Cutaneous and subcutaneous metastases from bladder carcinoma.

Cutaneous metastases of bladder carcinoma are very rare. The rate of cutaneous metastasis in urologic malignancies is 1.3% and this rate was found to be 0.84% for bladder carcinomas. Cutaneous metastasis of bladder carcinoma can be confused with cellulitis. This case report presents a 60-year-old patient operated on for bladder carcinoma and undergoing treatment for cellulitis because of erythematous lesions appearing in the suprapubic region in the early postoperative period. As there was no response to antibiotic treatment, skin biopsy was performed and cutaneous metastasis was diagnosed. Subsequently, chemotherapy with carboplatin and gemcitabine was started. The prognosis of bladder carcinoma with cutaneous metastasis has been reported to be poor.

Introduction

Cutaneous and subcutaneous metastases of bladder carcinoma are extremely rare. Bladder carcinoma most commonly metastasizes to the lymph nodes, liver, lungs and bones. Generally rates of cutaneous metastases of malignancies have been reported as 1.02%, 5.3% and 2.9%, respectively in 3 large series [1-3]. In these series, cutaneous metastases were most commonly reported for breast cancer. Cutaneous spread from primary urologic malignancies was reported to have a rate of 1.3% and this rate was 0.84% for bladder carcinoma [3]. Cutaneous metastasis from bladder carcinoma occurs most commonly to the locoregional area and via lymphatic drainage [4, 5]. Cutaneous metastases can be in many forms such as erysipeloid, nodular and inflammatory. Cutaneous metastases of urologic malignancies are known to show poor prognosis [3].

Case report

The 60-year-old male patient underwent radical cystoprostatectomy on January 15th, 2011. Histopathological examination revealed a high grade (grade 3) invasive urothelial carcinoma (pT4aNXM0). Surrounding the tumor, there was diffuse vascular embolus and perineural invasion (Fig. 1A). Distant metastases were not noted in abdominal MRI and thorax CT. In the first postoperative month erythematous papular lesions developed in the suprapubic region. They had erysipeloid appearance (Fig. 2). Physical examination revealed edema and clinically there was pain and leucocytosis and high levels of C reactive protein (CRP) were found in the peripheral blood. Suprapubic ultrasound was carried out. It revealed cutaneous and subcutaneous edema and there were numerous lymph nodes up to 3 cm in diameter in this region. Infection was primarily considered; thus antibiotic treatment with piperacillin-tazobactam was started. While leucocytosis improved, there was no improvement in the lesions or CRP levels, so a punch biopsy was taken from the lesions. Histopathology revealed carcinoma metastasis. Immunohistochemically, tumor cells were cytokeratin (CK) 7, CK 20 positive. It was considered to be cutaneous metastasis of bladder carcinoma and chemotherapy with carboplatin and gemcitabine was started.

Fig. 1

A – perivesical adipose tissue invasion and vascular invasion in cystectomy material; B – solid tumor areas within the epidermis; C – CK 7 positivity, D – CK 20 positivity

Fig. 2

Erythematous papular lesions in the suprapubic region

Discussion

Cutaneous metastasis of bladder carcinoma is more commonly seen in the male population [3]. Cutaneous metastasis can be the first finding of bladder carcinoma and clinically it can be confused with cellulitis [6]. However, it can be differentiated with skin biopsy. Also in our case, antibiotic treatment was primarily administered because of the picture of cellulitis and when a complete response could not be obtained skin biopsy was performed, revealing metastasis. Immunohistochemically positive cytokeratin expressed from the uroepithelial tissue in skin biopsy can be useful in differential diagnosis. More than 90% of bladder carcinoma cases with cutaneous metastasis consist of transitional cell histopathology [7]. There are options of radiotherapy and chemotherapy for cutaneous metastases [3, 8]. Despite treatment, cutaneous metastasis of bladder carcinoma is an indicator of poor prognosis; median disease-specific survival is less than 6 months [3, 8]. In conclusion, it should be kept in mind that erythematous lesions in the suprapubic region can belong to the cutaneous metastasis of bladder cancer in particular. Skin biopsy should be performed for differential diagnosis and chemotherapy should be started considering that these patients have a poor prognosis if metastasis is found.