Problems in early diagnosis of bladder cancer in a spinal cord injury patient: report of a case of simultaneous production of granulocyte colony stimulating factor and parathyroid hormone-related protein by squamous cell carcinoma of urinary bladder.
BACKGROUND
Typical symptoms and signs of a clinical condition may be absent in spinal cord injury (SCI) patients.


METHODS
A male with paraplegia was passing urine through penile sheath for 35 years, when he developed urinary infections. There was no history of haematuria. Intravenous urography showed bilateral hydronephrosis. The significance of abnormal outline of bladder was not appreciated. As there was large residual urine, he was advised intermittent catheterisation. Serum urea: 3.5 mmol/L; creatinine: 77 umol/L. A year later, serum urea: 36.8 mmol/l; creatinine: 632 umol/l; white cell count: 22.2; neutrophils: 18.88. Ultrasound: bilateral hydronephrosis. Bilateral nephrostomy was performed. Subsequently, blood tests showed: Urea: 14.2 mmol/l; Creatinine: 251 umol/l; Adjusted Calcium: 3.28 mmol/l; Parathyroid hormone: < 0.7 pmol/l (1.1 - 6.9); Parathyroid hormone-related protein (PTHrP): 2.3 pmol/l (0.7 - 1.8). Ultrasound scan of urinary bladder showed mixed echogenicity, which was diagnosed as debris. CT of pelvis was interpreted as vesical abscess. Urine cytology: Transitional cells showing mild atypia. Bladder biopsy: Inflamed mucosa lined by normal urothelial cells. A repeat ultrasound scan demonstrated a tumour arising from right lateral wall; biopsy revealed squamous cell carcinoma. In view of persistently high white cell count and high calcium level, immunohistochemistry for G-CSF and PTHrP was performed. Dense staining of tumour cells for G-CSF and faintly positive staining for C-terminal PTHrP were observed. This patient expired about five months later.


CONCLUSIONS
This case demonstrates how delay in diagnosis of bladder cancer could occur in a SCI patient due to absence of characteristic symptoms and signs.
Regional Spinal Injuries Centre, District General Hospital, Southport PR8 6PN, UK. vaidyanathansiu@hotmail.com
Subramanian
S
Vaidyanathan
Paul
P
Mansour
Munehisa
M
Ueno
Kazuto
K
Yamazaki
Meenu
M
Wadhwa
Bakul M
BM
Soni
Gurpreet
G
Singh
Peter L
PL
Hughes
Ian D
ID
Watson
Pradipkumar
P
Sett
D000328:Adult; D002294:Carcinoma, Squamous Cell / Q000150:complications / Q000175:diagnosis* / Q000378:metabolism*; D002648:Child; D042241:Early Diagnosis; D005500:Follow-Up Studies; D016179:Granulocyte Colony-Stimulating Factor / Q000096:biosynthesis*; D006801:Humans; D008297:Male; D044162:Parathyroid Hormone-Related Protein / Q000096:biosynthesis*; D013119:Spinal Cord Injuries / Q000150:complications*; D013997:Time Factors; D001749:Urinary Bladder Neoplasms / Q000150:complications / Q000175:diagnosis* / Q000378:metabolism*
D044162:Parathyroid Hormone-Related Protein; D016179:Granulocyte Colony-Stimulating Factor