Ileal Conduit stoma site metastasis in squamous cell carcinoma of urinary bladder
Authors: Gupta, Chaitali; Kumar, Rajeev
Corresponding Author: Shailesh Sahay, All India Institute of Medical Sciences, Urology, New Delhi, India. Email: [email protected]
Abstract
Tumour recurrence at the site of an ileal conduit stoma is rare. A 65 years old male chronic smoker was diagnosed as having squamous cell carcinoma of the urinary bladder. He underwent radical cystourethrectomy and ileal conduit urinary diversion. Three months after the surgery, he developed a subcutaneous swelling at the stoma site. Wedge biopsy of the swelling revealed a metastatic squamous cell carcinoma.
Introduction
Bladder cancer most commonly spreads by haematogenous and lymphatic routes. It also spreads by implantation in abdominal wounds, denuded urothelium, resected prostatic fossa, or traumatised urethra [1]. Implantation of tumour cells occurs most commonly with high-grade tumours. Tumour implantation into the resected prostatic fossa is uncommon but can occur primarily with high-grade and multiple tumours [2]. Rarely, inadvertent bladder perforation during endoscopic resection can result in tumour seeding or metastases [3]. Cancer recurrence after radical cystectomy has-been reported in ureteroileal anastomosis. Metastasis at an ileal conduit stoma site after radical cystectomy has not been reported in literature as far as we aware. We report squamous cell carcinoma (SCC) at the conduit stoma site after radical cystectomy for SCC of urinary bladder.
Case Report
A 65 year old male was diagnosed with squamous cell carcinoma of the urinary bladder on the basis of a transurethral resection biopsy of a bladder tumour. He underwent radical cystoprostatectomy and urethrectomy with ileal conduit urinary diversion. The specimen was removed en bloc. The histopathological examination revealed squamous cell carcinoma with muscle invasion (Figure 1A). All the margins (urethra, bilateral ureters, seminal vesicles and vas deferens) were free of tumour. Pelvic lymph nodes were not involved. Tumour was staged as pT2bNOMO. Three months after surgery, induration was noted near the ileal conduit stoma and wound infection was noted in the perineum and the penile shaft. Contrast-enhanced CT scan showed 3 X 2.5 cm soft tissue mass lesion in subcutaneous plain and infiltrating the right anterior abdominal wall at the site of the ileal conduit (Figure 1B). Wedge biopsy was taken from the perineal wound and peristomal mass lesion. The biopsy from perineum showed only chronic inflammatory infiltrates with granulation tissue. The biopsy from the conduit stoma edge was squamous cell carcinoma (Figure 1D).
Figure 1. A )Pre operative contrast-enhanced CT Scan abdomen showing urinary bladder tumour. B) Ileal conduit stoma site showing metastasis. C) Post operative abdominal CT scan showing conduit site metastasis. D) Microscopic photograph of conduit site showing squamous cell carcinoma.
Cytology from the conduit urine did not show any malignant cells. The perineal wound infection was managed and the patient was scheduled for chemoradiotherapy for metastasis at the stoma site.
Discussion
Ileal conduit has been widely in use for urinary diversion after a radical cystectomy, and primary malignant tumours arising in these conduits are uncommon. Although several cases have been reported, most are either transitional cell carcinoma (TCC) or adenocarcinoma. A case of squamous cell carcinoma (SCC) arising in a right ureteroileal anastomosis extending to an ileal conduit, which developed 11 years after a radical cystectomy for TCC of the bladder, has been reported [4]. Involvement of an ileal conduit with recurrent carcinoma following a radical cystectomy for TCC of the bladder is relatively rare. Rosvanis et al reviewed the reported cases of recurrent TCC in an Ileal conduit and found that most of the patients with upper urinary tract tumours recurred at the ureteroileal anastomosis. The authors suggested that surgical implantation or auto implantation from the upper tract might have influenced recurrence at the ureteroileal junction [5]. Most recurrent tumours in the ileal conduit reported to date have been either TCC or adenocarcinoma [6]. Filmer and Spencer reviewed primary malignancies in bladder augmentations and urinary conduits, most of which were adenocarcinoma, and suggested that the inflammatory response associated with bacteriuria at the anastomotic site between transitional and enteric epithelia render the area more susceptible to malignant transformation [7].
Our case had all the resection margins negative for malignancy including both ureters. All the lymph nodes were negative for tumour. The possible explanation in this patient can be by tumour implantation theory. As the same set of instruments was used in radical cystectomy and constructing the ileal conduit, there might have been some tumour cell implantation in stoma site. This in our knowledge is the first case of squamous cell carcinoma urinary bladder developing metastasis at conduit stoma site without involving the ureteroileal anastomosis.
References
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Date added to bjui.org: 24/06/2011
DOI: 10.1002/BJUIw-2011-029-web