Case Reports in Urology

Case Reports in Urology / 2014 / Article

Case Report | Open Access

Volume 2014 |Article ID 196425 | 4 pages | https://doi.org/10.1155/2014/196425

Distant Ureteral Metastasis from Colon Adenocarcinoma: Report of a Case and Review of the Literature

Academic Editor: J. Park
Received22 Nov 2013
Accepted21 Jan 2014
Published04 Mar 2014

Abstract

Carcinomas arising from organs neighbouring the ureter can directly infiltrate the ureter. Distant ureteral metastasis from colon adenocarcinoma is extremely rare and usually an incidental finding in performed autopsies. We report a case of a right ureteral metastasis in a 65-year-old Caucasian male with a history of rectal cancer for which he had been treated 4 years before. He presented with asymptomatic moderate right hydronephrosis. The patient underwent a right nephroureterectomy. Histology of the ureter revealed transmural adenocarcinoma with infiltration of the mucosa. Infiltration of the muscular coat of the bladder was found 2 years later. Thus, cystectomy and left ureterocutaneostomy were performed. The patient died 6 months later due to toxic megacolon during chemotherapy. The differential diagnosis of ureteral adenocarcinoma, especially in patients with previous history of colon adenocarcinoma, should include the possibility of distant metastasis from the primary colonic tumor.

1. Introduction

Distant metastases to the ureter may occur through lymphatic and/or blood vessels excluding ureteral involvement by direct extension [13]. These metastases have been reported more commonly arising from stomach, breast, lung, cervix, prostate, pancreas, and lymphoma [26]. Distant ureteral metastases from colon adenocarcinoma are considered to be very rare [210]. We present a case of this condition and review the English language literature.

2. Case Report

In November 2005 a 61-year-old male patient underwent rectosigmoidectomy for nonmetastatic rectal cancer (grade II, stage T3N1MO), which was followed by chemotherapy (oxaliplatin and capecitabine) and radiotherapy. He had no signs of relapse during the follow-up. In May 2009 an asymptomatic moderate right hydronephrosis in follow-up computed tomography (CT) scan was revealed. The ureteropyelogram (Figure 1) showed a 1.5 cm filling defect in the lower right ureter. Ureteroscopy revealed a papillary lesion. Urine cytology showed malignant cells strongly suspicious for adenocarcinoma which correlated with the biopsy findings where immunohistochemistry demonstrated carcinoma with glandular differentiation and positivity for cytokeratin (CK) 20, fully compatible with a metastatic colonic type adenocarcinoma. The patient was fully evaluated with colonoscopy and CT (Figure 2) with no signs of local or distant relapse.

The patient underwent right nephroureterectomy. Histology revealed intraluminal adenocarcinoma (grade II) with infiltration of the mucosa, muscular layer, and adventitia (Figure 3). Periureteral tissue was free of tumor. This was followed by 6 cycles of chemotherapy. The patient was closely followed up afterwards until February 2012, where infiltration of the muscular coat of the bladder by adenocarcinoma (CK7−, CK20+), without other metastases, was found.

In March 2012 radical cystectomy and extended pelvic lymphadenectomy with left ureterocutaneostomy were performed. Foci of a moderately differentiated adenocarcinoma were identified in the bladder wall, localized both in the lamina propria as well as in the perivesical adipose tissue. Neoplastic vascular plugs and carcinomatous perineural infiltration were also found. The neoplastic population was immunohistochemically positive for CK7, CK20, carcinoembryonic antigen (CEA), β-catenin, and p53. The surgical margins were free of neoplastic disease. Severe lymphatic inflammatory reaction without evidence of lymph node metastasis was found (pT3apNO). The patient died 6 months later due to toxic megacolon during chemotherapy.

3. Discussion

Distant ureteral metastasis from primary colon adenocarcinoma was first reported in 1936 [2]. The most common sites of primary lesion are the breast, stomach, lung, cervix, prostate, pancreas, and lymphoma [26]. Reviewing the English language literature, reports describing true ureteral metastases from colon cancer are scarce [210]. Twenty-three cases have been published worldwide so far (Table 1).


AuthorSite of primary lesion (number of cases)AgeLateralitySymptomOther sites of metastasesSegment of ureter involvedUreteral infiltrationTime after diagnosis of colon cancer

Presman and Ehrlich [2]Colon (2)NANANANANAPeriureteral and/or transmuralNA

Cohen et al. [3]Colon (6) and rectum (1)NANANAYesNAPeriureteral and/or transmuralNA

MacLean and Fowler [4]Rectum (2)NANANANANATransmuralNA

Fitch et al. [5]Rectum (1)51RightAbdominal painNoMiddle 1/3Transmural2 years

Richie et al. [6]Colorectal (7)NANANANANANANA

Williams and Chaffey [7]Sigmoid (1)69BilateralAnuria-uraemiaPeritoneal, liver and lung nodules, omentum, and bowel implantsRight lower 1/3
Left middle 1/3
Transmural-mucosal4 years

Brotherus and Westerlund [8]Rectum (1)70BilateralAnuriaSkin metastasis around the colostomyRight lower 1/3
Left lower 1/3
Transmural2 years

Fazeli-Matin et al. [9]Rectum (1)57LeftSepsis Mediastinal lymph nodesMiddle 1/3Transmural-mucosal3 years

Dickson et al. [10]Colon (1)78LeftNoNoNATransmural-mucosal4 years

Not Available.
Not Specified.

In the first half of the last century, these ureteral metastases have been only described as incidental findings during autopsy due to the fact that the majority of patients were asymptomatic [26]. MacLean and Fowler reported an incidence of 2 cases in 10.223 performed autopsies [4]. Symptomatic patients most frequently described low back pain, renal colic, and/or anuria in cases of bilateral ureteral obstruction [5, 7, 8]. The fact that hematuria is a rather uncommon finding can be explained considering that ulceration of the ureteral mucosa is not likely to occur [2, 3, 6].

There are two interesting parameters that must be emphasized. First, in the majority of cases, there were synchronous metastatic lesions in other organs or lymph nodes (Table 1). In our case, a single ureteral metastasis with no evidence of other metastatic lesions was found 4 years after primary rectal adenocarcinoma and metachronous bladder adenocarcinoma developed 2 years later. Second, in our patient the ureteral lesion occupied not only the muscularis and the adventitia but the mucosa as well. According to the literature, mucosal involvement is extremely rare, with only 3 definite cases published so far [7, 9, 10].

Metastatic tumour cell deposition in the ureter has been described as infiltration of the periureteral soft tissue with compression to the ureteral wall, transmural infiltration, or, uncommonly, infiltration of the local mucosa [2, 3]. The precise mechanism responsible for distant ureteral metastasis and the factors promoting this process are still quite unknown. MacKenzie and Ratner were the first to propose as rigid criteria for the diagnosis of distant ureteral metastasis the finding of malignant cells in the perivascular lymphatic spaces or in the blood vessels around the ureter [1]. Later, Presman and Ehrlich modified the criterion as the demonstration of malignant cells in a portion of the ureteral wall together with the absence of any neoplasm in adjacent tissues [2]. Our patient showed no tumoral lesions in the periureteral and retroperitoneal space during surgery indicating that the disease was true distant ureteral metastasis from the colon according to the criterion of Presman and Ehrlich that has been widely accepted and used to date.

Metastatic ureteral adenocarcinoma after primary colon adenocarcinoma is aggressive and has a poor prognosis without evidence of long-term survival in the reported cases [210]. Due to the rarity of the disease there are no standardized treatment protocols but chemotherapy remains mainstay in combination with the surgical treatment.

In conclusion, the colon is a very rare site of origin for distant ureteral metastasis. Although this condition is infrequently encountered in clinical practice, the possibility of metastatic ureteral carcinoma must be considered in the differential diagnosis, once there is a clinical or radiographic evidence of ureteral obstruction in a patient, who has a history of colon cancer regardless the stage and previous therapy.

Conflict of Interests

The authors declare that there is no conflict of interests regarding the publication of this paper.

References

  1. D. W. MacKenzie and M. Ratner, “Metastatic growths in the ureter. A report of three cases and a brief review of the literature,” Canadian Medical Association Journal, vol. 25, no. 3, pp. 265–270, 1931. View at: Google Scholar
  2. D. Presman and L. Ehrlich, “Metastatic tumors of the ureter,” Journal of Urology, vol. 59, pp. 312–325, 1948. View at: Google Scholar
  3. W. M. Cohen, S. Z. Freed, and J. Hasson, “Metastatic cancer to the ureter: a review of the literature and case presentations,” Journal of Urology, vol. 112, no. 2, pp. 188–189, 1974. View at: Google Scholar
  4. J. T. MacLean and V. B. Fowler, “Pathology of tumors of the renal pelvis and ureter,” Journal of Urology, vol. 75, pp. 384–415, 1956. View at: Google Scholar
  5. W. P. Fitch, J. R. Robinson, and H. M. Radwin, “Metastatic carcinoma of the ureter,” Archives of Surgery, vol. 111, no. 8, pp. 874–876, 1976. View at: Google Scholar
  6. J. P. Richie, G. Withers, and R. M. Ehrlich, “Ureteral obstruction secondary to metastatic tumors,” Surgery Gynecology and Obstetrics, vol. 148, no. 3, pp. 355–357, 1979. View at: Google Scholar
  7. D. F. Williams and B. T. Chaffey, “Metastatic adenocarcinoma of the sigmoid colon masquerading as bilateral intraluminal ureteral papillomas,” British Journal of Urology, vol. 38, no. 5, pp. 563–566, 1966. View at: Google Scholar
  8. J. V. Brotherus and R. M. Westerlund, “Metastatic carcinoma of the ureter. A report of three cases,” Scandinavian Journal of Urology and Nephrology, vol. 5, no. 1, pp. 86–90, 1971. View at: Google Scholar
  9. S. Fazeli-Matin, H. S. Levin, and S. B. Streem, “Ureteroscopic diagnosis of intraluminal metastatic rectal carcinoma,” Urology, vol. 49, no. 6, pp. 955–956, 1997. View at: Publisher Site | Google Scholar
  10. B. C. Dickson, V. L. Fornasier, C. J. Streutker, and R. J. Stewart, “Ureteric obstruction: an unusual presentation of metastatic colon carcinoma,” The Canadian Journal of Urology, vol. 14, no. 2, pp. 3526–3528, 2007. View at: Google Scholar

Copyright © 2014 Ferakis Nikolaos et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

3177 Views | 835 Downloads | 0 Citations
 PDF  Download Citation  Citation
 Download other formatsMore
 Order printed copiesOrder

We are committed to sharing findings related to COVID-19 as quickly and safely as possible. Any author submitting a COVID-19 paper should notify us at help@hindawi.com to ensure their research is fast-tracked and made available on a preprint server as soon as possible. We will be providing unlimited waivers of publication charges for accepted articles related to COVID-19. Sign up here as a reviewer to help fast-track new submissions.