Introduction: Facial cutaneous metastasis from primary bladder cancers are very rare and they are usually associated with poor prognosis. In literature, very few cases of cutaneous metastasis from urothelial malignancies are reported but we did not find any case of bladder cancer metastases localised to chin; usually cutaneous metastasis from bladder are localised in chest or scrotal skin.
Case report: We report a 66 years-old patient affected by transitional muscle-invasive cell cancer of bladder who underwent radical cystectomy and who developed in two months after operation a skin lesion localised to chin. We made the diagnosis of cancer through a TURB performed around one month before. It showed a transitional cell cancer (TCC) of bladder, high grade (WHO 2004) G2-G3 (WHO 1973). Clinical stage of bladder cancer was cT2 N0 M0; the patient was studied before operation through total body CT-scan, TB bone-scan negative for metastasis. The patient was symptomless and he had a good performance status. After open radical cystectomy, histological examination reported a TCC muscle-invasive, high grade (WHO 2004), G3 (WHO 1973), mainly localised in right bladder wall (Figure 1). Microscopically, the cancer reached the perivesical fat tissue (pT3a) with images of perineural neoplastic permeation. The remaining mucosa was affected by CIS (carcinoma in situ). All the lymph nodes were negative for metastasis (pN0). During follow-up, after around one month, the patient showed a single tender purple nodule localised at the chin. Initially, the lesion was thought to be a furuncle. It continued to enlarge with objective signs of phlogosis and relative lack of pain. Patient was treated by his GP doctor with topic antibiotic cream without results. We performed a maxillofacial surgery consultation; punch biopsy revealed metastatic carcinoma, similar microscopically and at immunohistochemistry with the primary bladder transitional cells cancer. Microscopically, it showed pleomorphic hyperchromatic cells with high mitotic activity and large nucleoli in dermis and epidermis (Figure 2). At this time, the patient was symptomless. Total body CT-scan revealed bone metastasis of lumbosacral column. After complete removing of skin lesion, the patient received oncological evaluation and started chemotherapy.
Discussion: In literature, the overall incidence of cutaneous metastasis from primary solid visceral cancers is low, around 2,9 and 5,3%; the most common site of metastasis is chest and the most common primary cancer is breast [1]. Cutaneous metastasis from transitional cells cancers are rare and bladder represents the primary cancer in 0,84% to 3,6% of cases [2]. Few cases of skin metastasis from TCC bladder cancer are described [3 - 4]. In literature, we did not find any case of facial metastasis, in particular to chin, from bladder cancer. Usually, presence of cutaneous metastasis is associated with poor prognosis. Cutaneous metastasis could be taken for other benign cutaneous disorders such as sebaceous cysts or furuncles, but in presence of cutaneous lesion with phlogosis signs, lack or low pain and tendence to enlarge and ulcerate it is necessary to put the suspect of a metastatic lesion. Cutaneous metastases from bladder TCC usually develop in locoregional skin in particular abdomen, genitalia and tights and it is supposed to be related to lymphatic spread [5]. In our case, chin localisation could be related to hematogenous spread. We think that histological examination of radical cystectomy could predict a high index risk that a cutaneous lesion could be metastasis: in particular, the stage T2 or superior, the presence of a carcinoma in situ and the perineural neoplastic permeation. In our case, lymph nodes were negatives (N0 disease) but we had a rapid progression of the disease with cutaneous metastases and bone metastases (lumbosacral column) in a patient totally symptomless. We think that cutaneous metastases are frequently associated with other more common sites of metastasis, such as bone and visceral metastasis, but their appearing could be earlier than the others.
Conclusions: In high grade bladder cancer, with negative prognostic features such as carcinoma in situ or perineural invasion, we think there is high risk to have, at the time of diagnosis, micro metastasis (not detectable with common imaging) or circulating cancer metastatic cells that may occur in short time after diagnosis.
References
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