bladder cancer is the ninth most common cancer in the world , with 430,000 new cases diagnosed in 2012 .
the estimated crude incidence per 100,000 persons was 9.3 in males and 2.8 in females , thus it was about three times more common in men compared with women .
the most common pathological type is transitional cell carcinoma . depending upon the depth of invasion , it is classified as superficial when the invasion is limited to the muscularis mucosae and advanced when the invasion involves muscles or the prevesical space .
the 5-year survival rate in patients with superficial low - grade tumor is as high as 85% while it is 4045% in patients with invasive high - grade tumor .
metastatic lesions were found in 68% of patients with invasive bladder cancer , and the most common sites for metastases were the lymph nodes ( 78% ) , liver ( 38% ) , lungs ( 36% ) , bone ( 27% ) , adrenal glands ( 21% ) and intestine ( 13% ) .
recently , there have been many reports on korean medicine therapy ( kmt ) to treat various kinds of cancer .
a 74-year - old korean man was admitted to our hospital on january 11 , 2014 with the clinical diagnosis of metastatic bladder cancer in both lungs . in his past medical history , he had presented to a different hospital with the symptoms of frequency , dysuria and hematuria , and was diagnosed with bladder cancer through cystoscopic examination on april 24 , 2013 .
a radical cystectomy with ileal conduit urinary diversion was done on may 10 , 2013 in another medical center , and the postoperative pathologic diagnosis was transitional cell carcinoma , t3an1mx . on pet - ct scan images on june 22 , 2013 , mild heterogeneous increased fdg uptake was observed in the urethral stump and recurrence was suspected .
thus , total urethrectomy was carried out on july 17 , 2013 . on the follow - up ct scan image on august 29 , 2013 , multiple metastatic nodules were found in both lungs , and the final diagnosis was revised as stage iv bladder cancer .
conventional chemotherapy was recommended but refused by the patient for fear of the expected adverse effects of chemotherapy .
the patient was admitted to our hospital on january 11 , 2014 with the following symptoms : aggravating cough , sputum , hemoptysis and dyspnea . since then
, he had been on kmt , and the state of the tumor was checked with simple x - ray because he refused any further studies .
multiple metastatic nodules in both lungs were observed on the chest posterior - anterior x - ray on that day .
the patient was administered the following medication : wild ginseng pharmacopuncture ( wgp ) 10 ml , cordyceps sinensis ( cs ) pharmacopuncture 10 ml , trichosanthes kirilowii pharmacopuncture 10 ml , platycodon grandiflorus pharmacopuncture 10 ml i.v .
the number and size of the nodules had increased on the chest posterior - anterior x - ray on march 13 , 2014 in comparison with that on january 11 , 2014 . due to the progression of the disease ,
, hangamdan s ( had s ) 1,000 mg t.i.d . and soram nebulizer solution 8 ml inhalation q.d . and continued for a month . as a result , the number and size of the nodules had decreased in both lungs , and the shadows of the remaining nodules had faded on the x - ray image on april 10 , 2014 .
after 1 additional month of the same treatment , most of the nodules had nearly disappeared on the chest x - ray image on may 17 , 2014 ( fig .
surgery , chemotherapy and radiotherapy compose the major therapeutic modalities for cancer treatment in the current western medicine . our patient with bladder cancer was treated with cystectomy first and then with urethrectomy , but the cancer recurred in the lungs . at this point , he abandoned all western medicine therapy and chose kmt for the treatment of cancer .
nebulizer therapy is the inhalation of liquid herbal extracts in the form of mist from a nebulizer .
oral herbal medicines consist of single or several kinds of herbs in the form of tablets , capsules or fluids . in general ,
pharmacopuncture solution , nebulizer solution and oral herbal distillate solution were produced through a distillation process .
briefly , a certain amount of a herb was decocted in distilled water for several hours , and the decoction was distilled to produce distillate solution which , in turn , was filtered with 0.45- and 0.2-m filters and sterilized in vials to be used as a final product .
cordyceps distillate solution for oral intake was made of cultivated cordyceps militaris through a distillation process .
briefly , about 6-year - old wg 500 g was ground and mixed with honey 500 g , divided into 8-gram pills , and wrapped with gold foils .
briefly , rhus verniciflua extract 18 liters and rehmanniae radix crudus juice 3 liters were mixed and concentrated with mild fire .
dioscoreae rhizoma 3 kg and ulmus pumila l. 3 kg were mixed with the concentrate .
this mixture was dried at a cool temperature and then ground to be filled in 500-mg capsules ( table 2 ) .
fresh ginseng was steamed at a high pressure , at a temperature of 120c for 3 h and dried .
it was ground , mixed with honey at a ratio of 1:1 , and divided into 4-gram pills . had s was made of c. militaris , p. ginseng radix , commiphora myrrha , calculus bovis , margarita , processed boswellia carteri , processed panax notoginseng radix , and processed cremastra appendiculata tuber at a ratio of 3:2:2:2:2:2:4:4 .
roughly 6-year - old wg 200 g was washed under running water , decocted in 2,000 ml distilled water , and the decoction was distilled to produce 1,500 ml fluid .
cs 200 g was washed under running water , decocted in 2,000 ml distilled water , and the decoction was distilled to produce 1,500 ml fluid .
the two fluids were mixed at a ratio of 1:1 , filtered with 0.45- and 0.2-m filters , and then sterilized in 8-ml vials .
each nebulizer therapy was done with this solution and an ultrasonic nebulizer ( omron , ne - u17 ) for 20 min .
[ 4 , 5 ] reported on the case of a patient with inoperable klatskin tumor who lived for more than 4.5 years treated with only kmt including wgp , and on another case of metastatic breast cancer in the lungs that was completely resolved with only kmt including wgp and cs pharmacopuncture .
cs was also reported to have a role in modulating the immune system and act as an adjuvant in cancer therapy .
t. kirilowii has been reported to have an antitumor effect through experiments using a549 lung cancer cells .
p. grandiflorus has been reported to show antimetastatic activities by inhibiting the invasion of cancer cells through a basement membrane .
reported a case that showed a significant anticancer effect of wgp , cs pharmacopuncture , t. kirilowii pharmacopuncture and soramdan in a patient with stage iv non - small cell lung cancer .
choi et al .   reported that processed r. verniciflua stokes may inhibit the growth of lewis lung carcinoma cells partly via inhibition of angiogenesis .
nebulizer therapy has been used for many years to treat various respiratory diseases , and this regional therapy to the lung parenchyma for lung cancer is accepted as feasible and efficient . at first , we prescribed various pharmacopunctures , oral herbal medicines and nebulizer therapy .
so , the first regimen was not assumed to have had sufficient efficacy , and the regimen was changed to hnd , had s and soram nebulizer solution ( table 1 ) . as a result ,
the number and size of the metastatic nodules had decreased and the shadows of the remaining nodules had faded in both lungs ; the second regimen was then continued for an additional month .
kim et al .   reported that heat processing - induced deglycosylation of ginsenosides contributes to improved anticancer activity of ginseng .
rg3 and rh2 , which are not found in fresh ginseng , were detected in the examination of ginsenoside contents of hnd ( table 3 ) .
it was shown that treatment of cancer cells with rg3 results in reduction of proliferation , metastasis and mortality [ 13 , 14 , 15 , 16 , 17 ] .
rh2 has been shown to have an anti - proliferative effect on human non - small cell lung cancer .
it is able to block cell proliferation , cause g1 phase arrest , enhance the activity of caspase-3 and induce apoptosis in non - small cell lung cancer a549 cells [ 18 , 19 ] .
had s is a modified version of hangam - plus that is used in the daejeon university east - west cancer center .
however , the ratio of c. militaris , c. appendiculata tuber and p. ginseng radix in had s is different from that of the original version .
reported that hangam - plus might improve the symptoms and prolong the survival of patients with advanced - stage non - small cell lung cancer .
this case report shows that metastatic bladder cancer in both lungs can be cured with kmt alone , without chemotherapy or radiotherapy .
hnd and had s cured metastatic bladder cancer , which was aggravated after treatment with various pharmacopunctures , soramdan , gunchildan and cs distillate .
it is impossible to draw any conclusion about the effect of each kmt modality on metastatic bladder cancer with only one case .
however , this report proposes to use hnd and had s more actively in the treatment of metastatic bladder cancer and other types of cancer as well .
more case reports and clinical studies are needed to prove the effectiveness of these medicines .
 abstractthis case report is aimed to investigate the effects of korean medicine therapy ( kmt ) including oral herbal medicine and herb nebulizer therapy in treating metastatic bladder cancer in the lungs . 
 a 74-year - old man was diagnosed with metastatic bladder cancer in both lungs in august 2013 . 
 he refused any chemotherapy and was admitted to our hospital in a much progressed state on january 11 , 2014 . 
 since then , he was treated with kmt until may 17 , 2014 . 
 the main oral herbal medicines were hyunamdan made of heat - processed ginseng , hangamdan s made of cordyceps militaris , panax ginseng radix , commiphora myrrha , calculus bovis , margarita , boswellia carteri , panax notoginseng radix and cremastra appendiculata tuber , and nebulizer therapy with soram nebulizer solution made of wild ginseng and cordyceps sinensis distillate . 
 their effect was evaluated considering the change of the main symptoms and using serial chest x - ray . 
 the size and number of multiple metastatic nodules in both lungs were markedly decreased and the symptoms had disappeared . 
 these results suggest that kmt can be an effective method to treat metastatic bladder cancer in the lungs . 
Introduction
Case Report
Discussion