One-Step Robot-Assisted Complete Urinary Tract Extirpation in Man with End-Stage Renal Disease on Dialysis: The First Case Report.

Urothelial carcinoma (UC) could be observed in urinary bladder (UBUC) and upper urinary tracts (UTUC). In the National Comprehensive Cancer Network guidelines for bladder cancer, extirpative surgery is indicated in certain cases. However, some extreme cases might also need the extirpation of the majority of the urinary tract, which is called complete urinary tract extirpation (CUTE). We present a patient diagnosed with high-grade UBUC and UTUC. He underwent dialysis for end-stage renal disease (ESRD) at the same time. Considering his non-functional kidneys and removing his high-risk urothelium at the same time, we performed robot-assisted CUTE to extirpate both his upper urinary tracts, urinary bladder, and prostate. In our experience, the console time was not significantly elongated, and the perioperative course was uneventful. To our knowledge, this is the first case report adopting a robotic system in such an extreme case. We conclude that robot-assisted CUTE is worth further study regarding its oncological survival outcomes and perioperative safety in patients with ESRD on dialysis.

Oncological safety and quality of life in men undergoing simultaneous transurethral resection of bladder tumor and prostate: results from a randomized controlled trial.

PURPOSE: To assess oncological safety and quality of life (QL) of men undergoing simultaneous transurethral resection of bladder tumor (TURBT) and transurethral resection of the prostate (TURP) for symptomatic benign prostatic hyperplasia (BPH). METHODS: Ninety-five men with a new diagnosis of bladder cancer (BC) and symptomatic BPH were randomized to receive TURBT + tamsulosin (Group 1) or TURBT + TURP (Group 2). Inclusion criteria were age ≤ 75 years, first diagnosis of BC up to 4 cm, and prostate volume ≤ 80 ml. All patients were evaluated preoperatively with digital rectal examination, PSA, maximal urine flow rate (Qmax), and International Prostate Symptom Score (IPSS). IPSS and Qmax were repeated at 1-year follow-up. QL was evaluated at 1 year using a modified version of the self-report bladder cancer subscale of the Functional Assessment of Cancer Therapy. RESULTS: Eighty-five men completed the study (43 in Group 1 and 42 in Group 2). Adjuvant instillation therapy was given to 26 patients in Group 1 and to 27 in Group 2. Average time to the first recurrence was 16.64 months in Group 1 and 17.7 in Group 2. Total recurrences were 27 in Group 1 and 22 in Group 2. Bladder neck/prostatic urethra recurrences were 9 in Group 1 vs. 8 in Group 2. QL, IPSS, and Qmax 12 months after surgery were better in Group 2. CONCLUSION: Concomitant TURBT and TURP appear to be oncologically safe procedures in terms of total and prostatic urethra recurrence, and improve QL in men with BC who require surgery for symptomatic BPH.

Adjuvant Radiotherapy Use by US Radiation Oncologists After Radical Cystectomy for Muscle-invasive Bladder Cancer.

AIMS: Historic trials suggested significant toxicity with adjuvant radiotherapy (ART) after radical cystectomy for muscle-invasive bladder cancer (MIBC). However, recent trials have found improved locoregional control and the 2016 National Comprehensive Cancer Network (NCCN) guidelines recommend ART consideration for select patients at high risk of local recurrence. ART practice patterns among US radiation oncologists are unknown and we carried out a survey to explore current trends. MATERIALS AND METHODS: We conducted a survey of US radiation oncologists regarding the management of patients with cT2-3N0M0 transitional cell MIBC. Responses were reported using descriptive statistics. Chi-square and univariate logistic regression of clinical and demographic covariates were conducted, followed by multivariable logistic regression analysis to identify factors predicting for ART use. RESULTS: In total, 277 radiation oncologists completed our survey. Nearly half (46%) have used ART for MIBC at least once in the past. In ART users, indications for ART include gross residual disease (93%), positive margins (92%), pathological nodal involvement (64%), pT3 or T4 disease (46%), lymphovascular invasion (16%) and high-grade disease (13%). On univariate logistic regression, ART use was associated with the number of years in practice (P=0.04), pre-cystectomy radiation oncology consultation (P=0.004), primarily treating MIBC patients fit for cystectomy (P=0.01) and intensity-modulated radiotherapy use (P=0.01). On multivariable logistic regression analysis, routine pre-cystectomy radiation oncology consultation (odds ratio 1.91, 95% confidence interval 1.04-3.51; P=0.04) and intensity-modulated radiotherapy use (odds ratio 2.77, 95% confidence interval 1.48-5.22; P=0.002) remained associated with ART use. CONCLUSIONS: ART use is controversial in bladder cancer, yet unexpectedly has commonly been used among US radiation oncologists treating patients with MIBC after radical cystectomy. NRG-GU001 was a randomised trial in the US randomizing patients with high-risk pathological findings for observation or ART after cystectomy. However, due to poor accrual it recently closed and thus it will be up to other international trials to clarify the role of ART and identify patients benefiting form this adjuvant therapy.

[The risk of bladder cancer in patients with prostatic hyperplasia and strategies to manage this combination].

The combination of bladder cancer with benign prostatic hyperplasia (BPH) occurs in 5-27% of cases. The link between these diseases has not yet been closely investigated. The main role in the pathogenesis of bladder cancer combined with BPH is played by the residual urine and prolonged exposure of urothelium to the urine carcinogens. The choice of surgical treatment modality for the combination of non-muscle invasive bladder cancer and BPH is still a matter of debate. There is no consensus on the safety and appropriateness of simultaneous transurethral resection of the bladder and prostate in these patients. On one hand, opponents of simultaneous surgery suggest sustained exposure to carcinogens and the spread of tumor cells in a transurethral resection through the prostate wound surface in the blood and lymphatic vessels. On the other hand, supporters refer to studies and meta-analyzes showing that the simultaneous resection neither increases the recurrence rate of bladder cancer nor causes metastasis and tumor progression.

What is the correct staging and treatment strategy for locally advanced prostate cancer extending to the bladder?

In locally advanced prostate cancer with bladder invasion, frequently encountered problems such as bleeding, urinary retention, hydronephrosis, and pain create distress for the patients. Therefore patients' quality of life is disrupted and duration of hospitalization is prolonged. Relevant literature about accurate staging and treatment of locally advanced prostate cancer with bladder invasion was investigated. Locally advanced prostate cancer can present as a large-volume aggressive tumor extending beyond boundaries of prostate gland, and involving neighboring structures which can be involved as recurrence(s) following initial local therapy. Survival times of these patients can range between 5 and 8 years. Their common characteristics are adverse and severe local symptoms unfavorably affecting quality of life Control of local symptoms and their effective palliation are independent clinical targets influencing survival outcomes of these patients. The treatment outcomes of locally advanced prostate cancer into the bladder are currently debatable. Although in the current TNM classification, it is defined in T4a, we think that this may be categorized as a subgroup of T3 and thus encourage surgeons for the indication of radical surgeries (radical prostatectomy, radical cystoprostatectomy) in selected patient populations after discussing issues concerning consequences of the treatment alternatives, and expectations with the patients. Cystoprostatectomy followed by immediate androgen deprivation therapy may be a feasible option for selected patients with previously untreated prostate cancer involving the bladder neck because of excellent local control and long term survival.

Risk of prostate and bladder cancers in patients with spinal cord injury: a population-based cohort study.

OBJECTIVE: To evaluate the risk of prostate and bladder cancers in patients with spinal cord injury (SCI). MATERIALS AND METHODS: We used data obtained from the National Health Insurance system of Taiwan for this study. The SCI cohort contained 54,401 patients with SCI, and each patient was randomly frequency matched with 4 people from the general population (without SCI) based on age, sex, and index date. Incidence rates, SCI cohort to non-SCI cohort rate ratios, and hazard ratios were measured to evaluate the cancer risks. RESULTS: Patients with SCI showed a significantly lower risk of developing prostate cancer compared with subjects without SCI (adjusted hazard ratio = 0.73; 95% confidence interval = 0.59, 0.90), after accounting for the competing risk of death. No significant difference in the risk of bladder cancer emerged between the SCI and control groups. Further analyses found a higher spinal level of SCI tended to predict a lower risk for prostate cancer. CONCLUSIONS: Patients with SCI incurred a lower risk for prostate cancer compared with people without SCI. The risk for bladder cancer did not differ between people with or without SCI.

Complementary and alternative medicine (CAM) in prostate and bladder cancer.

To provide an overview of the scientific and clinical studies underlying the most common vitamin and herbal preparations used in prostate and bladder cancer and evaluate the evidence behind them. A literature search was undertaken on PubMed using various keywords relating to the use of complementary and alternative medicine (CAM) in prostate and bladder cancer.Vitamin E and selenium supplementation can potentially have adverse effects by increasing the risk of prostate cancer. Initial clinical studies of pomegranate and green tea, investigating their chemotherapeutic properties in prostate and bladder cancer have yielded encouraging results. Curcumin, resveratrol, and silibinin have potential anticancer properties through multiple molecular targets; their clinical effectiveness in prostate and bladder cancer is yet to be evaluated. Zyflamend, like PC-SPES, is a combined CAM therapy used in prostate cancer. Acupuncture is popular among patients experiencing hot flushes who are receiving androgen-deprivation therapy for prostate cancer. Conclusive evidence for the use of CAM in prostate and bladder cancer is lacking and not without risk.

Outcome of simultaneous transurethral resection of bladder tumor and transurethral resection of the prostate in comparison with the procedures in two separate sittings in patients with bladder tumor and urodynamically proven bladder outflow obstruction.

BACKGROUND AND PURPOSE: A prospective randomized study was undertaken wherein transurethral resection of bladder tumor (TURBT) was performed along with transurethral resection of the prostate (TURP) in the same sitting (group A) in patients with bladder tumor and urodynamically proven bladder outflow obstruction. The outcome (recurrence and progression of superficial transitional cell carcinoma) was compared with patients who underwent TURBT and TURP in two separate sittings (group B) approximately 6 months apart. PATIENTS AND METHODS: Between January 2002 and December 2007, 48 patients were randomized for this study. The inclusion and exclusion criteria are described below. The patients were followed up according to standard protocols. The two groups were compared for the recurrence and progression of the bladder tumor. RESULTS: Mean age in both the groups were similar (group A = 56.06 +/- 4.45 years, group B = 57.36 +/- 3.65 years). The mean duration of follow-up was also similar between the two groups (group A, 35.71 +/- 12.8 months; group B, 37.55 +/- 14.12 months; P > 0.05). In group A, 12 (50%) patients had recurrence, while in group B, 11 (42.85%) patients had recurrence. The differences in recurrence, mean elapsed time to recurrence, and progression of tumor between the two groups were statistically insignificant. CONCLUSION: TURBT and TURP can be performed simultaneously without any increased risk of recurrence and progression of tumor, if performed in a properly selected group of patients.

Prostatic urothelial carcinoma: is transurethral prostatectomy necessary before bacillus Calmette-Guérin immunotherapy?

OBJECTIVE: To evaluate the efficacy of transurethral prostatectomy (TURP) followed by bacillus Calmette-Guérin (BCG) immunotherapy in patients with prostatic urothelial carcinoma (PUC) and compare the results of studies using combined TURP and BCG with studies in which TURP was not performed. PATIENTS AND METHODS: Patients with bladder cancer and PUC were treated with TURP followed by six weekly intravesical instillations of BCG. Response was determined and monitored by periodic bladder and prostatic urethra biopsies and urinary cytology. Also, the outcome of previous series using similar methodology was compared with the outcome of studies in which TURP was not performed. RESULTS: In all, 20 patients with PUC were treated with TURP followed by intravesical instillations of BCG. The median follow-up was 52.5 months. All patients had an initial complete response (CR). The prostatic urethra 5-year recurrence-free survival rate was 90%. However, bladder and prostatic urethra 5-year recurrence-free survival rate was only 30%. Five patients (25%) died from urothelial carcinoma (UC) after a median period of 58.5 months (two from bladder cancer metastases and three from upper tract metastases). The long-term prostatic urethra CR rate in studies using TURP before immunotherapy was significantly higher than the CR rate in studies using immunotherapy alone (P < 0.001). However, there was no difference when bladder and prostatic urethra CR rates were considered together (P = 0.54). CONCLUSION: In patients with PUC, TURP before BCG immunotherapy eliminates PUC in most cases, and is probably the preferred treatment for this disease. The risk of UC-specific mortality in these patients is high.

[Erectile dysfunction in patients treated for bladder and prostate cancer]. / Zaburzenia erekcji u pacientów leczonych z powodu raka pecherza moczowego i stercza.

The disorders of the erectile dysfunction are well-known complication connected with the operating interventions of abdominal and pelvic surgery. Radical treatment of the malignancy, vascular operations and transurethral resection can lead to the rise of these disorders. The majority of these interventions is carried out at patients in the old age at which the disorders of the erection already existed about the various degree of intensification before treating operating how also the presence of the illnesses of the leaders to their rise or intensification after finishing the treatment (diabetes, arterial hypertension, arteriosclerosis). Patients in the young aged wait not only curing from the malignancy from second side, but also the behaviour of the quality of the life (QOL - quality of life), which the correct erection enabling is one of elements satisfying living together.

Variantes histológicas del carcinoma urotelial con implicaciones diagnósticas, pronósticas y terapéuticas / Histological variants of urothelial carcinoma with diagnostic, prognostic and therapeutical implications

La mayoría de los carcinomas uroteliales (CU) tienen un patrón de crecimiento histológico de tipo papilar o de tipo sólido; sin embargo, en algunos casos existen variedades histológicas que difieren significativamente de estos patrones habituales En este artículo se han seleccionado aquellas variantes de CU que por su dificultad diagnóstica e implicaciones pronósticas o terapéuticas tienen que ser perfectamente identificadas y conocidas por los patólogos y los urólogos. Las variantes que hemos considerado de mayor interés tanto clínico como patológico han sido: CU variedad en nidos y/o tubular, CU variedad microquística, CU variedad micropapilar, CU con intenso estroma linfoide, tipo linfoepitelioma, CU variedad plasmocitoide y CU sarcomatoide. De cada uno de estos patrones se ha realizado una revisión de la literatura valorando los criterios diagnósticos, el comportamiento clínico y las posibilidades terapéuticas actuales. Además, sugerimos que estas variedades de CU deben ser reflejadas explícitamente en el informe del diagnóstico anatomopatológico, debido a sus implicaciones clínicas

Most of urothelial carcinomas (UC) have a pattern of histological growth of papillary or solid type; nevertheless, in some cases there are histological types that significantly differ from these habitual patterns In this paper we have selected those UC variants that by its diagnosis difficulty and therapeutical or prognosis implications have to be perfectly identified and known by pathologists and urologist. The variants that we have considered of greater clinical and pathological interest have been: tubular and/or nested UC, microcystic UC, micropapillary UC, lymphoepithelioma like UC, plasmacytoid UC and sarcomatoid UC. A revision of the literature has been made of each one of these patterns evaluating the criteria diagnoses, clinical behavior and the present therapeutic options. In addition, we suggest that these UC variants must be explicitly reflected in the pathology report, due to its clinical implications

Carcinoma urotelial de vejiga estadio T1: subestadiaje, patrones morfológicos de invasión y su significado pronóstico / Bladder urothelial carcinoma stage T1: substaging, invasion morphological patterns and its prognosis significance

Desde 1990 en que se publicaron las primeras series sobre subestadiaje, han aparecido numerosas publicaciones sobre el subnivel de invasión de los carcinomas de alto grado T1. La invasión profunda conlleva un elevado riesgo de progresión (alrededor del 30-35% de casos progresan) frente a los casos de invasión superficial por encima de la muscularis mucosae, en los que la progresión se encuentra alrededor del 10%, por lo que para la mayoría de autores vale la pena tener en cuenta los subT1, en el manejo del paciente. En esta revisión se presentan las series más exhaustivas que han valorado el subestadiaje y se valoran los diferentes métodos de efectuar esta estadificación teniendo en cuenta la dificultad inherente a las muestras que proceden de resección transuretral (RTU)

Since 1990 when the first series on substaging were published, they have published numerous publications on the invasion sublevel of high degree T1 carcinomas. The deep invasion entails a high risk of progression (around 30-35% of cases progress) as opposed to the cases of superficial invasion over “muscularis mucosae”, in which the progression is around 10%, reason why most authors consider subT1, in patient management. In this revision the more exhaustive series that have evaluated substaging are shown and also the different methods to carry out this staging considering the inherent difficulty to the samples that come from transurethral resection (RTU)

Leiomioma vesical. A propósito de dos casos y revisión de la literatura / Bladder leiomyoma. Report of two new cases and bibliographic review

Objetivo: Los tumores mesoteliales primarios de la vejiga son entidades raras, y de entre ellos el más frecuente es el leiomioma vesical, que puede crecer sin apenas manifestaciones clínicas o muy inespecíficas. Métodos: Presentamos el caso de un leiomioma vesical en dos pacientes y la revisión de la literatura. Resultados: El tratamiento fue mediante una resección transuretral, la evolución excelente y el seguimiento en consultas externas tras más de 5 años sin incidencias. Conclusiones: El abordaje quirúrgico sigue siendo la mejor solución, de fácil ejecución y con un porcentaje escaso de complicaciones. El pronóstico es bueno en cualquier caso y las recidivas son anecdóticas (AU)

Objective: Primary mesothelial tumors of the bladder are rare entities, being leiomyoma the most frequent of them. It may grow without any clinical symptoms or with very unspecific ones. Methods: We report two cases of bladder leiomyoma in 2 patients, and performed a bibliographic review. Results: They were treated by transurethral resection, with an excellent outcome, without incidences over five years of follow-up. Conclusions: Surgical treatment continues to be the best solution; it is easy to perform and has a very limited number of complications. Prognosis is good in any case and progression is anecdotic (AU)

Effects of simultaneous transurethral resection of prostate and solitary bladder tumors smaller than 3 cm on oncologic results.

OBJECTIVES: To investigate the effect on the oncologic outcomes of treatment with transurethral resection of patients with a solitary bladder tumor smaller than 3 cm with a superficial appearance and benign prostatic hyperplasia. METHODS: The follow-up data from 34 men (group 1) who had undergone transurethral bladder tumor resection alone and 31 men who had undergone both transurethral prostate resection and transurethral bladder tumor resection at the same operation (group 2) in our clinic from 1996 to 2004 were retrospectively examined. The groups were also compared with each other. The recurrence and progression rates, elapsed time to recurrence, and the recurrence rates in the bladder neck and prostatic urethra were determined and compared. Statistical analysis was performed using the Mann-Whitney U and chi-square tests. RESULTS: The patients were followed up for at least 12 months (mean 28.9, range 12 to 98). The average follow-up period for group 1 was 27.4 months (range 12 to 91) and was 30.5 months (range 12 to 98) for group 2. The recurrence and progression rates for groups 1 and 2 were 41.2% and 8.8% and 35.5% and 9.7%, respectively. Recurrence in the bladder neck and/or prostatic urethra developed in 1 patient in each group. No statistically significant differences were found between groups in terms of follow-up time, recurrence, progression, recurrence in the prostatic urethra and/or bladder neck, and elapsed time to recurrence. CONCLUSIONS: According to our results, transurethral prostate resection can be safely performed with transurethral bladder tumor resection simultaneously in selected patients with severe lower urinary tract symptoms and a superficial solitary tumor smaller than 3 cm.

Clinical model of lifetime cost of treating bladder cancer and associated complications.

OBJECTIVES: To estimate the lifetime cost of bladder cancer and the contribution of complications to the total costs. METHODS: We reviewed the medical records of a retrospective cohort of 208 patients with bladder cancer who registered at our comprehensive cancer center from 1991 to 1999. We multiplied the number of resources used during management of bladder cancer by their unit charges. We converted charges into costs using the Medicare cost-to-charge ratio and inflated these to 2005 U.S. dollars. We estimated future costs by creating two extreme hypothetical scenarios. In the best-case scenario, we assumed patients with superficial disease developed recurrences at the cohort's mean rate and that patients with muscle-invasive disease were disease free after definitive therapy. Survival was based on the U.S. life expectancy in both cases. In the worst-case scenario, we assumed patients with superficial disease developed muscle-invasive disease and that all patients subsequently died of bladder cancer. RESULTS: The average cost of bladder cancer was 65,158 dollars among the cohort patients. Sixty percent of this cost (39,393 dollars) was associated with surveillance and treatment of recurrences, and 30% (19,811 dollars) was attributable to complications. The lifetime cost of bladder cancer was lower for the worst-case scenario (99,270 dollars) than for the best-case scenario (120,684 dollars). However, a greater proportion of the costs were attributable to complications with the worst-case scenario (43%, 42,290 dollars) compared with the best (28%, 34,169 dollars). CONCLUSIONS: The management of bladder cancer and its associated complications results in a major economic burden. More cost-effective surveillance strategies and approaches for preventing complications are crucial to minimizing the disease's clinical and economic consequences.

[Simultaneous treatment for benign prostate hyperplasia and its concomitant diseases].

OBJECTIVE: To investigate the surgical treatment of benign prostate hyperplasia (BPH) and its concomitant diseases at the same time. METHODS: One hundred and fourteen operations were performed for BPH patients, including transurethral resection/vapor of the prostate (TURP/TUVP), inguinal herniorrhaphy, internal urethrotomy, transurethral resection of bladder tumor (TURBt) or vesical litholapaxy, and the data were reviewed. RESULTS: The procedures were successful in all cases. A follow-up of 3 to 60 months found a good outcome of TURP. There was no recurrence in 30 cases of inguinal hernia and 39 cases of vesical calculus. Of the 25 cases of urethral stricture, 1 had an obvious hypotension during the operation and 4 needed urethral dilatation after operation. Six of the 20 cases of bladder tumor underwent a second TURBt due to the recurring tumor which was far from prostatic urethra. CONCLUSION: Inguinal hernia, urethral stricture, bladder tumor or vesical calculus can be treated simultaneously during TURP.

Trichosporon asahii fungemia in a patient with non-hematological malignancy.

Trichosporon fungemia is usually seen in neutropenic patients with underlying hematological malignancies. In this report we describe a fatal case of Trichosporon asahii fungemia in a non-neutropenic patient with a non-hematological malignancy. For 1 week the patient exhibited hematuria, weakness, easy fatigability and headaches. At admission she had anemia, renal failure and evidence of right hydronephrosis and bladder wall masses as detected by CT scan. She did not have a history of tobacco abuse, contact with urinary carcinogens or Schistosoma infestation; her clinical picture was suggestive of bladder cancer. After some investigations the patient underwent radical cystectomy and ileal conduit surgery because of transitional cell carcinoma in the urinary bladder. After an initial uneventful improvement postoperatively the patient deteriorated and died of septic shock despite all reanimation efforts and antibiotherapy including fluconazole. The blood culture obtained 4 days before the patient died revealed T. asahii, which was isolated on the day she died and found to be resistant to fluconazole and caspofungin. This report suggests that clinicians remain aware that T. asahii fungemia may develop in clinically deteriorated patients even if they do not have a hematological malignancy.

[One-stage transurethral resection of the urinary bladder and the prostate in patients with superficial cancer of the urinary bladder combined with benign prostatic hyperplasia].

Combination of urinary bladder cancer (UBC) with benign prostatic hyperplasia (BPH) is a prognostically unfavourable factor. To assess clinical efficacy of one-stage transurethral resection of UBC and BPH in combination with adjuvant immunotherapy, we examined 181 patients with UBC stage Tis, Ta-T1 and BTH. All the patients have undergone one- and two-stage endoscopic operations. TUR of the urinary bladder and the prostate was made in 87 patients. Stage-by-stage TUR of the urinary bladder and TUR of the prostate were made in 94 controls. We conducted postoperative immunotherapy with BCG vaccine (imuron) as an adjuvant therapy in 114 (63%) patients. Postoperative UBC recurrence occurred in 124 (68.5%) patients: 49 (56.3%) patients of the study group and 75 (79.7%) controls (p < 0.05). Reoperation (TUR of the urinary bladder) was performed in all cases of UBC recurrence. Five-year survival in the study group was 71% and 68.0% survived in the control group (p > 0.05). The conclusion is made that in combination of superficial UBC with BPH indications appear for TUR of the urinary bladder and TUR of the prostate with adjuvant immunotherapy. Early elimination of infravesical obstruction lowers UBC recurrence rate and improves the patients' quality of life.

Synchronous solitary metastasis of transitional cell carcinoma of the bladder to the testis.

Primary tumors known to metastasize to the testis, in order of decreasing frequency, are prostate, lung, gastrointestinal tract, melanoma, and kidney tumors. Metastasis from bladder cancer to the testis is extremely rare, occurs with advanced and metastatic disease, and is usually a finding at autopsy. We report a rare, and probably the first, case of solitary and synchronous metastatic transitional cell carcinoma of the bladder to the testis, discovered on the preoperative workup. An incidentally discovered testicular mass in a man with high-grade, invasive bladder cancer should be considered a metastatic lesion until proven otherwise.