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|Year : 1985 | Volume
| Issue : 4 | Page : 212-4
Bilateral ureteric and renal pelvic invasion by metastatic oesophageal carcinoma (a case report).
Goel AK, Rao MS, Mathur RP, Vaidyanathan SS, Sen TK, Suryaprakash BB, Malik AK
|How to cite this article:|
Goel A K, Rao M S, Mathur R P, Vaidyanathan S S, Sen T K, Suryaprakash B B, Malik A K. Bilateral ureteric and renal pelvic invasion by metastatic oesophageal carcinoma (a case report). J Postgrad Med 1985;31:212
|How to cite this URL:|
Goel A K, Rao M S, Mathur R P, Vaidyanathan S S, Sen T K, Suryaprakash B B, Malik A K. Bilateral ureteric and renal pelvic invasion by metastatic oesophageal carcinoma (a case report). J Postgrad Med [serial online] 1985 [cited 2020 Feb 20];31:212. Available from: http://www.jpgmonline.com/text.asp?1985/31/4/212/5379
Obstructive uropathy is relatively common in patients with locally invasive pelvic malignancies whereas it is quite rare as a complication of remote primaries. Primary or metastatic lesions in the retroperitoneum usually compress the ureter. Ureteral invasion as such is very uncommon. A case of bilateral ureteric invasion by metastatic oesophageal carcinoma is presented. Rarity of such a clinical presentation is exemplified by the fact that of the 131 cases of obstructive uropathy treated at this centre between 1977 and 1981, there was only one case of ureteral compression by metastatic adenocarcinoma with the primary site not known. Recent reviews of ureteric metastasis,reveal no case of ureteral involvement from carcinoma of oesophagus. Apart from the rarity of ureteric metastasis from carcinoma of oesophagus producing obstructive uropathy, its subdiaphragmatic retroperitoneal spread with sparing of the liver is highlighted in this presentation.
A fifty year old male presented with oligoanuria and breathlessness of five days' duration to the emergency urology service. The pertinent fix-dings on physical examination were cachexia pallor, tachypnoea and distension of abdomen. There was no organomegaly. Urinary bladder was not palpable. Rectal examination revealed a normal sized and benign prostate. Chest examination showed bilateral rhonchi and basal crepitations. Hemoglobin was 9.4 gm%, blood urea: 150 mg%; serum creatinine: 8.7mg%, and serum potassium: 6.5 mEq/L. ECG showed evidence of hyperkalemia. Chest X-ray revealed widening of superior mediastinum. Emergency hemodialysis was performed because of hyperkalemia and fluid overload. Post-dialysis infusion urography revealed only a faint nephrogram in the left kidney. He suddenly developed massive gastro-intestinal bleeding and expired after 48 hours of hospitalisation.
Autopsy revealed a flat ovoid growth, 8 x 3 cm, involving the upper and middle third of the oesophagus which was not totally obstructing the lumen. There was a greater submucosal extension than the transmural infiltration. A satellite growth of 3 x 2 cm was found in the lower third of the oesophagus. Microscopically, it was a poorly differentiated squamous cell carcinoma. There was extensive spread in the retroperitoneum with tumour invasion of the back muscles and soft tissues. There was transcapsular extension of the tumour involving the renal cortex, medulla and pelvis bilaterally. The tumour was of the same morphology as the oesophageal carcinoma. Both ureters were markedly thickened throughout their length with narrowing of ureteral lumen. There was tumour invasion of all layers of the ureter. Both adrenals showed tumour metastasis. Pancreas also showed tumour of similar morphology within lymphatic spaces. Peripancreatic, mesenteric, paracolic and mediastinal lymph nodes showed tumour metastasis. Liver showed non-specific reactive hepatitis and was microscopically free of tumour. Lungs showed microscopic foci of tumour metastasis. Brain, heart and spleen were normal. Prostate showed benign hyperplasia.
Ureter is commonly involved by direct extension from pelvic or retroperitoneal malignancies. Early symptoms may be masked by the primary tumour or metastasis in other organs and by general poor health of the patient. Symptoms due to Ureteral metastasis preceded the recognition of primary tumour in this patient. Juddalso reported a case of melanoma in which symptoms of ureteral metastasis preceded the recognition of the primary tumour.
Involvement of ureters by metastatic malignancy is often bilateral. All levels of the ureter are involved with equal frequency. Often, there is periureteral soft tissue infiltration by the neoplasm with concentric compression of the lumen and ureteral invasion is very rare. This case revealed tumour invasion of all layers of the ureter and both the ureters were involved throughout their length. There was no case of metastatic ureteral invasion by squamous cell carcinoma of oesophagus amongst the 31 cases of metastatic ureteral carcinoma found in a series of about 3,200 consecutive autopsies.Only one case of ureteral metastasis was found in 79 patients with oesophageal carcinoma in whom autopsy was performed at the Chicago West Side Veterans Administration Hospital during a 15 year period.In 8,700 consecutive autopsies performed at this centre over a period of 20 years, this represents the first case of metastatic ureteral invasion by primary carcinoma of the oesophagus.
Secondary carcinoma of kidney was found in 1.8% of 4,413 successive autopsies at the Rosewell Park Memorial Institute, New York.Solitary metastasis to the kidney was the common finding. Unlike lymphoma, diffuse involvement was rare. All these 81 cases did not show metastatic involvement of the renal pelvis.In contrast, this patient exhibited diffuse involvement of both kidneys and a solid tumour in the renal pelvis, an extremely uncommon feature. Both the kidneys, the renal pelvis, and the ureters were densely adherent to the retroperitoneum and showed metastatic involvement by contiguity. The tumour, which had spread extensively into the retroperitoneum, showed transcapsular infiltration into the kidneys. These findings excluded the possibility of a concurrent second primary arising in the kidney or renal pelvis.
A review of autopsy findings in squamous cell carcinoma of the oesophagusshowed that 85% had metastatic disease. The average number of metastatic sites per patient was 3.3. The most common metastatic sites were lymph nodes (73%), lung (52%) and liver (47%). The unique finding in this patient was the sparing of liver by tumour metastasis which, however, had spread extensively to involve the retroperitoneum, back muscles, pancreas, kidneys, ureters and adrenals.
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