Metastatic Transitional Cell Carcinoma of the Urinary Bladder to the Shoulder Girdle

CASE REVIEW Metastatic Transitional Cell Carcinoma of the Urinary Bladder to the Shoulder Girdle Alon Z. Weizer, MD, Shahrokh F. Shariat, MD, John L. Haddad, MD, Susan Escudier, MD, Seth P. Lerner, MD Baylor College of Medicine, Houston, TX Transitional cell carcinoma (TCC) of the bladder typically metastasizes to the pelvic lymph nodes and to visceral sites including the lungs, liver, and bones. Other sites include the brain, especially after systemic chemotherapy. To our knowledge, we report the first case of TCC metastatic to the soft tissue of the shoulder girdle and discuss common and unusual sites of metastasis in TCC. [Rev Urol. 2002;4(2):97–99] © 2002 MedReviews, LLC Key words: Metastasis • Transitional cell carcinoma • Bladder cancer • Shoulder 54-year-old male presented with gross, painless hematuria in May 1997, and cystoscopy revealed a large sessile tumor covering the left ureteral orifice after resection pathology demonstrated a grade 3/3 transitional cell carcinoma (TCC) with areas of moderately differentiated adenocarcinoma extensively involving the muscularis propria with lymphovascular invasion and multifocal carcinoma in situ (CIS). Biopsies of the prostatic urethra were normal. p53 IHC was performed on the specimen obtained from the transurethral resection of the bladder tumor using a commercially available monoclonal antibody (DO-7; DAKO, Glostrup, Denmark). Figure 1A and B shows the specimen staining positive for p53 in more than 90% of the tumor cell nuclei and a hematoxylin and eosinstained specimen in the same area for comparison. A metastatic evaluation, including computed tomography scan of the abdomen and pelvis, bone scan, and chest radiographs was negative, and the clinical stage was T2N0M0. A VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY 97 Unusual TCC Metastasis continued A B Figure 1. (A) 200x magnification of the presenting mass stained with hematoxylin and eosin showing a high-grade transitional cell carcinoma of the urinary bladder with marked nuclear atypia. (B) The same area of the tumor showing strong immunostaining for p53. (DO-7). The patient then underwent a radical cystoprostatectomy with pelvic and iliac lymphadenectomy followed by an orthotopic continent urinary diversion. There was only residual CIS in the bladder and a microscopic metastasis to one perivesical lymph node. Because of the positive lymph node and lymphovascular invasion, he underwent 3 of 4 planned courses of adjuvant chemotherapy with methotrexate, vinblastine, doxorubicin, and cisplatin. This was discontinued because of toxicity, including nausea, vomiting, diarrhea, anorexia, anemia, apthous ulcers, and A 98 two febrile urinary tract infections. The patient presented 2 months later complaining of right shoulder and neck pain. There was a palpable soft tissue mass in the right posterior shoulder. A T2 weighted MRI showed two soft tissue masses with no bony involvement (Figure 2A and B). A fine-needle aspiration of one of these masses showed metastatic carcinoma consistent with high-grade TCC (Figure 3). The bone scan showed metastatic disease in the right scapula, left and right femur, left SI joint, and left ilium. The patient was started on a taxol/carboplatin regimen with B VOL. 4 NO. 2 2002 REVIEWS IN UROLOGY Figure 3. High-power view of a cluster of high-grade carcinoma cells obtained from the FNA of a soft tissue mass from the right shoulder. This Papanicolaouísstained cluster shows carcinoma in all cells characterized by a high nuclear-tocytoplasmic ratio, multiple nucleoli, and nuclear pleomorphism consistent with transitional cell carcinoma. subjective decrease in the shoulder mass after the first cycle receiving a total of two cycles. Five weeks after starting salvage chemotherapy, he was admitted to the hospital with rapid weight loss and dehydration and expired 10 months after his cystectomy. Discussion We performed an extensive MEDLINE search from 1966 to present and could not identify any cases of metastasis to the shoulder girdle from TCC of the urinary bladder. Tumors in this location are usually of Figure 2. (A) Coronal oblique T2weighted fast spin-echo MRI images demonstrating two heterogeneous signal intensity soft tissue masses (white arrowheads), one (A) deep to the supraspinatous muscle belly measured 4 x 2.2 x 2.6 cm. (B) The second was situated between the infraspinatous and teres minor muscle bellies and measured 2.6 x 2.5 x 2.5 cm. Surrounding edema was present. Unusual TCC Metastasis osseous origin. Metastatic involvement of this region usually involves the surrounding bony structures. The joint space or soft tissue of the shoulder girdle are usually involved only when there has been direct extension of a tumor from bone.1 In a report of 107 patients, the most common site of metastasis of TCC was to the regional lymph nodes (78%). Other common sites included the liver (38%), lung (36%), bone (27%), adrenal gland (21%), and intestine (13%).2 Many unusual sites of metastatic TCC have also been reported. In the same series, Babaian and colleagues. reported metastases to the heart, brain, kidney, spleen, pancreas, meninges, uterus, ovary, prostate, and testes in 1% to 8% of their patients.2 Dhote and colleagues reported metastases in the brain after systemic chemotherapy.3 Several case reports have demonstrated seeding and implantation of TCC to sites including nephrostomy tracts, laparoscopic and abdominal incisions, the labia minora, and the umbilicus. Other unusual sites include the breast, seminal vesicles, and vas deferens. Our experience with this patient also supports the potential application of p53 IHC in assessing prognosis and response to chemotherapy in patients with muscle invasive and metastatic TCC, as suggested by Sarkis et al.4 Esrig et al. demonstrated that accumulation of p53 by IHC was associated with an increased risk of recurrence and death, independent of tumor grade, stage, and lymph node status in 243 patients who underwent radical cystectomy.5 We have confirmed these findings in a group of 80 patients treated with radical cystectomy.6 References 1. 2. 3. 4. 5. 6. Marcove RC. Neoplasms of the shoulder girdle. Orthop Clin North Am.1975;6:541-552. Babaian RJ, Johnson DE, Llamas L, Ayala AG. Metastases from transitional cell carcinoma of urinary bladder. Urology. 1980;16:142-144. Dhote R, Beuzeboc P, Thiounn N, et al. High incidence of brain metastases in patients treated with an M-VAC regimen for advanced bladder cancer. Eur Urol. 1998;33:392-395. Sarkis AS, Bajorin DF, Reuter VE, et al. Prognostic value of p53 nuclear overexpression in patients with invasive bladder cancer treated with neoadjuvant MVAC. J Clin Oncol 1995;13:1384-1390. Esrig D, Elmajian D, Groshen S, et al. Accumulation of nuclear p53 and tumor progression in bladder cancer. N Engl J Med. 1994;331:1259-1264. Lerner, SP, Benedict, WF, Green, A et al. Molecular staging and prognosis following radical cystectomy using p53 and retinoblastoma protein expression [abstract]. J Urol. 1998;159 (suppl):165. Main Points • Transitional cell carcinoma (TCC) of the bladder commonly metastasizes to the pelvic lymph nodes, lungs, liver, bones, adrenals, or brain. • Unusual sites include the heart, kidney, spleen, pancreas, and reproductive system. • The first case of TCC metastatic to soft tissue of the shoulder girdle is reported, an area usually involved from bone tumor extensions. • p53 IHC may be useful in prognosis and response to chemotherapy. • Accumulation of p53 radical cystectomy. by IHC was associated with greater risk of recurrence and death in patients who had VOL. 4 NO. 1 2002 REVIEWS IN UROLOGY 99