Aggressive bladder carcinoma in an HIV-positive man with tetraplegia and neurogenic bladder

Abstract

Background/objective

Patients with neurogenic bladder secondary to spinal cord injury who are managed long term with an indwelling catheter are known to be at increased risk for transitional cell carcinoma of the bladder. Immunosuppression is a known risk factor for malignancies that often are more aggressive than those seen in normal populations.

Method

Case report and discussion of management recommendations.

Results

We summarize the case of a 44-year-old HIV-positive C5–C6 incomplete tetraplegic male (date of injury 1980), who was diagnosed with transitional cell carcinoma of the bladder and succumbed to disease within 6 months of diagnosis. The patient was a non-smoker who was never managed with an indwelling catheter. There has been no such case reported in the literature.

Conclusions

HIV infection in the presence of a neurogenic bladder may carry an increased risk of aggressive bladder malignancy. More studies are warranted to determine whether routine annual screening with cystoscopy in all patients with HIV and neurogenic bladder is indicated.

Case report

A 44-year-old HIV-positive man with C5–C6 American Spinal Injury Association (ASIA) Impairment Scale (AIS) B incomplete tetraplegia was evaluated regarding report of a bladder stone from an annual screening renal and bladder ultrasound. CT scan of the abdomen and pelvis failed to reveal a bladder stone, but soft tissue thickening with calcification in the bladder was noted, and cystoscopy was recommended.

The patient described a history of blood pressure elevations and sweating while ‘kicking off’ over the previous 3 months but denied ever having symptoms of autonomic dysreflexia before that time. The patient underwent sphincterotomy in 1996 and managed his bladder with a Texas catheter since the surgery. He denied ever using an indwelling catheter long term. The patient was a non-smoker with no occupational exposure to known carcinogens. Review of systems was otherwise non-contributory. The patient's past medical history was significant for HIV diagnosed 3 years prior to the current presentation with a CD4 count of 440 cells/mm³ and a viral load of less than 75 copies/ml. A recent cystometrogram revealed an incompetent sphincter, open bladder neck, a bladder capacity of 100 ml, a post-void residual of 15 ml, detrusor pressure from 15 to 30 cmH₂O, a maximum flow rate of 3.5 ml/second, and no vesicoureteral reflux or detrusor–sphincter dyssynergia.

On cystoscopy a complex bladder mass with vascular and avascular components was seen projecting from the posterior aspect and dome of the bladder. Cytology revealed atypical transitional cells. Pathology from transurethral resection of bladder tumor (TURBT) revealed grade three-out-of-three, muscle-invasive transitional cell carcinoma of the bladder. Testing for direct HIV invasion is not typically indicated and was not performed on this patient. Staging CT scan revealed local invasion (Fig. 1). Due to the presence of locally extensive disease, the patient was offered chemotherapy to potentially improve bladder resectability and overall survival.¹ The patient was informed that a radical cystectomy would be delayed until an objective response was seen radiographically. Within 2 weeks of pathologic diagnosis, he was started on cisplatin 75 mg/m² and methotrexate 250 mg/m² with leucovorin 50 mg every 6 hours for 72 hours. After one cycle of chemotherapy, the patient developed febrile neutropenia with subsequent sepsis and respiratory failure requiring intubation.

Figure 1.

An axial CT image through the lower pelvis without IV contrast shows an incompletely distended urinary bladder with lobulated bladder wall thickening most pronounced anteriorly, right greater than left. There are amorphous and linear calcifications along the thickened right lateral bladder wall and centrally in the bladder. There is mild stranding in the pelvis adjacent to the bladder without adjacent soft tissue mass. The normal prostate gland is noted posteriorly.

After recovery, 6 weeks after initial pathologic diagnosis, a follow-up CT revealed significant progression in tumor size (Fig. 2). The chemotherapy regimen was changed to cisplatin 75 mg/m² and docetaxel 75 mg/m² on a 21-day cycle. After one cycle, a follow-up CT showed continued increase in tumor burden. Due to disease progression through two chemotherapy regimens, the patient and his family decided not to pursue further treatment. During the following month, the patient had two admissions for fever, urinary tract infection, and obstruction of his nephrostomy tubes. Shortly thereafter, he developed persistent confusion secondary to hypercalcemia of malignancy. He continued to decline clinically and subsequently died less than 5 months after pathologic diagnosis.

Figure 2.

An axial CT image through the lower pelvis with IV and oral contrast following one cycle of chemotherapy shows interval disease progression. There is an extensive, heterogeneous, and necrotic soft tissue mass in the expected location of the urinary bladder and extending toward the right pelvic sidewall. The bladder mass is contiguous with new necrotic left external iliac adenopathy.

Discussion

There is no known relationship demonstrating an increased risk of urothelial carcinoma in HIV-positive patients, and a search of PubMed and Cochrane Review databases revealed only five published case reports^2–6 and one case series⁷ of bladder cancer in HIV-positive patients, totaling 10 reported outcomes. Two reports involved patients undergoing TURBT with no recurrence.^2,3 Another report described a man who succumbed to disease 5 months post-diagnosis, after failing to tolerate chemotherapy.⁴ The case series identified five additional patients, four of whom underwent TURBT with subsequent relapse, and the fifth presented with stage IV disease and received palliative treatment only.⁷ There is no report of an HIV-positive patient with a neurogenic bladder succumbing to such an aggressive malignancy. Lack of history of long-term catheter use makes this case all the more interesting.

While it has been documented that indwelling catheterization is a risk factor for bladder cancer,^8–10 other factors such as smoking and chronic urinary tract infections have also been implicated in the spinal cord injury population.^9,11 It has been customary for patients with neurogenic bladder to receive annual screening with renal and bladder ultrasound and basic metabolic panel, but this is done to monitor for upper tract deterioration and not to survey for cancer. Cystoscopies are usually reserved for patients with indwelling catheters or suspected bladder stones.^12–14 Given that immunosuppressed patients are at increased risk for not only infections but also the malignancy that such inflammation can incite,^5,15–17 an HIV-positive patient with a neurogenic bladder should be monitored closely for the development of bladder cancer. Because of the altered immune system, a low threshold for cystoscopy should be considered in this patient population. More studies are warranted to determine whether routine annual screening with cystoscopy is indicated in all patients with HIV and neurogenic bladder.