Clinical Advances in Hematology & Oncology
July 2013, Volume 11, Issue 7
Review
Ataxia in a Patient With Urothelial Carcinoma
Einar F. Sverrisson, MD, and Philippe E. Spiess, MD, FACS, FRCS(C)
Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, Florida
Urothelial carcinoma (UC) rarely metastasizes to the brain, but as Gardner and associates describe in their case report,1 the incidence rate of brain metastases from UC has increased from 1–3% up to 16%. This increase can be attributed to the introduction of the systemic chemotherapy regimen of methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC),2-4 which results in prolonged duration of remission, with a subsequent increase in the likelihood of such cancer dissemination.4 However, no data exist that show the comparable incidence of brain metastases in patients receiving the gemcitabine and cisplatin systemic regimen, which is more commonly used in patients with metastatic UC.
In this case report, the authors describe a 74-year-old man who was initially diagnosed with clinical T4bN2M0 UC during a Green Light Photo-Selective Vaporization of the Prostate (PVP). He underwent 3 cycles of salvage systemic chemotherapy with gemcitabine and cisplatin, and restaging studies demonstrated an excellent response. He then refused a radical cystectomy and subsequently underwent a bladder-sparing approach of chemoradiation with weekly cisplatin. Eleven months after completing this treatment, he presented with neurologic symptoms (unstable gait, fatigue, dizziness, disequilibrium, and diplopia), and a magnetic resonance imaging (MRI) of the brain revealed a solitary metastatic lesion in the left vermis. The patient underwent a resection, and the pathology was consistent with metastatic UC. He was then treated with whole-brain radiation therapy (WBRT) and did well for 9 months. Thereafter, he developed a recurrent brain tumor with leptomeningeal spread and was recommended and transferred for hospice care.1
As the authors point out in their discussion, the median survival for patients with UC and brain metastases is extremely poor. Current treatment options (which are dependent on tumor location and multiplicity) are limited to surgical resection, WBRT, and, more recently, stereotactic radiosurgery (SRS). However, data suggest that the survival benefit of surgical resection followed by WBRT compared to WBRT alone in patients with resectable disease is significant,5,6 which underscores the importance of a detailed assessment, including neurologic symptoms, as part of the follow-up for patients with UC. This raises the question of whether routine brain imaging should be a part of the follow-up schedule for such metastatic UC patients and, if so, at what frequency of neurologic imaging (ie, patients who have been treated with MVAC).
References
1. Gardner FP, Tan WW. Ataxia in a patient with urothelial carcinoma: pathologic confirmation, recovery, and improved survival. Clin Adv Hematol Oncol. 2013;11: 465-467.
2. Anderson RS, el-Mahdi AM, Kuban DA, Higgins EM. Brain metastases from transitional cell carcinoma of urinary bladder. Urology. 1992;39:17-20.
3. Bishop JR, Jr, Moul JW, Maldonado L, McLeod DG. Transitional cell carcinomatous meningitis after M-VAC (methotrexate, vinblastine, doxorubicin, and cisplatin) chemotherapy. Urology. 1990;36:373-377.
4. Dhote R, Beuzeboc P, Thiounn N, et al. High incidence of brain metastases in patients treated with an M-VAC regimen for advanced bladder cancer. Eur Urol. 1998;33:392-395.
5. Noordijk EM, Vecht CJ, Haaxma-Reiche H, et al. The choice of treatment of single brain metastasis should be based on extracranial tumor activity and age. Int J Radiat Oncol Biol Phys. 1994;29:711-717.
6. Patchell RA, Tibbs PA, Walsh JW, et al. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med. 1990;322:494-500.