Ataxia in a Patient With Urothelial Carcinoma: Pathologic Confirmation, Recovery, and Improved Survival

A 74-year-old man was diagnosed with urothelial carcinoma after he presented with urinary obstruction. He was initially diagnosed with a Green Light Photo-Selective Vaporization of the Prostate (PVP), which showed a bladder tumor that was biopsied and cauterized with the laser. Pathology showed a high-grade papillary urothelial carcinoma invading into the submucosa. He then underwent bilateral retrograde pyelography, transurethral resection of the bladder (TURB), and transurethral resection of the prostate (TURP). The pathology confirmed a high-grade urothelial carcinoma in addition to carcinoma in-situ disease that was noted throughout the bladder wall and in the prostatic urethra. Staging evaluation, which included computed tomography (CT) of the chest, abdomen, and pelvis, showed bilateral external iliac lymph nodes, the largest of which measured 1.7 cm × 3.2 cm. In addition, there was a soft tissue nodularity extending from his prostate posteriorly into his rectum. His final diagnosis was stage IV (T4bN2M0) urothelial carcinoma. He received neoadjuvant chemotherapy with gemcitabine and cisplatin for 3 cycles. After completion of neoadjuvant therapy, restaging with CT and magnetic resonance imaging (MRI) of the abdomen/pelvis showed resolution of the soft tissue focus between the prostate and the rectum, as well as resolution of the bilateral external iliac lymph nodes. There was no gross evidence of residual bladder carcinoma. The patient was offered radical cystectomy but declined. He was treated with chemoradiation 5,940 cGy with weekly cisplatin. He was observed every 3 months with laboratory data and CT of the chest, abdomen, and pelvis, which yielded no evidence of recurrent or metastatic disease. Eleven months after the completion of therapy, the patient presented to the clinic complaining of increasing unstable gait, fatigue, dizziness, as well as dysequilibrium and diplopia. MRI of the brain showed a single left vermis cerebellar mass with heterogeneous enhancement consistent with metastatic disease (Figure 1A). He was treated with resection of his Figure 1. Axial and coronal magnetic resonance imaging (MRI) showing a 3.3 × 2.7 × 3.0 cm mass with heterogeneous enhancement in the left cerebellar hemisphere (A). There is also surrounding vasogenic edema, as well as a light mass effect on the medulla (B). Postoperative axial and coronal MRI show changes consistent with posterior fossa craniotomy and resection of the previously seen posterior fossa mass. A small hyperdense focus in the posterior fossa was believed to be consistent with residual tumor. A