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CASE REPORT

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SYNCHRONOUS SOLITARY METASTASIS OF TRANSITIONALCELL CARCINOMA OF THE BLADDER TO THE TESTIS

KELLY MORGAN, SANDY SRINIVAS, AND FUAD S. FREIHA

ABSTRACTrimary tumors known to metastasize to the testis, in order of decreasing frequency, are prostate, lung,astrointestinal tract, melanoma, and kidney tumors. Metastasis from bladder cancer to the testis isxtremely rare, occurs with advanced and metastatic disease, and is usually a finding at autopsy. We reportrare, and probably the first, case of solitary and synchronous metastatic transitional cell carcinoma of theladder to the testis, discovered on the preoperative workup. An incidentally discovered testicular mass inman with high-grade, invasive bladder cancer should be considered a metastatic lesion until proven

therwise. UROLOGY 64: 808.e25–808.e26, 2004. © 2004 Elsevier Inc.

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he common sites of metastasis from transi-tional cell carcinoma of the bladder, in order of

ecreasing frequency, are the pelvic lymph nodes,iver, lung, bone, adrenal gland, and intestines.ther less commonly reported sites are the retro-eritoneal lymph nodes, brain, heart, skin, omen-um, peritoneum, and kidneys. We report a rareynchronous solitary metastasis of bladder transi-ional cell carcinoma to the testis.

CASE REPORT

A 74-year-old man, with a history of prostatearcinoma diagnosed and treated with externaleam radiotherapy in 1995, presented in 1999 withne episode of gross painless hematuria. Intrave-ous urography showed normal upper tracts, andystoscopy demonstrated evidence of radiationystitis but no tumor. He presented again in Sep-ember 2001 with gross, painless hematuria. Intra-enous urography again revealed normal upperracts. At cystoscopy, he had a 2-cm papillary tu-or arising from the posterior bladder wall. He

eveloped urinary retention after cystoscopy andequired an indwelling urethral catheter. In Janu-ry 2002, he underwent transurethral resection of

rom the Departments of Urology and Medical Oncology, Stan-ord University School of Medicine and Palo Alto Veterans Affairs

edical Center, Stanford, CaliforniaAddress for correspondence: Fuad S. Freiha, M.D., Department

f Urology, Stanford University Medical Center, 300 Pasteurrive, Room S-287, Stanford, CA 94305-5118Submitted: February 9, 2004, accepted (with revisions): May

w7, 2004

2004 ELSEVIER INC.LL RIGHTS RESERVED

he bladder tumor and the prostate. Pathologic ex-mination of the bladder tumor revealed grade 2,oninvasive transitional cell carcinoma. Patho-

ogic examination of the prostate revealed radia-ion-induced atrophy but no cancer. He did wellostoperatively and refused follow-up cystoscopyecause he was feeling well. In July 2002, he hadnother episode of hematuria. Cystoscopy in Au-ust 2002 revealed a recurrent large tumor occu-ying most of the left lateral bladder wall. Promi-ence of the left lobe of the prostate was also noted.ransurethral resection revealed grade 3 invasive

ransitional cell carcinoma in both the bladder andhe prostate.The metastatic workup included a normal chest

-ray and bone scan. Computed tomographyhowed thickening of the bladder wall and a pos-ible mass in the right posterolateral aspect of theladder with mild right hydronephrosis. He waseferred to the Palo Alto Veterans Affairs Medicalenter, where positron emission tomography re-ealed hypermetabolic masses in the right postero-ateral and left anterolateral aspects of the bladder.o other hypermetabolic activity was observed

nywhere else. His prostate-specific antigen levelas 0.08 ng/mL. On preoperative physical exami-ation, he had a firm and tender right testis. Scrotalltrasonography demonstrated a diffusely hyper-mic right testis with heterogeneous echogenicityuggestive of an infiltrative neoplasm.On October 24, 2002, he underwent cystopros-

atectomy and ileal conduit urinary diversion andight radical orchiectomy. The pelvic lymph nodes

ere palpably soft and normal in size. Because the

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atient had received prior pelvic irradiation, theodes were not resected to prevent lower extremity

ymphedema.Histopathologic examination of the surgical

pecimen revealed high-grade transitional cell car-inoma (Fig. 1) extensively invading the trigone,rostate, and base of the seminal vesicles. Transi-ional cell carcinoma in situ was present in separatereas of the bladder. The pathologic examinationf the testis revealed extensive invasion of the sem-niferous tubules by neoplastic cells (Fig. 2). Thenterstitium and vasculature of the testis were freef tumor. Immunoperoxidase stains for CK7 andK20 were positive, and stains for prostate-spe-ific antigen and prostatic acid phosphatase wereegative. The two positive stains, plus the negativerostate-specific antigen and prostatic acid phos-hatase stains, supported the finding of the bladderver the prostate as the primary site.The patient had an uneventful recovery and re-

eived adjuvant chemotherapy with four cycles ofisplatin and gemcitabine. At follow-up 1.5 yearsater, he was doing well and had no evidence ofecurrence.

COMMENT

Metastatic tumors to the testis are rare. Primaryumors known to metastasize to the testis, in orderf decreasing frequency, are the prostate, lung, gas-rointestinal tract, melanoma, and kidney, with aelatively high incidence of prostatic metastases,ost likely reflecting both the prevalence of the

isease and the use of orchiectomy in its treat-ent.1 Instances of other primary tumors metasta-

izing to the testis have been reported but are ex-

IGURE 1. Invasive transitional cell carcinoma ofladder.

remely rare. o

08.e26

A few isolated reports of bladder transitional cellarcinoma metastasizing to the testis have beenublished during the past few decades. To demon-trate how rarely this occurs, a retrospective reviewf 10 years of experience at the Mayo Clinic re-orted only 20 cases of metastatic carcinoma to theestis, and, of these, none were from bladder can-er.2 A study from the M.D. Anderson Cancer Cen-er reported 22 cases of secondary cancer of theestis collected during 17 years. Of these, the pri-ary tumor was bladder cancer in only one in-

tance.3 A review of 3474 consecutive autopsyases in adult men in Spain reported that 337 menad died of cancer, but, of these deaths, only 2ases of testicular metastases were found. One ofhese was metastatic bladder cancer.4To our knowledge, we report the first case of

ynchronous solitary metastasis of transitional cellarcinoma of the bladder to the testis. Several othernstances of transitional cell cancer metastatic tohe testis have been reported, but in all cases, theetastases were discovered subsequent to the di-

gnosis and treatment of the primary tumor. Inddition, most of these cases had multiple sites ofetastases.

REFERENCES1. Richie JP: Neoplasms of the testis, in Walsh PC, Retik

B, Vaughan ED Jr, et al (Eds): Campbell’s Urology, 7th ed.hiladelphia, WB Saunders, 1998, pp 2411–2452.2. Patel SR, Richardson RL, and Kvols L: Metastatic cancer

o the testes: a report of 20 cases and review of the literature.Urol 142: 1003–1006, 1989.3. Johnson DE, Jackson L, and Ayala AG: Secondary carci-

oma of the testis. South Med J 64: 1128–1131, 1971.4. Nistal M, Gonzalez-Peramato P, and Paniagua R: Sec-

IGURE 2. Metastatic transitional cell carcinoma toeminiferous tubules of testis.

ndary testicular tumors. Eur Urol 16: 185–188, 1989.

UROLOGY 64 (4), 2004