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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 1022-1025
Neurological deficit as the first manifestation of vesical transitional cell carcinoma


1 Yash Diagnostic Center, Yash Hospital and Research Center, Moradabad (UP), India
2 Neuron-Brain & Spine Center, Civil Lines, Kanth Road, Moradabad (UP), India

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Date of Web Publication6-Sep-2011
 

   Abstract 

Transitional cell carcinoma of urinary bladder (TCCUB) usually presents with hematuria. Cerebral and leptomeningeal metastases as a first manifestation of TCCUB have been occasionally reported in the medical literature. Hence, we report a case of an elderly man who presented with localizing neurological signs and whose magnetic resonance imaging brain showed multifocal cerebral and leptomeningeal lesions suspected to be metastatic deposits. Thorough search for the primary tumor revealed TCCUB.

How to cite this article:
Rastogi R, Singh AK, Rastogi U C, Mohan C, Rastogi V. Neurological deficit as the first manifestation of vesical transitional cell carcinoma. Saudi J Kidney Dis Transpl 2011;22:1022-5

How to cite this URL:
Rastogi R, Singh AK, Rastogi U C, Mohan C, Rastogi V. Neurological deficit as the first manifestation of vesical transitional cell carcinoma. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 Jan 28];22:1022-5. Available from: https://www.sjkdt.org/text.asp?2011/22/5/1022/84557

   Introduction Top


Majority (greater than 95%) of the vesical tumors are malignant, and approximately 90-95% of these are of the transitional cell type (TCC). The classic presentation is macroscopic painless hematuria. [1] The most common sites of metastases include lymph nodes, liver, lung, and bone. [2] Parenchymal metastases to brain from TCC are relatively infrequent at the time of presentation, but are often seen during chemotherapy in the advanced stages of transitional cell carcinoma of urinary bladder (TCCUB). [3] However, leptomeningeal metastases are very rare in TCCUB. [4] Few incidences of neurological signs and symptoms secondary to leptomeningeal and cerebral metastases as the first presentation of TCCUB exist in the current medical literature.


   Case Report Top


A 65-year-old man presenting with right hemiparesis and slight dysarthria was referred for brain magnetic resonance imaging (MRI). Past history was unremarkable. His clinical examination revealed grade IV power in the right upper limb and grade III on the right lower limb, with partial sensory loss in both limbs. There was slight slurring and disarticulation of speech. Routine laboratory examinations of blood and urine were unremarkable.

MRI brain with gadolinium injection revealed multifocal, parenchymal and leptomeningealbased lesions involving both supra- and infratentorial compartments with evidence of calcification on the gradient images suggestive of a high possibility of metastases with internal calcification [Figure 1], [Figure 2] and [Figure 3]. However, the possibility of primary tumor of the brain was not ruled out.
Figure 1: Transaxial GRE MR image shows two focal lesions with perifocal edema and internal calcification.

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Figure 2: Post-Gad T1W coronal MR image shows two enhancing leptomeningeal-based focal lesions in the supratentorial and infratentorial compartments, each showing leptomeningeal enhancement.

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Figure 3: Post-Gad T1W transaxial MR image shows two enhancing leptomeningeal-based focal lesions in the supratentorial compartment, each showing leptomeningeal enhancement.

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To search for a primary tumor, radiograph of the chest and ultrasonography of the abdomen were performed, and the latter revealed a soft tissue polypoidal mass arising from the right lateral wall of the urinary bladder away from the ureteric orifice, with multiple foci of calcification on the surface [Figure 4]. The mass measured 33.3 × 25.8 × 28.9 mm (13 mL in volume). However, the radiograph of the chest was unremarkable. Radiographs of the spine and pelvis did not reveal any evidence of focal lesions.
Figure 4: US image shows a polypoidal vesical mass with surface calcification along the right lateral wall of the urinary bladder.

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Based on the clinical and radiological findings, the presumptive diagnosis of vesical carcinoma, possibly of the transitional cell type with cerebral and leptomeningeal metastases was suggested. Cystoscopy and biopsy confirmed the polypoidal vesical mass to be TCC.

The patient was further planned for cerebrospinal fluid (CSF) examination and possible biopsy from brain lesions for histological confirmation of the metastatic lesions. But, unfortunately, the patient developed seizures and respiratory distress before the procedure, from which he could not be revived.

Hence, based on the clinical, radiological and histopathological features, the diagnosis of TCCUB with cerebral and lepto-meningeal metastases was eventually made.


   Discussion Top


TCCUB is a malignant tumor of the urinary bladder, commonly occurring in the elderly, with a male predominance. [5] The majority of the patients (80-90%) present with gross and painless hematuria. Irritative symptoms similar to prostatism, including dysuria, urgency and increased frequency of urination, are the primary manifestations in only 30-40% of the patients. Flank pain may be the presenting feature in patients with hydroureteronephrosis secondary to invasion of ureters with carcinoma. Patients with nodal or bony metastatic disease may present with pelvic pain and limb swelling secondary to iliac vessel compression. [5] Cough may be a presenting symptom in cases of pulmonary metastases, but it is usually not the first manifestation of TCCUB. [6]

Central nervous system metastases uncommonly occur in TCCUB, [7] except in advanced cases on therapy. [3] Neurological symptoms as the first and only manifestation of TCCUB have rarely been reported in the medical literature, as was encountered in our case. [7],[8],[9] Moreover, leptomeningeal metastases, although commonly seen in leukemias and other solid tumors, are rarely encountered with TCCUB. [4],[9] In the case reported by Bruna et al, partial seizures caused by meningeal carcinomatosis was the presenting symptom of TCCUB, [9] while in the case reported by Wang et al, the signs of leptomeningeal metastases occurred in a known patient of TCCUB. [4] However, in our case, leptomeningeal disease and cerebral metastases were responsible for the neurological symptoms, and they were the first manifestation of otherwise quiescent TCCUB.

Surface calcifications are quite common in TCCUB. However, the presence of matrix calcification favors adenocarcinoma than other cell types. [10]

To summarize, TCCUB may remain quiescent and rarely present with cerebral and leptomeningeal metastases. Hence, TCCUB should be considered in all patients presenting with multifocal lesions in both compartments of the cranial cavity, especially those with leptomeningeal enhancement and those showing signs of internal calcification.


   Acknowledgments Top


We are highly thankful to Mr. Shivam and Mr. Hanook Lawrence for their kind help in the acquisition of images.

 
   References Top

1.Barentsz Barentsz J. Bladder cancer. In Clinical Urography. Eds. Pollack HM, McClennan BL et al. W.B. Saunders Company, Philadephia. 2 nd edition, 2000:1642-4.  Back to cited text no. 1
    
2.Babaian RJ, Johnson DE, Llamas L, Ayala AG. Metastases from transitional cell carcinoma of urinary bladder. Urology 1980;16:142-4.  Back to cited text no. 2
    
3.Dhote R, Beuzeboc P, Thiounn N, et al. High incidence of brain metastases in patients treated with an M-VAC regimen for advanced bladder cancer. Eur Urol 1998;33:392-5.  Back to cited text no. 3
    
4.Wang J, Ngan S, Dina R, Strickland N, Waxman J. A very unusual presentation of metastatic transitional cell carcinoma of the bladder. Curr Urol 2007;1:50-2.  Back to cited text no. 4
    
5.Steinberg GD. Bladder Cancer. http://www.emedicine.com/med/topic2344.htm. Downloaded on 20/06/08.  Back to cited text no. 5
    
6.Alexander PW, Sanders C, Nath H. Cavitary pulmonary metastases in transitional cell carcinoma of urinary bladder. AJR Am J Roentgenol 1990;154:493-4.  Back to cited text no. 6
    
7.Carrero López VM, Caballero J, De la Rosa F, et al. Cerebral metastasis as first manifestation of a bladder carcinoma. Actas Urol Esp 1994; 18:906-10.  Back to cited text no. 7
    
8.Angulo JC, López JI, Unda-Urzaiz M, Flores N. Bladder carcinoma and brain metastases before systemic chemotherapy. Actas Urol Esp 1992; 16:140-3.  Back to cited text no. 8
    
9.Bruna J, Rojas-Marcos I, Martínez-Yelamos S, et al. Meningeal Carcinomatosis as the First Manifestation of a Transitional Cell Carcinoma of the Bladder. J Neuro Oncol 2003;63:63-7.  Back to cited text no. 9
    
10.Khan AN. Transitional cell carcinoma. http://www.emedicine.com/RADIO/topic711.htm. Downloaded on 20/06/08.  Back to cited text no. 10
    

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Correspondence Address:
Rajul Rastogi
Yash Diagnostic Center, Yash Hospital and Research Center, Civil Lines, Kanth Road, Moradabad (UP)- 244001
India
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PMID: 21912039

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgments
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