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    Home > Active Ingredient News > Urinary System > A rare case of bladder cancer with skin metastases, have you seen it?

    A rare case of bladder cancer with skin metastases, have you seen it?

    • Last Update: 2022-02-24
    • Source: Internet
    • Author: User
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    Introduction The skin is an extremely rare metastatic site for bladder urothelial carcinoma
    .

    Pure skin metastases without systemic metastases are very rare, with less than 10 cases reported in the literature
    .

    In this case, pelvic lymphadenectomy and radiotherapy were performed in the past for cervical cancer, resulting in various lymphatic fistulas in the skin
    .

    The investigators believe that the most likely mechanism for skin metastases in this case is lymphatic spread through lymphatic fistulas
    .

    Immunotherapy is one of the most important treatment options for patients who cannot receive cisplatin
    .

    Background Bladder cancer incidence and mortality are higher in men, about four times higher than in women
    .

    The reported incidence of skin involvement in all urological malignancies is 1.
    1% to 2.
    5%
    .

    The incidence of bladder cancer skin metastasis was 0.
    84%
    .

    The most common sites of metastasis from bladder cancer are the liver, lungs, and bones
    .

    The case is a female, 80 years old, who presented with hematuria for 6 to 7 months
    .

    Complaints of dysuria, groin pain, and urgency
    .

    Chronic medical history included hypertension, anemia, atherosclerotic heart disease, and primary mitral and tricuspid regurgitation
    .

    Both KPS score and ECOG score were 2
    .

    Past medical history included left nephrectomy, radiation therapy for cervical cancer and pelvic lymph node dissection, and lymphatic drainage skin fistula
    .

    Physical examination revealed tenderness in the right costovertebral angle, and multiple cutaneous fistulas that had existed for approximately 20 years were seen in the skin
    .

    Cystoscopy was performed because of suspected tumor, and tumor lesions were found in the bladder triangle
    .

    Pathology after transurethral resection of bladder tumor (TURBT) showed pT2G3 urothelial carcinoma
    .

    CT of the chest and abdomen for radiological staging showed no metastases
    .

    The patient underwent radical cystectomy + urethrectomy + right ureterocutaneostomy
    .

    Postoperative pathological results showed urothelial carcinoma (T4aN0M0)
    .

    Immunohistochemistry showed positive for cytokeratin (CK) 7 and GATA3
    .

    The patient was ineligible for a cisplatin-containing regimen and received pembrolizumab
    .

    About two months after radical cystectomy, the patient complained of a red, painful, tender mass in the abdomen that manifested as erythema nodosum (Figure 1)
    .

    Skin nodule biopsy revealed extensive infiltration from CK7 GATA3 YMA CK-positive high-grade transitional cell bladder cancer (Figure 2)
    .

    Fig 1 Multiple skin metastases on the abdominal wallFig 2 a) Hematoxylin and eosin staining showed infiltration of superficial dermis urethral carcinoma; b) Hematoxylin and eosin staining showed infiltration of urethral carcinoma in deep dermis; c) Immunohistochemical staining showed positive GATA3 nuclei ;d) Immunohistochemical staining showed positive cytoplasmic CK7
    .

    Discussion Bladder cancer is one of the most difficult and time-consuming malignancies to treat
    .

    According to the American Cancer Society (ACS), the 5-year relative survival rate of bladder cancer patients is about 77%, but the 5-year survival rate of patients with metastatic bladder cancer has dropped significantly to only 5%
    .

    Most bladder cancer patients die from metastatic disease
    .

    The study by Mueller et al found that the overall incidence of skin metastases from primary solid visceral malignancies was 2.
    9%, the incidence of skin metastases from urological malignancies was 1.
    3%, and the incidence of skin metastases from bladder cancer was less than 1%
    .

    The prognosis for patients with skin metastases from bladder cancer is poor
    .

    Studies have shown that more than 98% of patients who are diagnosed with skin metastases from urinary tumors survive less than 1 year
    .

    In addition, median disease-specific survival was less than 6 months from the first appearance of skin metastases
    .

    The literature shows that there may be four different mechanisms for the occurrence of skin metastases: 1) hematogenous; 2) lymphatic; 3) spread from the underlying tumor; 4) iatrogenic engraftment
    .

    The patient had a history of pelvic lymphadenectomy and radiotherapy
    .

    Physical examination revealed a lymphatic fistula in the skin for 20 years
    .

    The researchers believe that the most likely mechanism responsible for skin metastases in this patient is the lymphatic spread of tumor cells through the lymphatic fistula
    .

    Based on the patient's existing comorbidities and KPS and ECOG scores, there are not many treatment options
    .

    Chemotherapy is the preferred option
    .

    MVAC regimens (methotrexate + vinblastine + doxorubicin hydrochloride + cisplatin) or gemcitabine + cisplatin are known regimens with reported remission rates as high as 70%
    .

    But the prognosis remains poor
    .

    The FDA has approved six drugs for metastatic bladder cancer (avelumab, nivolumab, pembrolizumab, atezolizumab, enfortumab vedotin, erdatinib)
    .

    Immunotherapy is one of the most important options for platinum-intolerant patients
    .

    Due to adverse events, chemotherapy could not be continued, and the investigators changed the treatment regimen to immunotherapy
    .

    To date, this is the second case where immunotherapy has been used for bladder cancer skin metastases
    .

    Conclusion Skin metastases from bladder urothelial carcinoma are extremely rare
    .

    Skin metastases have been shown to be a poor prognostic factor
    .

    All clinicians need to pay attention to skin lesions, which may be early symptoms of metastatic disease
    .

    To avoid misdiagnosis, a skin biopsy should be performed
    .

    In most cases, palliative care is usually used due to the advanced stage of the disease and the poor prognosis of skin metastases
    .

    References: Öztürk H, Yurtsever S, Özer A, et al.
    Cutaneous metastasis of bladder urothelial carcinoma; A rare conditions, Urology Case Reports (2021), doi: https://doi.
    org/10.
    1016/j.
    eucr.
    2021.
    101955 .

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