SESSION TYPE: Cancer Case Report Posters I
PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM
INTRODUCTION: We report a case of micropapillary bladder carcinoma metastatic to the lungs masked by active Wegener’s vasculitis.
CASE PRESENTATION: A 70 year-old man presented with increased cough for 2 months. Five years earlier he was diagnosed with Wegener’s vasculitis presenting as diffuse alveolar hemorrhage and PR3-positive ANCA acute glomerulonephritis. He had received cyclophosphamide and prednisone followed by mycophenolate maintenance therapy. He has extensive smoking history and emphysema. His physical examination was unremarkable. His serology showed PR3-ANCA=3712 EU/ml, C-reactive protein (CRP)=64 mg/L and worsening renal insufficiency. Chest CT revealed a new right upper lobe (RUL) ground-glass opacity (Figure 1A,1B) and trans-bronchial biopsy showed absence of alveolar hemorrhage and negative cultures. High-dose steroids were restarted for serology evidence of active vasculitis and mycophenolate was continued. A chest CT one month later showed extension of the RUL lesion (Figure 1C). During his RUL lesion workup, the patient reported painless hematuria and cystoscopy revealed a posterior-wall bladder tumor. Biopsy revealed micropapillary urothelial carcinoma invading lamina propria, lymphovascular spaces and sparing muscularis propria (Figure 2A,2B). Magnetic resonance imaging of the pelvis showed a 4-cm bladder tumor with retroperitoneal/pelvic lymphadenopathy. Ten weeks later, chest CT revealed increased RUL lesion size with satellite nodules and new pre-vascular lymphadenopathy (Figure 1D). Serology showed PR3-ANCA=816 EU/ml and CRP=52mg/L. A RUL wedge resection revealed high-grade carcinoma, with histologic features and immunoprofile favoring metastatic micropapillary bladder cancer. There was no evidence of active vasculitis (Figure 2C,2D). The patient died 2 days later from refractory hypoxemia secondary to extensive pulmonary vascular and lymphatic tumor invasion.
DISCUSSION: Metastasis of urothelial neoplasia without previous muscle invasion is unusual.(1) Wegener’s vasculitis causes diffuse pulmonary ground-glass opacities that could mask pulmonary metastatic disease. ANCA alone is an inadequate indicator of disease activity but is strongly associated with vasculitic relapses. ANCA levels remained elevated in our patient; therefore, the patient’s persistent dyspnea and new lung infiltrates initially suggested active vasculitic relapse. The diagnosis of bladder cancer, with pulmonary lesion progression and new lymphatic involvement, supported underlying metastatic disease. The wedge resection revealed extensive lymphovascular tumor involvement that accounted for patient’s refractory hypoxemia and death.
CONCLUSIONS: Metastatic bladder carcinoma to the lungs can be masked by active Wegener’s vasculitis relapse.
1) Dougherty DW, Gonsorcik VK, Harpster LE, et al. Superficial bladder cancer metastatic to the lungs: two case reports and review of the literature. Urology. 2009 Jan;73(1):210.e3-5.
DISCLOSURE: The following authors have nothing to disclose: Mauricio Danckers Degregori, Fang Zhou, Diana Nimeh, David Steiger
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