Urol Radiol 13:187-189 (1992)

Urologic Radiology © Springer-VedagNewYorkInc. 1992

Metastasis to the Bladder from Pancreatic Adenocarcinoma Presenting with Hematuria Karl S. Chiang, Neela Lamki, and Patricia A. Athey Department of Radiology, Baylor College of Medicine, Texas Medical Center, Houston, Texas, USA

Abstract. Pancreatic adenocarcinoma infrequently involves the urinary tract. Hematuria may result from either direct invasion of the kidneys or from metastases to the urinary tract. The bladder may be involved in the late stages from metastases, but rarely is it associated with hematuria since mucosal involvement is very unusual. We report a second case of bladder metastases and hematuria as a presenting symptom of pancreatic carcinoma. Key words: Pancreatic adenocarcinoma -- Bladder metastases -- Bladder cancer.

Pancreatic adenocarcinoma is the fifth leading cause of cancer deaths in women and sixth in men in America [1]. Classically, it presents with anorexia, weight loss, vague abdominal pain, and jaundice when the head of the pancreas is involved. Contiguous spread of the carcinoma is more prevalent than distant metastases. Metastases to the lungs, bones, and genitourinary tract have been reported infrequently at necropsy. We report a rare case of panereatic adenocarcinoma presenting with hematuria from bladder metastases depicted on initial crosssectional imaging. Case Report A 64-year-old black woman was admitted for evaluation of jaundice and hematuria. The patient was in good health until 2 months

Address offprint requests to: Dr. Neela Lamki, M.D., Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Texas Medical Center, Houston, TX 77030, USA

prior to admission when she began experiencing anorexia, weight loss, subjective fever and chills, and poor control of her insulindependent diabetes mellitus. She also noticed hematuria on two separate occasions 2 weeks prior, which was treated as cystitis. The physical examination was significant only for scleral icterus. Laboratory exam revealed a negative hepatitis screen, elevated amylase, elevated liver function enzymes, and a very high conjugated hyperbilirubinemia. Endoscopic retrograde cholangiopancreatography demonstrated irregular extrinsic narrowing of the distal common bile duct at the level of the pancreatic head, as well as intrahepatic biliary dilation. A mass in the area of the head of the pancreas was revealed by computed tomography (CT) of the abdomen (Fig. 1). Other images (not shown) revealed omental metastases. Cross-sections through the pelvis incidentally demonstrated focal thickening of the right wall of the bladder (Fig. 2). During hospitalization the patient intermittently passed blood clots in her urine. Cystoscopy revealed a papillary tumor on the right posterior dome of the bladder corresponding to the CT images. At exploratory laparotomy and cystoscopic biopsy, extensive pancreatic adenocarcinoma was found that encased the porta hepatis and extended down to the distal left ureter where it also encased the ureter at the same level as demonstrated on the retrograde pyelogram (Figs. 3 and 4). The omentum was infiltrated with tumor, and there were also small metastases to the liver. Resection of the bladder mass revealed adenocarcinoma invading the muscularis, as well as the mucosa itself. Due to the extensive tumor involvement a Whipple procedure was not performed, and the patient was referred for palliative radiation therapy and percutaneous biliary drainage.

Discussion Carcinoma of the head of the pancreas usually causes biliary obstruction and jaundice. Often locally invasive it can spread to the stomach, splenic vein, duodenum, adrenal glands, transverse colon, and left kidney [2]. Displacement of the kidneys is a far more common presentation than invasion or metastases to the renal parenchyma itself. Ureteral involvement is not uncommon with pancreatic car-

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Fig. 1. Contrast-enhanced CT at the level of the head of the pancreas demonstrates a low attenuation, irregular mass which distorts the medial wall of the descending segment of duodenum.

Fig. 2. An area of focal thickening in the bladder wall on the fight corresponding to the tumor mass (between arrows).

Table 1. Reported cases of pancreatic carcinoma with bladder metastases

Reference

Number with pancreatic carcinoma

Number with bladder metasrases

Number with hematuria

Bell [10] Dyk et at [8] Goldstein [6]" Kiefer [11] Klinger [4] Sheehan [7] Sommers and Meissner [9]

609 1 146 31 8 21 142

2 1 4 1 2 1 4

0 0 0 1 0 0 0

Fig. 3. Retrograde pyelogram demonstrating tumor encasement of the left ureter (arrow).

cinoma. Of the 20 cases of urinary involvement with pancreatic carcinoma reviewed by Warden et al., eight demonstrated either ureteral metastases or obstruction by tumor encasement [3]. The left ureter is more frequently involved, and the site is usually at the pelvic brim as in our case [3]. This predilection may be explained by the communication of the common iliac lymphatic channels with the ureteral lymphatic channels at that level [3]. Bladder metastases are even more exceptional and mostly found in advanced stages with peritoneal seeding. Dissemination may follow the hematogenous route or occur from "drop metastases." Most bladder wall metastases are small and not likely to cause hematuria unless there is mucosal ulceration [4-7]. Dyk et al.

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bladder metastases in Bell's series of autopsies [ 10]. Klinger reported on a series of 5000 autopsies in which 142 cases showed genitourinary metastases from other primaries. None of the 28 cases of hematuria were due to bladder metastases from pancreatic carcinoma [4]. The only known case previously reported in the American literature o f pancreatic adenocarcinoma presenting with hematuria was by Kiefer in 1927 [ 11]. We have presented a similar case, but with radiographic findings. References

Fig. 4. Contrast-enhanced CT at the level of the left ureteral tumor reveals a narrowed, encased left ureter (arrow).

reported a dramatic case of extensive bladder metastases from pancreatic carcinoma that caused bladder malfunction and subsequent hydroureters but without hematuria [8]. The most common primaries with metastases to the bladder are gastric carcinoma, malignant melanoma, breast carcinoma, and lung carcinoma [5]. Review of the American literature confirms the infrequency of bladder metastases from pancreatic adenocarcinoma as shown in Table 1. Of the 142 autopsied cases of pancreatic adenocarcinoma tabulated by Sommers and Meissnet, only four had bladder metastases [9]. There were only two of 609 pancreatic carcinomas with

1. Boring CC, Squires TS, Tong T: Cancer statistics 1991. CA 41:19-36, 1991 2. Freeny P, Lawson T: Radiology of the Pancreas. New York: Springer-Vedag, 1982, p 404 3. Warden SS, Fiveash JG, Tynes WV II, et al.: Urologic aspects of pancreatic adenocarcinoma. J Urol 125:265-267, 1981 4. Klinger M: Secondary tumors of the genito-urinary tract. J Uro165:144-153, 1951 5. Ganem EJ, Batal JT: Secondary malignant tumors of the urinary bladder metastatic from primary loci in distant organs. J Urol 75:965-972, 1956 6. Goldstein AG: Metastatic carcinoma to the bladder. J Urol 98:209-215, 1967 7. Sheehan E, Greenberg D, Scott R Jr: Metastatic neoplasms of the bladder. J Urol 90:281-284, 1963 8. Dyk van D, Lang R, Jutrin Y, et al.: Bizarre urologic manifestations of pancreas carcinoma. Hepatogastroenterology 27:62-63, 1980 9. Sommers SC, Meissner WA: Unusual carcinomas of the pancreas. AMA Arch Pathol 58:101-111, 1954 10. Bell ET: Carcinoma ofthe pancreas: A clinical and pathologic study of 609 necropsied cases. Am J Pathol 33:499-523, 1957 11. Kiefer E: Carcinoma of the pancreas. Arch Intern Med 40: 1-29, 1927

Metastasis to the bladder from pancreatic adenocarcinoma presenting with hematuria.

Pancreatic adenocarcinoma infrequently involves the urinary tract. Hematuria may result from either direct invasion of the kidneys or from metastases ...
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