Pulmonary Metastasis Due to Superficial
Transitional Cell Carcinoma of Urinary
Bladder, A Rare Case Report and Literature Review
Ikram Ul Haq Chaudhry*, Irfan S Khan, Ahsan Cheema, Hadi Mutairi and Ibrahim Oraifi
Division of Chest Surgery, Urology and Pathology, King Fahad Specialist Hospital, Saud Arabia
Submission: September 28, 2018; Published: October 12, 2018
*Corresponding author: Ikram Ul Haq Chaudhry, Division of Chest Surgery, Urology and Pathology, King Fahad Specialist Hospital, Dammam, Saud Arabia.
How to cite this article: Ikram U H C, Irfan S K, Ahsan C, Hadi M, Ibrahim O. Pulmonary Metastasis Due to Superficial Transitional Cell Carcinoma of
Urinary Bladder, A Rare Case Report and Literature Review. J Anest & Inten Care Med. 2018; 7(5): 555722. DOI: 10.19080/JAICM.2018.07.555722
Urinary bladder Transitional Cell (TCC) carcinoma usually remains superficial. Only 5-20% cases can progress to muscle invasion and metastasis. Liver, lung, mediastinum and bone are the common sites for metastasis. Although long term survival of patients with metastasis is poor. We present a rare case of TCC with pulmonary nodule which treated with Video Assisted Thoracoscopic (VATS) lung resection. Histopathology report revealed transitional cell carcinoma of urinary bladder origin. Patient remained disease free to date as her CT scan of thorax and follow up cystoscopic examinations showed no recurrence.
Keywords: TCC; Urinary bladder; Metastasis; Lung; VATS; Surgery
TCC is the most common malignant neoplasm of urinary tract. Overall incidence of urinary bladder cancer is 10.1 and 2.5 per 100,000 in male and female respectively . American cancer society reported 68,810 new cases of TCC in 2008. Seventy percent of newly diagnosed TCC cases have superficial disease (stage Ta, T1, or carcinoma in situ) . Due to recent advances in chemotherapy and early diagnosis survival rate has increased significantly in patients with urinary bladder cancer and this has led to increase in the number of patients developing a second primary cancer which is almost 16% according to NC I surveillance . The stage and grade of TCC has great impact on survival and prognosis. We present two cases of urinary bladder cancer with pulmonary nodule. Pulmonary nodules were resected by Video
Assisted Thoracoscopic Surgery (VATS) and histopathology report revealed metastatic TCC of urinary bladder origin.
52 years old lady had nine years history of superficial urothelial carcinoma of the urinary bladder. She was treated with intravesical BCG therapy; follow up cystoscopic and biopsy showed no recurrence. In 2010, CT scan of the chest showed right upper lobe pulmonary lesion (Figure 1A). By VATS pulmonary nodule was resected. Her post-operative recovery was uneventful. Histopathology report showed metastatic TCC of urinary bladder origin (Figures 2A & 2B). Recent CT scan of chest showed no evidence of recurrence (Figures 1A & 1B).
Urinary bladder cancer is more common in smokers and in
those who are exposed to aromatic amines e.g. working in paint,
iron and aluminum, printing, tar and gas industries . Incidence
of bladder cancer is related to duration and number of cigarette
packs consumed. Two out of three urinary bladder cancer patients
are smokers. In another study Livi & Germic reported smoking
related risk of two primary cancers is 10-20 % [5,6].
Superficial bladder cancer by nature remains confined to
superficial layers but local recurrence is more common. TCC
commonly remains confined to urinary bladder; distal spread
is usually via lymphatic. The most common sites of distant
metastasis are distant lymph nodes, liver, lung, mediastinum, bone
and adrenal gland. Pulmonary metastasis is most of the time well
defined solitary and without any calcification or cavitation. Only
4 % of lung lesions progresses to cavitation due to necrosis. The
important prognostic factors for survival are site of metastasis
and response to advent chemotherapy [7,8].
As the patients with lung and soft tissue metastasis has better
survival as compared to those who have liver and bone metastasis.
Prognosis is poor if Karnosfsky performance status is less than 80
which includes weight loss, elevated serum alkaline phosphatase
or LDH levels and non TCC histopathology [9,10]. Metastatic
site can reveal adenocarcinoma or squamous cell carcinoma
this can be reflection of stem cell function of TCC or the second
primary . Pulmonary nodule in the presence of TCC should
be differentiated from second primary lung carcinoma. Some
urological surgical procedures such as ureterosigmoidostomy may
induce second primary neoplasm . Superficial bladder cancer
rarely progresses to invasive or metastasis stage. Sometimes
superficial bladder cancer patient can have second primary lung
cancer Finnish cancer registry data showed 1300 second primary
cancer patients in 77548 lung cancer patients including 140 cases
of urinary bladder cancer .
Diagnosis of urinary bladder cancer is based on several
factors including symptoms, imaging investigations including
IVU, USS and CT will clinch the diagnosis. Urine cytology may be
positive for malignant cells in high grade tumors and in cases of
CIS. Preoperative work up and correct diagnosis and staging using
proper diagnostic modalities are essential for treatment and future
prognosis. Superficial urinary bladder cancer rarely progresses
to invasive or metastasis stage though it is more common cancer
in urogenital system, only a few cases of superficial urinary
bladder cancer with pulmonary metastasis have been reported in
In conclusion we report a rare case of lung metastasis from
TCC of urinary bladder. This was resected by VATS, after seven
years patient CT scan thorax showed no recurrence (Figure 3).
Mainstay of treatment for superficial TCC is bladder sparing
surgery followed by intravesical chemotherapy. Although lung
metastasis is rare after TCC of urinary bladder still surgical
resection is mandatory and can provide excellent long-term