Combined Modalities Treatment of Pulmonary Metastasis from an Urachal Adenocarcinoma
A 37-year old man, non-smoker, underwent a partial cystectomy with resection of urachus and umbilicus in 2002 for a mucinous urachal adenocarcinoma. Thoracic and abdominal computed tomography (CT) scan showed no abnormalities. Four years later, he was referred for multiple lung nodules (in the middle lobe, the right upper lobe, and left lower lobe) without any other visceral lesion (). There was no deterioration in performance status, and no symptom. Bronchoscopy showed no anomaly and no histological diagnosis was obtained. There was no evidence of infectious disease. A surgical removal of the right upper lobe nodule was performed by axillary thoracotomy. Pathological findings confirmed metastasis of the urachal adenocarcinoma. The patient was treated with chemotherapy consisting of three courses on Day 1 and Day 14 of 5-fluorouracil 400 mg/m2 as intravenous (i.v.) bolus followed by 2400 mg as i.v. continuous injection over 46 h and irinotecan 90 mg/m2. Tolerance was acceptable, despite a grade 2 neutropenia. CT scan showed lung nodules had almost disappeared. Four months later, the disease progressed with increasing size of the previously described lung nodules. Three cycles of chemotherapy with the same drugs were administered, with an acceptable clinical tolerance; due to a persistant neutropenia, chemotherapy was administered on Day 1 and Day 21 instead of Day 1 and Day 14 and the patient had to receive granulocyte colony-stimulating factor (G-CSF). There was then a small regression of the nodules, with persistent activity on PET scan on the right lower lobe nodule. A surgical approach was decided, and a metastasectomy (in the right upper and lower lobes) was performed. Two months later, a CT scan showed two new nodules, one on the left upper lobe and one on the left lower lobe () with a high metabolic activity on PET scan. The same chemotherapy was administered to the patient. After four cycles, the disease was stable, with decreased activity on PET scan. A surgical removal of the metastases was performed, with a wedge resection of the anterior part of the left basal pyramid and metastasectomy in the anterior part of the left upper lobe. During follow up, six months later, another PET scan showed a new nodule in the right lower lobe and a new mass on the right upper lobe, with parietal involvement (); a CT-guided transparietal biopsy of this mass confirmed the recurrence of the urachal carcinoma. Chemotherapy was administered, consisting of three courses on Day 1 and Day 14 of 5-fluorouracil 400 mg/m2 as i.v. bolus followed by 1200 mg as i.v. continuous injection over 46 h, irinotecan 90 mg/m2 and bevacizumab 5 mg/kg. Tolerance was fair with mild vomiting and no changes in hematologic parameters. The disease was stable. Three courses of chemotherapy with an association of capecitabine 2000 mg/m2/day from Day 1 to Day 14 and oxaliplatin 130 mg/m2 on Day 1and Day 21, with grade 3 nausea and vomiting, were administrated. There was a slight decrease in the metabolism intensity of the metastases on PET scan. Surgery (right pneumonectomy with rib resection) was proposed to the patient. The patient died during surgery because of hemorrhagic shock due to a pulmonary artery wound, in June 2009, seven years after the diagnosis of urachal carcinoma, and three years after appearance of metastases.