Bladder cancer is the 11th common malignancy worldwide, whereas in India, it is the 17th commonly encountered cancer. Environmental exposure is the major risk factor. Patients most frequently present with hematuria. Less commonly, obstructive or irritative bladder symptoms with pain may occur.
Management is based on the depth of invasion and the extent of disease. For metastatic disease, systemic chemotherapy is the preferred option.
Bladder cancer often metastasizes to lymph nodes, lungs, liver, and bones. Cutaneous involvement is rare, seen in only 5.3% of malignancies. Out of these, 0.84% are reported in bladder cancer. Here, we report a rare case of carcinoma urinary bladder with scalp metastasis.
A 65-year-old male, chronic smoker, no known comorbidities had reported to the Surgery department with the complaint of hematuria for 1.5 years. Contrast-enhanced computed tomography showed a 20 mm × 18 mm lesion along its right lateral and posterior bladder wall [Figure 1]. Transurethral resection of bladder tumor bladder revealed nonmuscle invasive high-grade urothelial carcinoma (Stage 1). In view of the high-grade lesion, intravesical bacillus Calmette-Guérin instillations were given weekly for 6 weeks; thereafter, the patient was the loss to follow-up.
A year later, the patient presented with acute-onset hematuria. Physical examination was not contributory. Magnetic resonance imaging pelvis revealed posterior and right lateral bladder wall lesion (2.3 cm × 2.6 cm) compressing right vesicoureteric junction causing hydroureteronephrosis. Bladder serosa was maintained. Chest X-ray was normal. The patient underwent radical cystectomy with an ileal conduit considering Stage 2 disease. Histopathology revealed a high-grade urothelial carcinoma extending through bladder wall, with focal involvement of prostate. Necrosis, serosal involvement, and lymphatic embolization were seen [Figure 2].
There was loss to follow-up postsurgery, and the patient presented after 4 months with a forehead scalp swelling, 3 cm × 3 cm, soft, tender, nonerythematous, and nonpulsatile [Figure 3]. Noncontrast head computed tomography head revealed a soft-tissue swelling on the left forehead with intact bony tables [Figure 4]. MRI revealed hyperintense signal on T2-weighted image [Figure 5]. Fine-needle aspiration cytology from the lesion was consistent with metastatic urothelial carcinoma, showing large atypical cells with high N: C ratio, hyperchromatic nucleus, and scant-to-moderate cytoplasm with moderate atypia [Figure 6]. Necrosis and inflammatory cells were noted in the background with tumor cells positive for CK7 and CK20.
In view of consistently high urea, creatinine, and poor general condition, he was started on single-agent injection of gemcitabine. Increase in size of scalp lesion was seen after 2 cycles of the drug. Whole-body positron-emission tomography-computed tomography outlined Fluorine 18 fluorodeoxyglucose -enhancing lesions in the left frontal scalp, rectus sheath, right gluteal muscle (5.0 cm × 4.4 cm), and left posterior compartment thigh muscle. Lytic lesion was seen in the right humerus head. Palliative radiotherapy of dose 20 Gy in 5 fractions was given to scalp lesion at a depth of 3 cm with two lateral fields and 8 Gy in single fraction was given each to the right humeral head and right hemipelvis using cobalt 60 Theratron 780E® machine. Marginal decrease in scalp swelling was seen 1 month after radiotherapy. The patient was kept on follow-up with symptomatic management. He expired after 2 months of palliative radiation.
Bladder cancer is a global issue with male predilection. Urothelioma is the predominant histology, smoking being leading cause of it.
The common sites of bladder metastasis are lymph nodes, lungs, liver, and bones. Muscle invasive bladder cancer with poor differentiation is associated with higher risk of metastatic disease, others being tumor size and grade.
Metastatic cutaneous involvement is rare in bladder cancer. Skin involvement could be due to iatrogenic implantation (most common), direct tumor invasion, or be a result of hematogenous and lymphatic spread.
The initial presentation can be hematuria. However, the patient may present with only cutaneous lesions without any urinary symptoms. The patient may have more than one metastatic site.
Diverse appearances of these lesions without any clear clinical demarcating criterion from other dermatological lesions have been reported,[3–5] requiring evaluation for such mimicking conditions.
In biopsy and immunohistochemical investigation, synchronous expression of CK-7 and CK-20 are seen in 89% of cutaneous lesions, still immunohistochemistry (IHC) status is variable from case to case.[2,5] High positive IHC stating for p63 was seen by Kerkein et. al. Cohen et al. mentioned that positive results were seen for CK7 and pan-keratin but negative for CK20 and p63. Although p63, p40, CK7, CK20, and uroplakin were positive, consistent with uroepithelial carcinoma of the bladder in the case described by Hasan O et. al.
Although bladder metastasis is chemosensitive, the response is usually short live. Gemcitabine with cisplatin is the preferred regimen; methotrexate, vinblastine, doxorubicin, and cisplatin being an alternative. In case of renal impairment, gemcitabine, paclitaxel, vinblastine, and doxorubicin can be administered safely. Newer drugs such as PD L1/PD inhibitors, CTLA4 antibodies are promising.
Palliative radiotherapy is indicated for relief of pain and prevention of fracture in cases with bone metastasis. In our case, the patient had mild relief.
Immunotherapy with atezolizumab has also been tried and removed recently by the Food and Drug Administration from options. In view of poor control of disease by the current management strategies, most patients could not live more than 6 months from the diagnosis of cutaneous lesions.
Resistance to treatment and poor prognosis is seen with cutaneous metastases. It may be the initial sign of advanced disease. Upon detecting skin metastasis, other common and uncommon sites for bladder cancer involvement should undergo evaluation. Bone metastasis extending to the skin needs to be evaluated carefully to rule out exclusive cutaneous metastasis.
Rare manifestation, delay in diagnosis, and ineffective treatment are resulting in ominous outcomes. Definitive management options for such cases need to be explored and hence require further studies and experiences.
Cutaneous manifestation of bladder cancers is rare. Presentation is variable with resistance to known treatment. The patients with known diagnosis of bladder cancer with an evolving cutaneous manifestation should be evaluated for the probability of metastasis to other sites too. Muscle invasion and high-grade tumor are poor prognostic factors, and the same can be concluded for the cutaneous region. Although the treatment of choice for metastatic bladder cancer is either chemotherapy or palliative radiotherapy, management strategies are to be established for cutaneous metastasis which are rare and associated with poor survival.
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The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
- Dr. Arun Kumar Rathi- General support by the department chair
- Dr. Kishore Singh- Review of case report
- Dr. Nita Khurana- Pathology slide review
- Dr. Nidhi Verma- Pathology slide review
- Dr. Savita Arora- General support by the department.
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