1. Supraclavicular metastasis from urothelial bladder carcinoma: A case report S. Farmahan, T. Mirza, P. Ameerally Oral Maxillofacial Department, Northampton General Hospital, England Northampton General Hospital Introduction Metastases to the left supraclavicular lymph node usually originate from head and neck, breast or abdominal cancers.1 Affected patients often have widespread disease with a poor prognosis. Genitourinary primaries with supraclavicular metastases are very rare.2 Transitional cell carcinoma of the urinary bladder (also known as urothelial carcinoma) accounts for 90% of all bladder malignancies.3 Metastasis to the head and neck region is rare with relatively few cases reported in the literature. In most of these cases, metastases were found in the orbits or jawbones. There have only been two other reported cases of neck lymph node metastases from bladder cancer. We present a patient with a metastatic tumour in the left supraclavicular region that originated from a transitional cell bladder carcinoma. The patient had widespread malignant disease. Case report A 78-year-old man with hypertension presented with persistent microscopic haematuria on repeated mid stream urine testing having been treated with antibiotics for a urinary tract infection. The patient complained of a one month history of suprapubic ache and discomfort on passing water. On examination, a large benign-feeling prostate was palpable. A urine dipstick taken in the outpatient clinic was negative. An ultrasound scan revealed a simple cyst in the mid pole of the left kidney and an enlarged prostate. His PSA (prostate specific antigen) was 3.1ug/L (normal range 0 – 4ug/L). Flexible cystoscopy revealed two or three small papillary lesions on the posterior bladder wall. A TURB (transurethal resection of the bladder) was arranged to remove the bladder lesions. Histology revealed a G3 pTa transitional cell bladder carcinoma as well as carcinoma in situ. A CT IVU performed revealed locally advanced bladder cancer with extensive intra-abdominal lymphadenopathy. After discussion with the patient, a conservative approach to treatment was pursued. At an outpatient follow up appointment 2 months later, a large left supraclavicular firm, fixed mass was detected with multiple bilateral neck nodes, confirmed by a MRI neck (see below). Oral examination and nasoendoscopy were unremarkable. FNA confirmed metastasis from transitional cell carcinoma of the bladder. A CT chest revealed large volume level IV and left supraclavicular region lymphadenopathy, mediastinal, left axillary and intra-abdominal lymphadenopathy of moderate size, right and left para-aortic lymph nodes extending along the length of the aorta with no obvious soft tissue lesions within the lungs. Due to his widespread disease, the patient was treated with palliative chemotherapy (eight 3-week cycles of Gemcitabine and Cisplatin). Left supraclavicular mass Bilateral cervical neck nodes measuring 47mm x 35mm Discussion Lymphatic drainage from the superior part of the bladder passes to the external iliac lymph nodes, and from the inferior part of the bladder to the internal iliac nodes. Some lymphatic vessels from the neck region of the bladder drain into the sacral or common iliac lymph nodes. In a report of 107 patients, the most common site of metastasis of urinary bladder carcinoma was the regional lymph nodes (78%).4 Other common sites include the liver (38%), lung (36%), bone (27%), adrenal gland (21%), and intestine (13%).4 Many unusual sites of metastatic urinary bladder carcinoma have also been reported. Babaian et al. reported metastases in the heart, brain, kidney, spleen, pancreas, meninges, uterus, ovary, prostate, and testes.4 Metastases of urothelial bladder cancer to the head and neck region and cervical or axillary lymph node sites occur infrequently according to a retrospective autopsy study.5 Hessan et al. retrospectively reviewed 845 cases of urogenital tract tumors for metastases to the head and neck region lymph nodes. Of the 207 patients with metastasis, only 2 cases had head & neck region metastasis from urinary bladder carcinoma origin.6 Clinicians should be aware that although exceedingly rare, metastatic tumours in the supraclavicular nodes may arise from transitional cell carcinoma of the urinary bladder. This is usually an indicator of widespread disease with poor prognosis.