Cutaneous metastasis of transitional cell carcinoma of the urinary bladder: Cytological aspect

Abstract

Cutaneous metastasis from transitional cell carcinoma urinary bladder is a rare clinical entity associated with poor prognosis. This case report describes a 51-year-old male who presented with multiple cutaneous metastases arising from high grade transitional cell carcinoma bladder with lamina propria invasion. The prominent cytological features include medium sized to large pleomorphic cells with irregular nuclear outlines, coarse chromatin pattern, and tumor giant cells. An awareness of this rare clinical entity and high index of suspicion is needed for diagnosis.

Introduction

Cutaneous metastasis from transitional cell carcinoma urinary bladder is a rare clinical entity associated with poor prognosis.[1] Cutaneous metastasis from internal malignancies is rare and it may be the first sign of an advanced disease. Overall incidence of documented cutaneous metastases is 5.3% of all cancer patients.[2] Breast cancer is a leading cause of cutaneous metastases, where the most common sites affected are the chest and abdomen.[2]

The reported incidence of cutaneous spread from primary urologic malignancies is 1.3%. Urinary bladder malignancies altogether account for 0.84% of cutaneous metastases.[3] The most common metastatic sites for bladder cancer are lymph nodes, liver, lung and bone and even gall bladder.[4] Skin, spleen, heart, kidney, pancreas, brain, and stomach are uncommon sites of distant metastases.[5,6] Skin metastasis can present as nodular, inflammatory, and fibrotic type.[3] Nodular metastases are common and may be of solitary or multiple type.[3,5] In this case report, we present a patient with transitional cell carcinoma bladder who developed multiple subcutaneous nodular metastases 10 months after the initial diagnosis.

Case Report

A 51-year-old male patient presented with multiple nodular swellings over the body since 3 weeks. These swellings were of varying sizes. Swellings were present over left subscapular region, umbilical region and right shoulder and measured 3.5 cm × 3 cm, 2.5 cm × 2 cm and 2 cm × 1 cm respectively. There was no lymphadenopathy and the patient did not have any other significant finding except those mentioned above. His routine investigations like fasting blood sugar, complete blood count differential, blood urea nitrogen, creatinine, sodium, potassium, aspartate transaminase, alanine transaminase, alkaline phosphatase, and albumin did not reveal any abnormality.

Fine-needle aspiration cytology (FNAC) was performed from left subscapular and umbilical region subcutaneous swellings. The smears were richly cellular and revealed identical morphology. They comprised moderate to markedly pleomorphic cells arranged discretely with large hyper chromatic nuclei displaying irregular nuclear outlines and also presence of tumor giant cells. Due to these features, a cytological diagnosis of metastatic malignancy was suggested [Figure 1].

Figure 1.

Tumor cells with large hyper chromatic nuclei with irregular nuclear outlines and admixed tumor giant cells (H and E, ×400) (inset: Pap, ×400)

In the past history, the patient had hematuria 10 months back for which he was evaluated in a different institute. There he underwent transurethral resection of bladder tumor. The histopathological examination revealed a high grade transitional cell carcinoma of bladder with lamina propria invasion [Figure 2]. After this, patient did not avail any therapy and he came to our institute with multiple skin nodules, 10 months later.

Figure 2.

High grade transitional cell carcinoma of bladder with tumor cells arranged in solid nests and islands (H and E, ×100)

Chest radiograph showed multiple nodular opacities in the right lung lower zone suggestive of metastasis. Ultrasound abdomen revealed hypoechoiec mass of size 5.5 cm × 4.9 cm showing vascularity and attachment to the left lateral and inferior wall of the urinary bladder suggesting recurrence of the bladder tumor. The staging of the primary tumor was not done as the patient got admitted in another institute.

Discussion

Cutaneous spread from primary urologic malignancies is rare.[3] Metastatic infiltration of the skin or subcutaneous tissues can occur due to direct tumor invasion, hematogenous, lymphatic spread or as a result of iatrogenic implantation of tumor cells.[3] An iatrogenic implantation is considered the main cause of cutaneous spread in the majority of patients with transitional cell carcinoma bladder.[7]

Gross appearance of cutaneous metastases is not distinctive and may mimic many common dermatologic disorders.[2]

In our patient cutaneous and lung (asymptomatic) metastasis occurred 10 months after the diagnosis of primary disease. Considering that up to 20% of patients with bladder cancer have lymphatic or vascular spread, primary skin metastasis is quite rare, as noted in our patient.[8]

Similar to our case, Swick and Gordon[9] have reported a 69-year-old male with previously resected superficially invasive primary transitional cell carcinoma of the bladder who presented with distant cutaneous and central nervous system metastases associated with recurrent bladder cancer. The previous history of operated bladder tumor suggested the possibility of transitional cell carcinoma metastasis in our case. The FNAC findings along with past history, clinical and radiological findings helped to arrive at the definitive diagnosis. The prognosis of patients with cutaneous spread of bladder cancer is generally poor and the median survival is less than 12 months.[10] Soon after diagnosis, our patient was lost to follow-up.