Meningeal carcinomatosis from transitional cell carcinoma of the bladder

Metastatic urothelial carcinoma to the brain, spinal cord and spine: A contemporary multi-institutional clinicopathologic analysis of 24 cases

Only case reports and small series of metastatic urothelial carcinoma (UCa) to the central nervous system (CNS) or spine have been published. We identified 24 cases at our institutions. The mean patient age was 64 years (range: 41-78 years) with a male predominance. Nineteen (79%) cases involved the brain, 3 (13%) and 2 (8%) cases involved the spinal cord and spine, respectively. Most cases (79%) were a single mass with a mean size of 2.8 cm (range: 0.9-5.5 cm). With the exception of 3 cases demonstrating micropapillary UCa, all metastases showed morphologic features of conventional UCa. Prior to CNS and spinal metastases, there was a history of UCa involving only the bladder in 16 (67%) patients, ureter in 1 (4%) patient, and kidney/renal pelvis in 1 (4%) patient. In 1 additional patient (4%) each, the primary tumor involved both bladder and ureter, bladder and kidney/renal pelvis, and ureter and kidney/renal pelvis, respectively. Three (13%) patients had no known primary site. In two patients, the diagnosis of primary UCa was made concurrently as the CNS metastasis, and ranged up to 30 years in other patients. Follow-up was available in 14 patients with a mean duration of 7 months (range: 0-23 months), and 4 patients died of disease. Both clinicians and pathologists should be aware that concurrent or late CNS or spine metastases may occur and could present as a solitary mass even over a decade after the initial diagnosis.

Central Nervous System Metastasis in Patients With Urothelial Carcinoma: Institutional Experience and a Comprehensive Review of the Literature

INTRODUCTION

Central nervous system (CNS) metastasis in patients with urothelial carcinoma (UC) is uncommon and poorly understood. We aimed to explore the clinical behavior and outcomes of this unique patient population.

MATERIALS AND METHODS

We performed a retrospective analysis of patients with UC and CNS metastasis, treated in our institution (2006-2018), along with an exploratory patient-point meta-analysis of a similar patient population derived from a comprehensive literature review. Data regarding diagnosis, management, and outcomes were extracted. Overall survival, time to CNS metastasis (TTCM), and residual survival (RS) from CNS involvement to death were calculated (Kaplan-Meier method). Cox regression was used for testing key clinicopathologic associations.

RESULTS

We identified 20 "institutional" and 154 "literature" patients with adequate data granularity for analysis. Median TTCM was 17.7 (institutional cohort) and 10 (literature cohort) months. Most patients who developed CNS metastases had previous non-CNS metastasis (15/20 [75%] and 103/154 [67%], respectively). CNS lesions without previous history of metastasis were identified in 5/20 (25%) and 33/154 (21%) cases and those patients had a shorter TTCM. CNS lesions in the absence of known UC history were also documented in 18/154 (12%) literature cases. Multifocal CNS disease was associated with shorter RS in both cohorts in univariate, but not multivariate, analysis.

CONCLUSION

We observed a variability in disease presentation and course, with a subset of patients showing an early predilection for CNS insult, potentially reflecting a diverse underlying biology. Genomic profiling studies, elucidating the molecular landscape, and driving future treatments should be considered in this setting.

Meningeal carcinomatosis from bladder cancer: A case report and review of the literature

A 66-year-old Japanese male patient was referred to Saitama Medical University International Medical Center for treatment of bladder cancer (clinical stage T2 or higher without metastasis), and underwent radical cystectomy with pelvic lymphadenectomy. The histopathological diagnosis was high-grade urothelial carcinoma (pathological stage T2bN2, ly1, v0) and 2 cycles of adjuvant systemic chemotherapy (gemcitabine plus cisplatin) were administered. At 15 months after the operation, mediastinal and lung hilar lymph nodes and multiple bone metastases were identified on computed tomography imaging. After 3 cycles of the previous regimen as salvage systemic chemotherapy, the lymph node metastases had shrunk and the bone metastases were stable; therefore, further chemotherapy was planned. At 26 days after the initiation of the 4th cycle, the patient felt nausea and lower limb weakness. Spinal and brain magnetic resonance imaging with contrast medium revealed diffuse enhancement at the surface of the spinal cord and brain. In addition, abnormal signal intensity in the subarachnoid space was observed on fluid-attenuated inversion recovery imaging; therefore, the patient was diagnosed with meningeal carcinomatosis (MC). Treatment, including whole-brain radiotherapy, was planned for MC; however, the patient's condition rapidly worsened and he succumbed to the disease 14 days after the diagnosis of MC. The definitive diagnosis of MC was confirmed at autopsy.

Leptomeningeal carcinomatosis as primary presentation of metastatic urothelial cancer

Leptomeningeal spread of carcinoma, referred to here as leptomeningeal carcinomatosis, is an uncommon complication of many cancer types. Its manifestations as the presenting symptoms of a new cancer diagnosis is even less common. This case describes the manifestations of leptomeningeal spread of urothelial carcinoma with review of pathophysiology driving the presenting symptoms of hypertension and headache. In the Discussion section, we address the standard and novel interventions for management of increased intracranial pressure.

Meningeal Carcinomatosis: An Extremely Rare Involvement of Urinary Bladder Carcinoma

Meningeal carcinomatosis (MC) is a rare presentation of solid tumors, particularly breast cancer, lung cancer, and malignant melanoma. Recently, the incidence of MC has been reported to be increasing. It has a bad prognosis despite aggressive therapy. The usual clinical presentation is multifocal involvement of the neuraxis, with headache and radicular pain being the most common initial symptoms. The most frequent signs are motor deficits, altered mental status, and cranial nerve involvement. The treatment of MC remains controversial and no straightforward guidelines exist in the literature. MC from urinary bladder tumors is rare. In this case report, we present a 52-year-old male patient with meningeal metastasis from a primary urinary bladder carcinoma along with a review of the related literature.

Muscle invasive bladder cancer culminating with leptomeningeal carcinomatosis

This case reports highlights a rare metastatic manifestation of transitional cell carcinoma of the bladder. The onset of symptoms associated with meningeal irritation should be investigated. However, there is little consensus in the treatment of leptomeningeal carcinomatosis and it should be considered a poor prognostic sign with symptomatic management.

Urine and serum cathepsin B concentrations in the transitional cell carcinoma of the bladder

BACKGROUND

It has been shown that expression and activity of lysosomal proteolytic enzymes (i.e., cathepsin B) correlate with tumor progression in various neoplasms. We investigate possible correlation of cathepsin B concentrations with grading and invasivity of tumorous bladder tissue.

METHOD

Cathepsin B concentrations in serum and urine were measured in 40 patients (29 men, 11 women, mean age 68 years) with transitional cell carcinoma (TCC) of the bladder without metastases and in control group of 64 healthy subjects (28 men, 36 women, mean age 55 years) using commercially available enzymatic immunoassay. Concentration of cathepsin B in urine was adjusted on creatinine. Urinary creatinine in all samples was measured by enzymatic creatinase method. Patients were divided into groups according to the grading (low grading: 18 patients, high grading: 22 patients) and invasivity of the carcinoma (nonmuscle-invasive tumors: 23 patients, invasive tumors: 17 patients).

RESULT

Concentrations of cathepsin B in urine were significantly elevated in patients than in control group (Median = 3.87 μg/L vs. 1.35 μg/L, P = 0.0002). Similarly, the ratio of U-cathepsin B/creatinine was significantly higher in patients (Median: 0.44 μg/mmol creatinine vs. 0.17 μg/mmol creatinine, P < 0.0001). U-cathepsin B may prove to be useful biomarker (area under the curve [AUC] = 0.72 and 0.73 for the U-cathepsin B/creatinine ratio, respectively). S-cathepsin B significantly correlated with grading of carcinoma (P = 0.02) and U-cathepsin B and U-cathepsin B/creatinine are positively associated with invasive tumors (P = 0.0001 and P = 0.002).

CONCLUSION

Cathepsin B concentrations correlate well with grading and invasivity of tumors and may have diagnostic value in investigation of bladder cell carcinoma. New index U-cathepsin B/Creatinine ratio is more appropriate biomarker to monitor TCC, than U-cathepsin B so far.

Solitary cerebral metastasis from transitional cell carcinoma after a 14-year remission of urinary bladder cancer treated with gemcitabine: Case report and literature review

BACKGROUND

Brain metastases are the most common adult brain tumors, frequently arising from primary tumors in the lung, breast, skin, kidneys, and colon. Transitional cell carcinoma (TCC), the most common type of urinary bladder cancer, is a rare cause of brain metastasis with an ominous prognosis.

CASE DESCRIPTION

A 68-year-old female presented with right-sided paresis and focal motor seizures of her right upper and lower extremities 14 years after being diagnosed and treated for primary TCC of the urinary bladder with gemcitabine-based chemotherapy. MRI imaging revealed a 3.1 × 3.1 × 2.7 cm heterogeneously enhancing mass located along the posterior aspect of the left frontal convexity. The lesion was accessed using a transsulcal approach and was surgically debulked along the motor cortex with motor strip mapping, followed by adjuvant whole-brain radiation therapy. Pathological examination confirmed metastatic carcinoma with features of TCC, a rare entity among metastatic brain tumors.

CONCLUSION

Brain metastases may present several years later in patients with TCC of the urinary bladder who have been treated with surgery and chemotherapy. Chemotherapeutic agents that penetrate the blood-brain barrier, such as gemcitabine, may delay development of cerebral metastasis from primary TCC of the urinary bladder.

Leptomeningeal carcinomatosis from urinary bladder adenocarcinoma: A clinicopathological case study

We report a 73-year-old male patient with leptomeningeal metastasis from urinary bladder adenocarcinoma. He was presented with prominent hyperactive delirium during the course of the disease. Meningeal carcinomatosis was detected 5 days before his death, but the primary site of the malignant tumor could not be determined. Necropsy revealed leptomeningeal infiltration of many adenocarcinoma cells that covered the cerebrum. The leptomeninges of the right middle frontal gyrus, superior temporal gyrus, precentral gyrus and inferior parietal lobe were most severely affected by tumor cell infiltration. Cerebral edema was found to extensively cover the basal part of the temporal lobe. In the cerebrum, tumor cells were clustered in the perivascular spaces and had invaded localized areas of the frontal lobe. Vascular cell adhesion molecule (VCAM)-1 expression was detected in the small vessels of the cerebral upper cortical layers and of temporal subcortical u-fibers. Numerous astrocytes positive for cytokeratin AE1/AE3 were found in the frontal and temporal lobes. Meningeal carcinomatosis from urinary bladder adenocarcinoma is extremely rare and up-regulation of the adhesion molecules in the meningeal adenocarcinoma was confirmed.

Meningeal carcinomatosis as the first manifestation of a transitional cell carcinoma of the bladder

Meningeal carcinomatosis (MC) as first manifestation of a transitional cell carcinoma (TCC) of the bladder is rare. We report a 66-year-old man, smoker, who presented with two episodes of secondarily generalized partial motor seizures. The routine blood test, brain computed tomography (CT) scan, brain magnetic resonance imaging and electroencephalogram were normal. Cerebral spinal fluid (CSF) revealed a significant pleocytosis and a morphology compatible with non-differentiated non-small cell carcinoma. Broncofiberscopy, gastrofiberscopy, thoracicoabdominopelvic CT-scan and bone scintigraphy were normal but the urine cytology revealed malignant cells similar to those found in the CSF. TCC was diagnosed by cystoscopy and later necropsy confirmed the MC of this tumor. In this report we review the literature and analyze patient survival.

Neurologic complications of bladder carcinoma: a review of 359 cases

BACKGROUND

Carcinoma of the urinary bladder accounts for approximately 2% of all malignant tumors and usually spreads through both local invasion and hematogenous dissemination. In the current study, the authors reviewed a large series of patients to determine the nature and frequency of neurologic complications.

METHODS

In the current study, the authors reviewed the records of 359 patients with bladder carcinoma who were treated at the study institution between 1962-2001.

RESULTS

Fifty-two patients (14%) were reported to have neurologic complications. Complications resulting from neurologic metastases were relatively infrequent (5%). Seven patients (2%) had lumbosacral plexopathies and 6 patients (2%) had metastatic epidural spinal cord compression. Brain metastases were present in only 4 patients (1%). Nonmetastatic complications were more common than metastatic complications and were comprised of metabolic encephalopathies in 24 patients (7%), peripheral neuropathies in 9 patients (2.5%), cerebral infarctions in 6 patients (2%), and seizures in 5 patients (1%). No cases of neurologic infection or carcinomatous meningitis were reported.

CONCLUSIONS

The results of the current study demonstrate that neurologic complications are relatively uncommon in patients with bladder carcinoma and that local extension into peripheral nerves or bone, rather than hematogenous dissemination, is the most common cause of neurologic complications resulting from bladder carcinoma.

Leptomeningeal carcinomatosis after major remission to taxane-based front-line therapy in patients with advanced breast cancer

AIM

To determine the incidence of leptomeningeal carcinomatosis (LMC), as the first manifestation of systemic progression, in breast cancer patients after obtaining a major response (complete response, CR or >80% partial response, PR) to first-line taxane-based chemotherapy treated between 1996 and 2000 in our Medical Oncology Unit.

PATIENTS AND METHODS

Patients with histologically proven breast cancer having either metastatic disease, or high-risk locoregional disease that were entered into treatment protocols with first-line taxane (paclitaxel or docetaxel) plus anthracyclines or mitoxantrone combinations and developed LMC as the first evidence of progression after major response (CR or >80% PR) were analyzed in the present study (n = 155).

RESULTS

Seven patients with a median age of 54 (range: 40-70) years developed LMC as their first evidence of progression after taxane-based regimens with a median interval of 6 months (range: 2-18) from start of treatment to diagnosis of LMC. Five patients received intrathecal (i.t.) methotrexate treatment and whole brain radiotherapy (RT), while one patient received i.t. methotrexate and RT to lumbar spine. Two patients responded to treatment for LMC, while two achieved stable disease and three progressed. Two patients had elevated cerebrospinal fluid tumor markers (more than serum marker levels) that proved useful in monitoring response to treatment. Median survival after LMC was 3.6 months (range: 1-31+) and correlated positively to the interval from the initiation of taxane-based therapy to LMC (r = 0.84, P = 0.019). Seven out of 86 responders (8.1%; 95% confidence interval, 2.4-13.9) developed LMC as the first sign of progression after a major response to first-line chemotherapy.

CONCLUSIONS

LMC after a major response to front-line taxane-based regimens represents a grave disease manifestation and its incidence appears increased when compared in retrospect to non-taxane-treated patients. Prospective evaluation of the incidence of LMC after taxane versus non-taxane-based treatment from large randomized multiinstitutional trials is warranted and identification of potential prognostic factors might help identify patients requiring appropriate prophylactic therapy.

Transitional cell carcinoma presenting as a solitary brain lesion: a case report and review of the world literature

Transitional cell carcinoma of the urinary tract will account for roughly 50,000 new cases of cancer in the US this year. Metastatic involvement to the brain is uncommon with this malignancy. When it does occur, it is usually in the setting of widespread metastatic disease. A rare case of transitional cell carcinoma of the bladder presenting as a solitary brain lesion is reported. In addition, we reviewed the world literature regarding transitional cell carcinoma metastatic to the central nervous system. Our review suggests that metastatic transitional cell carcinoma of the central nervous system has become increasingly common as more effective chemotherapeutic regimens have been developed to control the primary disease. The recent literature also suggests that, much like other metastatic disease to the brain, outcome and survival in patients without widespread disease is improved by aggressive surgical and oncological management.

Solitary meningeal recurrence in a patient with transitional cell carcinoma of the bladder with locally bulky disease at presentation

Patients with locally advanced transitional cell carcinoma (TCC) of the bladder are at high risk for systemic relapse, with liver, bone and lung being the commonest sites of metastases. We report the case of a 52-year-old woman with a solitary meningeal relapse, a rare site of recurrence, after 8 months of complete remission obtained with M-VEC for locally advanced TCC of the bladder. We speculate on the likely risk factors related to this unusual site of recurrence.

[Carcinomatous meningitis: rare complication of bladder cancer]

The sites of metastases of transitional cell carcinoma of the bladder are nodes, liver, lung and bone, but the meningeal infiltration is rare. Therefore, one case of meningeal carcinomatosis is reported. After cystectomy for an undifferentiated carcinoma of the bladder, the patient received adjuvant chemotherapy. Three months after treatment completion, symptoms of cerebellar ataxia occurred and gradually confusion appeared. The initial cerebra spinal fluid showed clumps of malignant cells. The patient died 15 days after the neurological symptoms occurred. The clinical diagnosis of meningeal carcinomatosis is based on neurological manifestations at more than one level of the neuraxis. Symptoms may present simply as headache or confusion. Meningeal carcinomatosis from urothelial cancer seems to show some specific features: poorly differentiated tumour and high frequency of cerebellar symptoms. Intrathecal treatment essentially has a pain-effect. Mean survival time is as short as 20 weeks. The increasing incidence of this neurological complication in urothelial cancer does not only result from an increase in patient longevity but also from possible side-effects of chemotherapy, so as localized changes in blood-brain barrier permeability induced by antineoplastic drugs. Therefore, we may wonder whether meningeal carcinomatosis might not be regarded as an iatrogenic effect.