A Patient with Cancer of the Bilharzial Bladder

Figure 1. Bone scan showing multiple metastases (arrows).

History of the present illness

A 57 year old agricultural worker presented to a hospital with fever and an altered level of consciousness. He had been having bone pain since January 2004, for which he had received non-steroidal anti-inflammatory analgesics without benefit. The condition was aggravated by the development of severe chest pain in May 2004. Investigations performed at the time, including an ECG, showed no abnormality. Cardiac enzymes were elevated; LDH, was 1170 U/L the normal being up to 423. Echocardiography was normal with the ejection fraction of 68%.

A chest X-ray on 9th June 2004 showed a pathological fracture of the 6th rib. A bone scan performed one week later revealed multiple osseous lesions, actively taking up isotope, which were randomly distributed throughout the skeleton. The lesions were considered to be consistent with metastatic deposits (Fig 1). Laboratory investigations on 19th June 2004 included a complete blood count that showed a moderate normocytic, normochromic anemia and moderate thrombocytopenia. Liver function tests revealed hypoalbuminemia. Kidney function tests were normal. An abdominal ultrasound showed liver cirrhosis and splenomegaly and a transrectal sonogram showed a slightly enlarged prostate gland with a heterogeneous pattern and no detectable focal lesions.

Tumor markers, including carcinoembryonic antigen, alpha-feto protein and PSA (prostate specific antigen), were slightly elevated. Because a primary tumor accounting for the bony metastases had not been identified,investigations for multiple myeloma were performed. There was no Bence-Jones proteinuria and b2 micro-globulin level was only slightly elevated. Serum protein electrophoresis confirmed the hypoalbuminemia and also showed hypergammaglobulinemia and beta-gamma bridging. A bone marrow aspiration performed on 5th July 2004 revealed a hypercellular marrow with erythroid hyperplasia but no evidence of infiltration by neoplastic cells. Computerized tomography (CT) of the chest on 15 July 2004 showed a right rib fracture with abundant callus formation but no other abnormalities. CT of the abdomen and pelvis showed mild to moderate hepato-splenomegaly with liver cirrhosis, minimal ascites (Fig 2), left para-aortic and iliac lymph nodes of 8-11 mm in diameter and a soft tissue mass in the bladder measuring 6.5 x 3.2 x 4 cm, involving the right lateral wall and base of the urinary bladder with para-vesical extension (Fig 3). The patient refused cystoscopic examination and biopsy under general anesthesia because of a concern that his liver function would deteriorate as a consequence.

Past history

The patient had a history of Hepatitis C Virus (HCV) infection. He was also diabetic and suffered from hyper-tension, for which he had been receiving medical treatment for 10 years.

Admission to NCI, Cairo

The patient was admitted to the NCI, Cairo, on 8th August 2004 and was noted to be febrile, hypertensive (blood pressure 170/100) and tachycardic (pulse 99/minute). The patient was drowsy, but oriented with respect to person, time and place. Heart and lung examination revealed no abnormalities but abdominal examination revealed hepato-splenomegaly and ascites. Laboratory investigations at the time of admission revealed severe anemia (hemoglobin 5.7gm%), an absolute monocytosis and thrombocytopenia (platelets 39,000 per cu mm.). Liver function tests showed hyperbilirubinemia and hypoalbuminemia. There was mild hyperuricemia and hypocalcaemia and normal renal function tests A random blood sugar was normal. Urine cytology showed malignant epithelial cells consistent with urothelial carcinoma. Additional radiological examinations included a CT scan of the head, which revealed sub-cortical arteriosclerotic leukoencephalopathy with suspected small deep parietal lacunar infarcts. The base of the skull had a patchy osseous texture of uncertain origin.

Final diagnosis

The patient was diagnosed as having bilharzial related bladder cancer with bone metastases at presentation together with HCV infection, diabetes mellitus, severe anemia, hypertension, arteriosclerotic leukeoencephalopathy and a possible acute infection.

Discussion

This patient provides an example of a common oncologic problem faced by physicians in Egypt. The patient had bilharzial related bladder cancer presenting at an advanced stage with bone metastases. Although metastases in bilharzial associated bladder cancer are uncommon, bone is the most common site of metastasis.

The patient also had impaired liver function due to both bilharzial and HCV infections. This difficult medical situation, with compromised hepatic function poses several questions. Firstly, since disease is disseminated, the only realistic therapy is systemic chemotherapy, but this is complicated by the impaired hepatic function and is influenced by the fact that prospects for cure in this patient with widely metastatic disease are essentially zero. Should he be treated with chemotherapy that is either modified, or selected in the hope of causing minimal additional liver impairment or increased toxicity because of the presence of cirrhosis? What is the cost-benefit ratio?

Both the advanced state of this patient’s cancer and his several underlying chronic diseases pose enormous and probably insurmountable medical problems. Such complex patients consume extensive resources yet are much more commonly encountered in developing nations where resources are limited. In bilharzial associated bladder cancer, even patients with surgically resectable disease may subsequently die from hepatic schistosomiasis or from renal infection associated with urinary bypass following total cystectomy. Information from studies conducted in affluent nations often provide little help in deciding optimal management of such complex and advanced cases. In the case of bilharzial bladder cancer, there are also important biological differences from the common transitional cancer of western countries – which generally presents at an early stage. Clinical trials in developing countries themselves are essential to determine optimal management, but all too many of these patients may be candidates only for palliative care – which is also not widely available in the setting of poor countries and poses additional problems, such as the availability of opiates and the difficulties of both home and clinic-based terminal care in low-resource populations. Clearly, greater efforts need to be focused on prevention and early detection, and in the case of bilharzial associated bladder cancer, on the underlying parasitic disease as well as the cancer it predisposes to.

Figure 2. CT scan of the abdomen showing stet and ascites (arrows). L = liver.

Figure 3. CT scan of the pelvis with contrast (white) in the bladder, showing a large filling defect (mass) extending posteriorly (arrows).