Cytological Findings of a Rare Case of Transitional Cell Carcinoma Bladder Presenting with Supraclavicular Lymphnode Metastasis.

Sir,

Spread from urinary bladder cancer primarily occurs to lymphnodes, bone, lung, liver, and peritoneum in a decreasing order.[1] The lymphatic spread usually involves pelvic and retroperitoneal lymphnode whereas involvement of head and neck nodes is extremely rare.

A 65-year-old woman presented with complaints of left supraclavicular swelling for 1 month. On examination, the swelling was 1.1 × 0.9 cm in size, firm-to-hard in the left supraclavicular region. No other lymphnodes were palpable. There was no history to suggest any possible primary – no hoarseness of voice, dysphagia, abdominal pain, or breast lump.

Fine needle aspiration (FNA) smears from the supraclavicular lymphnode were highly cellular. The cells were predominantly present singly with few loosely cohesive clusters. They showed moderate-to-marked pleomorphism, with cells having scant to moderate cytoplasm and eccentric round nuclei with irregular nuclear membranes, coarse chromatin, and prominent single to multiple nucleoli. Cercariform cells with cytoplasmic tails with flattened ends and eccentric globose hyperchromatic nucleus were present in the smears. Twelve cercariform cells were counted [Figure 1].

Figure 1

(a and b) Fine needle aspiration smears from supraclavicular lymph node shows tumor cells arranged singly and in loose clusters with hyperchromatic nucleus and irregular nuclear membrane in a lymphoid background. Few cercariform cells are also seen (red arrow). (a-b: Pap stain x 40)

Based on the findings of FNA smears, the patient was further investigated. She gave a history of hematuria. Two voided urine samples were cytologically examined. The cytospin smears revealed predominantly single cells with occasional discohesive clusters. The tumor cells were oval-to-polygonal with enlarged hyperchromatic nuclei and scant-to-moderate cytoplasm with coarse chromatin and prominent nucleoli. The cells displayed marked nuclear pleomorphism. Atypical mitosis was also identified [Figure 2a and b]. Computed tomography (CT) scan of the abdomen revealed a hypodense polypoidal mass lesion in the urinary bladder completely occupying the bladder with intense homogeneous contrast enhancement. Few aortocaval, left paraaortic, common, external, and internal iliac lymphnodes with intense heterogenous enhancement were also seen [Figure 2c and d]. Therefore, a diagnosis of high-grade urothelial carcinoma with left supraclavicular nodal metastasis was made.

Figure 2

(a and b) Urine cytology showing tumor cells present singly with hyperchromatic enlarged nucleus along with cercariform cells (red arrow). (Pap stain x40). (c and d) Computed tomography of the abdomen showing urinary bladder mass (blue arrow) and paraaortic lymph nodes (red arrow)

Previously, only three case reports of urinary bladder transitional cell carcinoma with supraclavicular metastasis have been reported. Two of these cases presented with generalized lymphadenopathy and not isolated supraclavicular adenopathy.[12] Tunio et al. reported a case of transitional cell cancer metastasis to cervical lymphnodes without generalized lymphadenopathy.[3] Our case also had only isolated supraclavicular lymphnode metastasis in addition to the regional lymphnode metastasis. There was no generalized lymphadenopathy.

Cercariform cells with cytoplasmic tails and flattened ends with eccentric hyperchromatic nucleus are highly suggestive of transitional cell carcinoma. Renshaw et al. observed that >10 cercariform cells were present in metastasis from transitional cell carcinomas while they were uncommon in malignancies with squamous differentiation.[4] Hida et al. concluded that >20 cercariform cells per case are more likely to be associated with metastatic transitional cell carcinoma.[5] To conclude, the presence of cercariform cells in smears from lymphnode should raise a suspicion of transitional cell carcinoma metastasis even if the lymphnodes are in the head and neck region.

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