Pleural Metastasis in a Patient With Bladder Cancer

With Bladder CancerA 49-year-old, heavy-smoker presented with macroscopic hematuria.Diagnostic work-up disclosed a bladder tumor.Transurethral resection of the bladder revealed a muscle-invasive bladder cancer.Initial work-up failed to demonstrate metastatic spread.The patient had a cystoprostatectomy with pelvic lymphadenectomy.The pathology (Figs 1 and 2) revealed a sarcomatoid variant of urothelial carcinoma with undifferentiated spindle cell neoplasm and chondrosarcomatous heterologous elements staged pT3pN0M0 according to the WHO Classification. 1 The patient refused adjuvant treatment.Three months later, he developed left pleural effusion.Chest x-rays showed thickened pleura with pleural effusion (Fig 3).The patient underwent symptomatic pleurodesis.Pleural biopsy showed the same histological pattern as for initial tumor.Chest computed tomography examination after pleurodesis revealed thickening of the pleura associated with heterologous calcifications and multiple lung metastases (Fig 4).The patient had evidence of disease progression after two cycles of MVAC (methotrexate, vinblastine, adriamycin and cisplatin) regimen. 2 Second-line treatment with gemcitabine and cisplatin resulted in disease stabilization for 4 months.The thickening of the pleura increased on chest computed tomography (Fig 5).The patient died 12 months after initial diagnosis.This report describes an unusual metastasis to the pleura in a patient with urothelial cancer.Only a few cases have been reported in the literature.3 Moreover, the radiological presentation of the secondary tumor, with heterologous calcifications due to the chondrosarcomatous component, is unusual.The radiological differential diagnoses are sarcomatous tumor, calcifications due to pleurodesis, or pleural mesothelioma, which is rare.Sarcomatoid carcinoma of the urinary bladder represents only 0.3% of all histological types.4 The sarcomatoid variant of urothelial carcinoma corresponds to all biphasic malignant neoplasms exhibiting morphologic and/or immunohistochemical evidence of epithelial and mesenchymal differentiation (with presence or absence of heterologous elements acknowledged at diagnosis). 1 This tumor variant is highly aggressive and has a poor prognosis.5,6 Nodal and distant organ metastases at diagnosis are common, [6][7][8] and 70% of patients die of cancer at 1 to 48 months (mean, 17 months).6 The outcome of our patient was fatal within 12 months of diagnosis.