LATE RECURRENCE CARCINOMA
CELL
OF BLADDER
JOHN F. REDMAN, B. T. TRANUM,
OF TRANSITIONAL
M.D.
M.D.
From the Departments of Urology and Medicine (Section of Hematology), University of Arkansas College of Medicine, Little Rock, Arkansas
ABSTRACT - The case is presented of a patient with local recurrence eleven years after preoperative irradiation and cystourethrectomy.
of transitional
cell carcinoma
It has been stated from a series of patients undergoing preoperative irradiation or total cystectomy that most patients who are not cured of bladder cancer die within three years.’ Pearse, Pappas, and Hodges’ recording ten-year survivals after radical cystectomy for bladder cancer noted that 10 per cent of five-year survivors had residual carcinoma that ultimately caused death. Because of the importance of information concerning recurrence patterns of bladder tumor, we report an instance of late recurrence of transitional cell carcinoma of the bladder treated by cystourethrectomy following irradiation.3 Case Report A fifty-six-year-old white female, with a history of cystectomy and ileal conduit diversion eleven years previously, was seen at University Hospital in February, 1975, with a history of a malodorous vaginal discharge of several months’ duration. Pelvic examination demonstrated an 8 by &cm. firm, bosselated, fixed mass in the right side of the pelvis. An ulcerated lesion was noted in the right vaginal fornix. Biopsy obtained from the vaginal lesion showed undifferentiated transitional cell carcinoma (Fig. 1). An ileostogram demonstrated a normal-appearing ileal segment and collecting structures. Review of her previous history disclosed that her first diagnosis of transitional cell carcinoma
UROLOGY
!
JULY 1976 / VOLUME
VIII,
NUMBER
1
FIGURE 1. Low-power photomicrograph metastatic transitional cell carcinoma.
showing
51
of the bladder was made in 1963. At that time she was noted to have several superficial vesical lesions. After segmental resection the patient received 4,000 r of external irradiation to the bladder in December, 1963. The tissue diagnosis was grade II transitional cell carcinoma, Stage A. In April, 1964, the patient was found to have recurrent multiple superficial lesions over much of the bladder. Treatment consisted of ileal conduit diversion and complete cystourethrectomy. No mention was made of the status of the lymph nodes. It was noted that there was moderate fibrosis presumably secondary to the previous irradiation. Microscopically, the lesion at the time of cystectomy was grade II to III with no evidence of muscle invasion. Scarcely any portion of the bladder mucosa was free of tumor. The patient continued symptom-free until December, 1974, when she first noted the vaginal discharge. Comment Although a rather late recurrence, our patient’s history demonstrates the malignant potential of transitional cell carcinoma even when presumed to be superficial. In a study of the natural progression of superficial bladder tumors it is reported that one third of patients died of bladder cancers4 Even grade I carcinoma may have demonstrable lymphatic invasion in 6 to 7 per cent of patients. 5 It is possible that in our pa-
52
tient pelvic nodal metastasis had occurred prior to irradiation, segmental resection, or cystectomy and had been trapped by fibrosis with later emergence. If so, the case for pelvic lymphadenectomy when cystectomy is done for vesical carcinoma is certainly valid. 6 As stated by Rubin “the most neglected factor in genitourinary cancer, which may aflect future treatment and prognosis, is defining the status of lymph nodes.” 4301 Wpst Markham Street Little Rock, Arkansas 72201 (DR. REDMAN) References 1. SCOTT, R., JR., KOFF, W. J., HUDGINS, P. T., and MCCULLOUGH, D. : Preoperative irradiation in the surgical treatment of transitional cell cancer of the bladder: preliminary report based on 12 years of experience, J. Urol. 109: 405 (1973). 2. PEARSE, H. D., PAPPAS, J. T., and HODGES, C. V.: Radical cystectomy for bladder cancer: lo-year survival, ibid. 109: 623 (1973). 3. RUBIN, P. : Current concepts in genitourinary oncology: a multidisciplinary approach, ibid. 106: 315 (1971). 4. VAFIKARAI(IS,M. J., GAETA, J., MOORE, R. H., and MURPHY, G. P.: Superficial bladder tumors. Aspects of clinical progression, Urology 4: 414 (1974). 5 WIRTANEN, G. W., and MILLER, R. C.: Bladder lymphatics and tumor dissemination, J. Urol. 109: 58 (1973). 6. DRETLER, S. P., RAGSDALE,B. D., and LEADBETTER, The value of pelvic lymphadenectomy in the W. F.: surgical treatment of bladder cancer, ibid. 109: 414 (1973).
UROLOGY /
JULY 1976 /
VOLUME VIII, NUMBER 1
CELL
OF BLADDER
JOHN F. REDMAN, B. T. TRANUM,
OF TRANSITIONAL
M.D.
M.D.
From the Departments of Urology and Medicine (Section of Hematology), University of Arkansas College of Medicine, Little Rock, Arkansas
ABSTRACT - The case is presented of a patient with local recurrence eleven years after preoperative irradiation and cystourethrectomy.
of transitional
cell carcinoma
It has been stated from a series of patients undergoing preoperative irradiation or total cystectomy that most patients who are not cured of bladder cancer die within three years.’ Pearse, Pappas, and Hodges’ recording ten-year survivals after radical cystectomy for bladder cancer noted that 10 per cent of five-year survivors had residual carcinoma that ultimately caused death. Because of the importance of information concerning recurrence patterns of bladder tumor, we report an instance of late recurrence of transitional cell carcinoma of the bladder treated by cystourethrectomy following irradiation.3 Case Report A fifty-six-year-old white female, with a history of cystectomy and ileal conduit diversion eleven years previously, was seen at University Hospital in February, 1975, with a history of a malodorous vaginal discharge of several months’ duration. Pelvic examination demonstrated an 8 by &cm. firm, bosselated, fixed mass in the right side of the pelvis. An ulcerated lesion was noted in the right vaginal fornix. Biopsy obtained from the vaginal lesion showed undifferentiated transitional cell carcinoma (Fig. 1). An ileostogram demonstrated a normal-appearing ileal segment and collecting structures. Review of her previous history disclosed that her first diagnosis of transitional cell carcinoma
UROLOGY
!
JULY 1976 / VOLUME
VIII,
NUMBER
1
FIGURE 1. Low-power photomicrograph metastatic transitional cell carcinoma.
showing
51
of the bladder was made in 1963. At that time she was noted to have several superficial vesical lesions. After segmental resection the patient received 4,000 r of external irradiation to the bladder in December, 1963. The tissue diagnosis was grade II transitional cell carcinoma, Stage A. In April, 1964, the patient was found to have recurrent multiple superficial lesions over much of the bladder. Treatment consisted of ileal conduit diversion and complete cystourethrectomy. No mention was made of the status of the lymph nodes. It was noted that there was moderate fibrosis presumably secondary to the previous irradiation. Microscopically, the lesion at the time of cystectomy was grade II to III with no evidence of muscle invasion. Scarcely any portion of the bladder mucosa was free of tumor. The patient continued symptom-free until December, 1974, when she first noted the vaginal discharge. Comment Although a rather late recurrence, our patient’s history demonstrates the malignant potential of transitional cell carcinoma even when presumed to be superficial. In a study of the natural progression of superficial bladder tumors it is reported that one third of patients died of bladder cancers4 Even grade I carcinoma may have demonstrable lymphatic invasion in 6 to 7 per cent of patients. 5 It is possible that in our pa-
52
tient pelvic nodal metastasis had occurred prior to irradiation, segmental resection, or cystectomy and had been trapped by fibrosis with later emergence. If so, the case for pelvic lymphadenectomy when cystectomy is done for vesical carcinoma is certainly valid. 6 As stated by Rubin “the most neglected factor in genitourinary cancer, which may aflect future treatment and prognosis, is defining the status of lymph nodes.” 4301 Wpst Markham Street Little Rock, Arkansas 72201 (DR. REDMAN) References 1. SCOTT, R., JR., KOFF, W. J., HUDGINS, P. T., and MCCULLOUGH, D. : Preoperative irradiation in the surgical treatment of transitional cell cancer of the bladder: preliminary report based on 12 years of experience, J. Urol. 109: 405 (1973). 2. PEARSE, H. D., PAPPAS, J. T., and HODGES, C. V.: Radical cystectomy for bladder cancer: lo-year survival, ibid. 109: 623 (1973). 3. RUBIN, P. : Current concepts in genitourinary oncology: a multidisciplinary approach, ibid. 106: 315 (1971). 4. VAFIKARAI(IS,M. J., GAETA, J., MOORE, R. H., and MURPHY, G. P.: Superficial bladder tumors. Aspects of clinical progression, Urology 4: 414 (1974). 5 WIRTANEN, G. W., and MILLER, R. C.: Bladder lymphatics and tumor dissemination, J. Urol. 109: 58 (1973). 6. DRETLER, S. P., RAGSDALE,B. D., and LEADBETTER, The value of pelvic lymphadenectomy in the W. F.: surgical treatment of bladder cancer, ibid. 109: 414 (1973).
UROLOGY /
JULY 1976 /
VOLUME VIII, NUMBER 1
