Latent Carcinoma of the Bladder

Abstract

MALIGNANT disease usually presents clinically with symptoms referable to the primary focus or origin, but occasionally this is not so, and the first indication of the existence of a malignant tumour is the appearance of metastases. The discovery of the primary focus is often a diagnostic problem, and the manner of investigation depends upon the known metastatic behaviour patterns of tumours. Carcinoma of the bladder rarely causes this problem, but two such cases are reported here. CASE REPORTSCaw I.-F. D., a female aged 53. reported to hospital o n the 14th December 1950 with a swelling of the neck uhich had been present for two years. It had inci-eased rapidly in size in the previous eight months and had caused pain. The only other symptoms were an attack of diarrhea and colicky abdominal pain six week\ before she attended hospital.On examination she appeared t o he in good general health. In the left supraclavicular fossa there was a large mass of hard lymph nodes, 6 cm. in diameter, fixed to the deep structures and obviously malignant in chiiraetcr. O t h e r n i x no abnormality was found. The diagnosis was thought to be possibly a primary carcinoma of the stomach or bronchus with metastases in the supraclavicular nodes. An extensive series of investigations was performed, which included radiological examination of the chest.gastro-intestinal tract, and lumbo-dorsal spine, and routine blood and urine examinations. No abnormality other than a diglit degree of anzmia \bas found. A biopsy of the mass in the neck was performed and the histological report by Dr Trevor Shaw stated that the tumour consisted of highly cellular carcinoma, that n o structure of' the lymph gland remained, and that no firm opinion of the possible origin of the tumour could be suggested from the histological appearances. Nasopharyngoscopy, bronchoscopy. and gastroscopy were carried out, but all failed t o reveal any primary turnour in the accepted common Sites of origin for such a metastatic tumour mass. In view of the negative findings the ma<> in the neck was treated by X-ray therapy as though it were a primary focus.The progress of the case was noted at monthly follow-up examination and in three months the mass resolved completely. After six months she was found to have developed e d e m a of the right leg and a palpable right kidney. but there were n o syniptoms referable to the urinary tract. She refused admission t o hospital for further investigation but a few days later was admitted elsewhere with a cerebral thrombosis from which she died. A post-mortem e.xamination was performed which revealed massive infarction of the middle portion of the left cerebral hemisphere and multiple recent infarcts in the spleen and kidneys. There was a right hydronephrosis and hydro-ureter, due to a hard, sessile, nodular tumour of the bladder, 3 cm. in diameter, around the right ureteric orifice. which had infiltrated through the whole thickness of the bladder wall (Fig. I). A chain of involved lymph nodes extended from the iliac vessels to the celi...