Meningeal carcinomatosis from transitional cell carcinoma of the bladder

Response rates of over 50% can be achieved in patients with metastatic transitional cell carcinoma of the bladder treated with cisplatin-based chemotherapy. With prolonged survival, intraparenchymal brain metastases may occur in as many as 12% of patients who received methotrexate, vinblastine, doxorubicin, and cisplatin (M-VAC) chemotherapy. Meningeal carcinomatosis from urothelial cancer is rare, however. A 71-year-old man, with metastatic, transitional cell carcinoma of the bladder, attained an excellent partial response to M-VAC chemotherapy. He subsequently presented with an acute confusional state 6 months after diagnosis. Head computed tomographic studies were nondiagnostic. Gadolinium-enhanced magnetic resonance images (MRI), however, demonstrated multifocal 1-cm nodules in the brain parenchyma and enhancement of the meninges. Meningeal carcinomatosis was confirmed by lumbar puncture. Records of 40 patients with advanced transitional cell carcinoma of the bladder treated with chemotherapy between 1977 and 1992 at a cancer center were reviewed retrospectively for the occurrence of documented meningeal carcinomatosis, intraparenchymal brain metastases, or both. Among 13 responders, only 1 other patient, a 64-year-old man, was identified who had minimal metastatic disease and attained a complete response to methotrexate and cisplatin. The patient relapsed 2 years after response, with cerebellar metastases and meningeal carcinomatosis. Central nervous system (CNS) metastases in patients with transitional cell carcinoma of the bladder are unusual. Although parenchymal brain metastases may be more common after prolonged remissions induced by combination chemotherapy, meningeal carcinomatosis remains uncommon. MRI may be a useful adjunct in the diagnosis of CNS metastases. A high index of clinical suspicion for the occurrence of CNS metastases from transitional cell carcinoma is encouraged.