Downloaded from www.ajronline.org by 117.29.37.130 on 11/04/15 from IP address 117.29.37.130. Copyright ARRS. For personal use only; all rights reserved
493
Case Report
Cavitary Pulmonary Metastases Carcinoma of Urinary Bladder Priscilla
W. Alexander,1
Colleen
Sanders,
and
Hrudaya
in Transitional
Nath
Multiple cavitary nodules are not generally recognized as a manifestation of pulmonary metastases from transitional cell carcinoma of the bladder [1]. We present two cases of cavitary pulmonary nodules proved to be metastases from transitional cell carcinoma of the bladder. We submit that cavitary nodules should be considered as a variant of pulmonary involvement by metastatic transitional cell carcinoma of the bladder. We also recognize the need to prove the cause of cavitary nodules, suspected to be metastases, through biopsy.
racic
needle
with
squamous
those
seen
Case
Reports
Case 1 A 52-year-old
man
na. A bladder of grade tion was
were
tumor
was
were and
transurethrally,
normal.
of a persistent
areas
later
cough.
the
therapy patient
A chest
an
the
diagnosis
differentiaat this time
performed
of deep nodes
had hematu-
and
was
All lymph
No adjuvant
years
had
gross
carcinoma with squamous on a chest radiograph
Several present.
who
developed
cystoprostatectomy
were
one-half
of paraplegia
for 9 years
resected
created.
tumor
dissection history
was
A radical
conduit
by bladder Two
a history
catheter
IV/lV transitional cell established. Findings
normal.
ileal
with
suprapubic
muscular sampled
radiograph
with revealed
we
considered considered
Received
AJR 154:493-494,
metastatic of a second
18, 1989; accepted
Department
to H. Nath,
for
possibility
September
All authors: requests
unusual the
of Radiology,
a 4-month multiple
Cardiopulmonary March
transitional
cell
carcinoma,
primary
tumor.
Transtho-
after revision University
October
of Alabama
543-0493
specimen
man
transurethral
transitional
cytologic
resected
developed
resection
differentiated
papillary
Findings
on
therapy,
a radical
creation
of an ileal
findings
from
the
an initial
surgery
chest
cell
carcinoma
were
similar
to
bladder.
conduit patient
radiograph
several
of which
were
walls
and
were
cavitated. air/fluid
carcinoma were
performed.
One
complaining The
levels
(Fig.
After
and
radiation
were
with
one-half
years
a nonproductive
pulmonary
2). The
poorly
diagnosed.
ureterectomy of
numerous cavities
hesitancy. II/IV
was
normal. distal
showed
urinary a grade
bilateral
returned,
A chest nodular
and
and tumor,
cell
radiograph
cystectomy
the
hematuria
of a bladder
transitional
cough.
nodules,
characterized appearance
by of the
chest was thought to be consistent with metastatic disease. The need to exclude a second primary tumor led to a transbronchial needle biopsy by which metastatic transitional cell carcinoma was diagnosed. The cytologic findings closely resembled those of the previously
resected
bladder
tumor.
Discussion The spread
cell carcinoma of the bladder is lymphatics, affecting the gluteal, obturator, and iliac lymph nodes. Distant metastasis typically does not occur in the absence of penetration of the deep muscular layer of the bladder by tumor. The most common sites of distant metastases are liver, lung, mediastinum, bone, primarily
due
of transitional
to the
regional
23, 1989. at Birmingham
School
of Medicine,
Section.
1990 0361 -803X/90/1
in the
The
invasion in a pelvic
nodules, several of which had undergone cavitation. The cavity walls were thick and slightly nodular (Fig. 1). Because cavitated nodules were
metastatic
and an
was instituted. presented
showed
differentiation.
A 56-year-old
thick indwelling
biopsy
2
After
after
Case
Cell
© American
Roentgen
Ray Society
619 5. 19th
St.,
Birmingham.
AL 35233.
Address
reprint
Downloaded from www.ajronline.org by 117.29.37.130 on 11/04/15 from IP address 117.29.37.130. Copyright ARRS. For personal use only; all rights reserved
494
ALEXANDER
Fig. 1.-Chest radiograph shows a cavitary pulmonary nodule in right lower lobe. An intramural nodule is noted within cavity (arrowheads). Several other cavitary nodules also are present.
and adrenal gland in decreasing order of frequency [1 2]. Patterns of usual pulmonary involvement include multiple nodules, a solitary mass, or interstitial micronodules. When multiple nodules are present, they are characteristically round and well-circumscribed without calcification or cavitation [1]. The differential diagnosis of multiple pulmonary cavities is not extensive. More common causes include bacterial, fungal, and parasitic infections and immunologic disorders such as Wegener granulomatosis or rheumatoid necrobiotic nodules. Cavitary pulmonary metastases are uncommon. Metastatic squamous cell cancer originating from the larynx, pharynx, esophagus, or uterine cervix accounts for up to two thirds of cavitary metastases. Adenocarcinoma of the colon or rectum is the primary tumor in nearly all of the remaining cavitary metastases. Transitional cell carcinoma ofthe bladder is rarely cited as a cause of cavitary metastases [3-6]. Ten cases of cavitary pulmonary metastases caused by bladder carcinoma have been reported. Five of those were transitional cell carcinoma, two were squamous cell cancer, and the remainder were not specified. The presence of squamous differentiation in the reported cases of transitional cell carcinoma was not documented. The mechanism by which squamous cell cancer undergoes cavitation involves central desquamation and cornification allowing accumulation of semiliquid debris. The debris is expelled into the airway, leaving a residual cavity lined with malignant squamous epithelium [3]. As 50-80% of poorly differentiated transitional cell carcinomas show areas of squamous metaplasia, as in case 1, these metastatic tumors may cavitate by central desquamation. Nonsquamous neoplasms may cavitate after growth to several centimeters in diameter, which results in central ischemia and necrosis [3]. In metas,
ET AL.
Fig. 2.-Chest radiograph shows multiple lungs. Some nodules have become confluent. and several contain air/fluid levels.
AJR:154,
cavitary Cavities
March
1990
nodules (arrows) in both have thick nodular walls
tases from poorly differentiated transitional cell carcinoma without squamous differentiation, cavitation could be due to central necrosis. Chemotherapy also has been implicated as a cause of cavitation [7]. The mechanism in this situation is probably also tumor necrosis. The liquified contents may be removed by the lymphatics or expectorated. In this instance, the cavity walls are usually thin and virtually imperceptible on plain chest radiographs. In summary, we present two cases of multiple cavitary pulmonary nodules proved by biopsy to be metastatic transitional cell carcinoma. Cavitary nodules should be considered as an uncommon manifestation of pulmonary involvement by metastatic transitional cell carcinoma. Early biopsy by either transthoracic or transbronchial means will confirm the metastatic nature of excavated pulmonary nodules in a patient with known transitional cell carcinoma of the bladder and will exclude the presence of a second malignant tumor.
REFERENCES 1 . Goldman SM, Fajardo AA, Naraval RC, Madewell JE. Metastatic transitional cell carcinoma from the bladder: radiographic manifestations. AJR i979;1 32:419-425 2. Fetter TR, Bogaev JH, McCusky B, Seres JL. Carcinoma of the bladder: sites of metastases. J Urol 1959:81 :746-748 3. Dodd GD, Boye JJ. Excavating pulmonary metastases. AJR 1961:85: 277-293 4. Chaudhuri MR. Cavitary pulmonary metastases. Thorax 1970:25:375-381 5. Weintraub RA. Roentgenogram of the month. Dis Chest 1963:44:633-634 6. Margolis AM, Liss HP. Unusual etiology of cystic lesions in the lung. Chest
i986;89:857-858 7. Kier A, Godwin JD. Residual cavities of lung metastases therapy. Comput Radio! i986;1 0:293-296
following
chemo-
493
Case Report
Cavitary Pulmonary Metastases Carcinoma of Urinary Bladder Priscilla
W. Alexander,1
Colleen
Sanders,
and
Hrudaya
in Transitional
Nath
Multiple cavitary nodules are not generally recognized as a manifestation of pulmonary metastases from transitional cell carcinoma of the bladder [1]. We present two cases of cavitary pulmonary nodules proved to be metastases from transitional cell carcinoma of the bladder. We submit that cavitary nodules should be considered as a variant of pulmonary involvement by metastatic transitional cell carcinoma of the bladder. We also recognize the need to prove the cause of cavitary nodules, suspected to be metastases, through biopsy.
racic
needle
with
squamous
those
seen
Case
Reports
Case 1 A 52-year-old
man
na. A bladder of grade tion was
were
tumor
was
were and
transurethrally,
normal.
of a persistent
areas
later
cough.
the
therapy patient
A chest
an
the
diagnosis
differentiaat this time
performed
of deep nodes
had hematu-
and
was
All lymph
No adjuvant
years
had
gross
carcinoma with squamous on a chest radiograph
Several present.
who
developed
cystoprostatectomy
were
one-half
of paraplegia
for 9 years
resected
created.
tumor
dissection history
was
A radical
conduit
by bladder Two
a history
catheter
IV/lV transitional cell established. Findings
normal.
ileal
with
suprapubic
muscular sampled
radiograph
with revealed
we
considered considered
Received
AJR 154:493-494,
metastatic of a second
18, 1989; accepted
Department
to H. Nath,
for
possibility
September
All authors: requests
unusual the
of Radiology,
a 4-month multiple
Cardiopulmonary March
transitional
cell
carcinoma,
primary
tumor.
Transtho-
after revision University
October
of Alabama
543-0493
specimen
man
transurethral
transitional
cytologic
resected
developed
resection
differentiated
papillary
Findings
on
therapy,
a radical
creation
of an ileal
findings
from
the
an initial
surgery
chest
cell
carcinoma
were
similar
to
bladder.
conduit patient
radiograph
several
of which
were
walls
and
were
cavitated. air/fluid
carcinoma were
performed.
One
complaining The
levels
(Fig.
After
and
radiation
were
with
one-half
years
a nonproductive
pulmonary
2). The
poorly
diagnosed.
ureterectomy of
numerous cavities
hesitancy. II/IV
was
normal. distal
showed
urinary a grade
bilateral
returned,
A chest nodular
and
and tumor,
cell
radiograph
cystectomy
the
hematuria
of a bladder
transitional
cough.
nodules,
characterized appearance
by of the
chest was thought to be consistent with metastatic disease. The need to exclude a second primary tumor led to a transbronchial needle biopsy by which metastatic transitional cell carcinoma was diagnosed. The cytologic findings closely resembled those of the previously
resected
bladder
tumor.
Discussion The spread
cell carcinoma of the bladder is lymphatics, affecting the gluteal, obturator, and iliac lymph nodes. Distant metastasis typically does not occur in the absence of penetration of the deep muscular layer of the bladder by tumor. The most common sites of distant metastases are liver, lung, mediastinum, bone, primarily
due
of transitional
to the
regional
23, 1989. at Birmingham
School
of Medicine,
Section.
1990 0361 -803X/90/1
in the
The
invasion in a pelvic
nodules, several of which had undergone cavitation. The cavity walls were thick and slightly nodular (Fig. 1). Because cavitated nodules were
metastatic
and an
was instituted. presented
showed
differentiation.
A 56-year-old
thick indwelling
biopsy
2
After
after
Case
Cell
© American
Roentgen
Ray Society
619 5. 19th
St.,
Birmingham.
AL 35233.
Address
reprint
Downloaded from www.ajronline.org by 117.29.37.130 on 11/04/15 from IP address 117.29.37.130. Copyright ARRS. For personal use only; all rights reserved
494
ALEXANDER
Fig. 1.-Chest radiograph shows a cavitary pulmonary nodule in right lower lobe. An intramural nodule is noted within cavity (arrowheads). Several other cavitary nodules also are present.
and adrenal gland in decreasing order of frequency [1 2]. Patterns of usual pulmonary involvement include multiple nodules, a solitary mass, or interstitial micronodules. When multiple nodules are present, they are characteristically round and well-circumscribed without calcification or cavitation [1]. The differential diagnosis of multiple pulmonary cavities is not extensive. More common causes include bacterial, fungal, and parasitic infections and immunologic disorders such as Wegener granulomatosis or rheumatoid necrobiotic nodules. Cavitary pulmonary metastases are uncommon. Metastatic squamous cell cancer originating from the larynx, pharynx, esophagus, or uterine cervix accounts for up to two thirds of cavitary metastases. Adenocarcinoma of the colon or rectum is the primary tumor in nearly all of the remaining cavitary metastases. Transitional cell carcinoma ofthe bladder is rarely cited as a cause of cavitary metastases [3-6]. Ten cases of cavitary pulmonary metastases caused by bladder carcinoma have been reported. Five of those were transitional cell carcinoma, two were squamous cell cancer, and the remainder were not specified. The presence of squamous differentiation in the reported cases of transitional cell carcinoma was not documented. The mechanism by which squamous cell cancer undergoes cavitation involves central desquamation and cornification allowing accumulation of semiliquid debris. The debris is expelled into the airway, leaving a residual cavity lined with malignant squamous epithelium [3]. As 50-80% of poorly differentiated transitional cell carcinomas show areas of squamous metaplasia, as in case 1, these metastatic tumors may cavitate by central desquamation. Nonsquamous neoplasms may cavitate after growth to several centimeters in diameter, which results in central ischemia and necrosis [3]. In metas,
ET AL.
Fig. 2.-Chest radiograph shows multiple lungs. Some nodules have become confluent. and several contain air/fluid levels.
AJR:154,
cavitary Cavities
March
1990
nodules (arrows) in both have thick nodular walls
tases from poorly differentiated transitional cell carcinoma without squamous differentiation, cavitation could be due to central necrosis. Chemotherapy also has been implicated as a cause of cavitation [7]. The mechanism in this situation is probably also tumor necrosis. The liquified contents may be removed by the lymphatics or expectorated. In this instance, the cavity walls are usually thin and virtually imperceptible on plain chest radiographs. In summary, we present two cases of multiple cavitary pulmonary nodules proved by biopsy to be metastatic transitional cell carcinoma. Cavitary nodules should be considered as an uncommon manifestation of pulmonary involvement by metastatic transitional cell carcinoma. Early biopsy by either transthoracic or transbronchial means will confirm the metastatic nature of excavated pulmonary nodules in a patient with known transitional cell carcinoma of the bladder and will exclude the presence of a second malignant tumor.
REFERENCES 1 . Goldman SM, Fajardo AA, Naraval RC, Madewell JE. Metastatic transitional cell carcinoma from the bladder: radiographic manifestations. AJR i979;1 32:419-425 2. Fetter TR, Bogaev JH, McCusky B, Seres JL. Carcinoma of the bladder: sites of metastases. J Urol 1959:81 :746-748 3. Dodd GD, Boye JJ. Excavating pulmonary metastases. AJR 1961:85: 277-293 4. Chaudhuri MR. Cavitary pulmonary metastases. Thorax 1970:25:375-381 5. Weintraub RA. Roentgenogram of the month. Dis Chest 1963:44:633-634 6. Margolis AM, Liss HP. Unusual etiology of cystic lesions in the lung. Chest
i986;89:857-858 7. Kier A, Godwin JD. Residual cavities of lung metastases therapy. Comput Radio! i986;1 0:293-296
following
chemo-
