Urothelial carcinoma of the bladder presenting with abnormal inguinal metastasis

Abstract

Inguinal lymph node metastasis in urothelial carcinoma is exceptionally rare. Here, We report a case of bladder cancer with inguinal lymph node metastasis and, through searching our hospital’s database, identified two additional similar patients managed at our center since 1990. All patients underwent PET/CT scans, and in two cases, inguinal lymph node biopsies confirmed metastatic urothelial carcinoma. One elderly female presented with inguinal lymph node metastasis as the initial sign of recurrence. This report underscores the increased risk of distant metastasis and highlights the critical need for vigilant monitoring of patients with recurrent bladder cancer following repeated TURBT procedures.

1 Introduction

Urothelial carcinoma of the bladder (BC) is one of the most common malignancies of the urinary tract. While bladder cancer commonly metastasizes to regional lymph nodes, distant metastasis, particularly to the inguinal lymph nodes (ILN), remains rare. Metastasis to the inguinal lymph nodes is typically associated with malignancies originating in the lower extremities, lower trunk, or reproductive organs. This report describes a patient of bladder cancer with inguinal lymph node metastasis, potentially due to retrograde seeding or direct extension during repeated TURBT procedures.

2 Case presentation

A 55-year-old female patient presented with a medical history of right ureteral cancer, prompting laparoscopic radical nephroureterectomy in April 2020. Pathological analysis confirmed the diagnosis of high-grade, invasive urothelial carcinoma with infiltration of the muscle layer, vascular invasion, and clear surgical margins devoid of tumor tissue. Subsequently, the patient underwent adjuvant chemotherapy (gemcitabine-cisplatin, five cycles) and radiation therapy (60Gy) as part of her treatment plan. Despite this multimodality approach, the patient experienced recurrent bladder tumors over the subsequent months, necessitating five transurethral resections of bladder tumors (TURBTs) and adjuvant intravesical therapy (BCG). Each pathology report consistently indicated high-grade, lamina propria-invasive urothelial carcinoma. Notably, the patient expressed considerable apprehension regarding the prospect of a radical cystectomy with urinary diversion and, consequently, declined the recommended surgical intervention. In June 2024, a PET/CT scan was conducted, revealing bilateral inguinal lymphadenopathy and heightened metabolic activity in the left vaginal wall ( Fig. a). A biopsy of the right inguinal lymph node definitively confirmed the presence of metastatic urothelial carcinoma. Conversely, the vaginal biopsy showed reactive atypical hyperplasia, excluding malignancy at that specific site.

At the time of presentation, no new bladder masses or additional abnormal lymph nodes were identified. Considering that the patient has a solitary kidney and has previously experienced systemic chemotherapy side effects, other treatment options such as MVAC (Methotrexate, Vinblastine, Doxorubicin, Cisplatin) and GC (Gemcitabine + Cisplatin) raise concerns regarding potential renal toxicity. However, the vedolizumab and tirapazamine regimen has been evaluated in a prospective, single-arm, multicenter clinical trial (NCT06354231). This study confirmed the efficacy of this approach in preserving renal function in patients with a solitary kidney, renal insufficiency, or multiple upper urinary tract urothelial carcinoma. Based on these findings, the patient was initiated on a regimen of immunotherapy, specifically with vedolizumab and tirapazamine, which she is currently undergoing as part of her ongoing management.

3 Discussion

Bladder cancer (BC) is a leading cause of cancer-related morbidity and mortality worldwide. Nearly 90 % of bladder cancers are transitional cell carcinomas (TCC), and approximately 50 % of patients eventually develop metastases. Lymphatic spread is common, with the internal iliac and obturator lymph nodes being the most frequent sites of involvement. However, inguinal lymph node metastasis is exceedingly rare and typically associated with malignancies originating from the lower trunk, perineum, or reproductive organs. We conducted a targeted search within our hospital’s medical record system and identified two additional patients with similar conditions ( Table 1 , Fig. b- c ). All three patients had a history of transurethral resection of bladder tumors (TURBT) and were diagnosed with high-grade urothelial carcinoma, subsequently receiving adjuvant chemotherapy.

Table 1

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