Bladder metastasis of gastric signet-ring cell carcinoma

Abstract

Metastatic lesions in urinary bladder represent less than 2% of all bladder neoplasms.1 Most of them reach to bladder by direct invasion (the female genital tract, prostate and lower gastrointestinal tract). The other primary tumors originate from the skin, stomach, breast, or lung.2 Signet-ring cell carcinomas identified in the bladder are rare entities and may represent metastases from other primary sites, usually from the gastrointestinal tract. Signet-ring cell carcinoma is a subtype of mucin producing adenocarcinomas, and is associated with aggressive clinical course and early metastatic disease.3 We present a case with gastric signet-ring cell carcinoma metastasing to urinary bladder. Case report A 58-year-old woman complaining of dysphagia, diffuse hypogastric pain, a weight loss of 7–8 kg in the past month was diagnosed as having carcinoma of stomach by endoscopic biopsy. Abdominal tomography revealed a malignant tumoral mass in gastric lesser curvature and lymph nodes without any metastasis. Radical gastrectomy and lymph node dissection were performed. The histopathological examination of the resected specimen revealed stomach adenocarcinoma with signet-ring-cell component and 15 metastatic lymph nodes. Lymphovascular and perineural invasion was positive. TNM classification was T3N3M0(Fig. 1). The patient was given adjuvant chemotherapy (4 cycles of 5-fluorouracil and calcium folinate) and radiotherapy (45 Gy-25 days). Ten months later, she was admitted with pain, anorexia, poor oral intake, nausea and vomiting. On physical examination, a decreased skin turgor tonus was found. There was no defensive rebound and ascites. There was no anemia in the laboratory tests, and the tumor markers were normal. Gastroscopy was performed and no recurrence was detected. Abdominal magnetic resonance imaging was reported that “a mass lesion was detected (metastasis?, bladder ca?) that can not be distinguished from the bladder wall in the superolateral vicinity of the left bladder.”(Fig. 2) In the precense of microscopic hematuria, cystoscopy showed a solid lesion approximately 5 cm in size at left bladder wall. In the thorax CT there was no metastasis. A complete TUR-B was performed. The histopathological examination of the resected specimen was adenocarcinoma metastasis with neoplastic cells contain focally signet-ring cell components. In immunohistochemical analyses, CK7 (+), CK20 focally (+), Gata 3 (−), Uroplakin (−) and histochemical analyses, mucicarmine (+), PAS/AB (+), intra-extracelluler mucin (+)(Fig. 3). After TUR-B the patient was given chemotherapy (6 cycles of capecitabine and oxaliplatin). Nine months later, the recurrence was detected in the bladder and TUR-B was performed, three cycles of irinotecan and capecitabine and then three cycles of irinotecan, capecitabine and oxaliplatin was given to the patient. The patient is under follow-up (medical oncology, urology and radiation oncology clinics), and is considered disease free with bone scintigraphy and abdominal computered tomography in the 6th months after the cessation of last chemotherapy. Open in a separate window Fig. 1 Histopathologic appearance of gastric adenocarcinoma with ring cells; cytokeratin staining (A), hematoxylin eosin staining(B).