bokobo P, Atxa de la Presa MA, and Cuesta Angulo J: [Transitional cell carcinoma in a young heavy marijuana smoker]. Arch Esp Urol 54: 165–167, 2001. 11. Fleshner N, Garland J, Moadel A, et al: Influence of smoking status on the disease-related outcomes of patients with tobacco-associated superficial transitional cell carcinoma of the bladder. Cancer 86: 2337–2345, 1999. 12. Aveyard P, Adab P, Cheng KK, et al: Does smoking status influence the prognosis of bladder cancer? A systematic review. BJU Int 90: 228 –239, 2002.
UROLOGY 67 (1), 2006