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Case R eport
Transitional Ce ll Carcinoma of the
Ure te r and Struvite Calculi
Biomedical Sciences Center, Federal University of Uberlândia, Uberlândia, Brazil
Danielo Garcia de Freitas Adriano Scaff Garcia Osvaldo de Freitas Filho
INTRODUCTION
The a sso c ia tio n o f prima ry c a rc ino ma o f the ure te r a nd lithia sis is e xtre me ly ra re , with sc a ly c e ll c a rc ino ma b e ing o b se rve d in 3 0 % to 5 0 % o f the c a se s.1 W e re po rt a ra re c a se o f tra nsitio na l c e ll c a rc ino ma a nd struvite c a lc ulus.
CASE REPORT
The pa tie nt, a 6 0 -ye a r-o ld pha e o de rma l female, repo rted a histo ry o f rig ht-side nephritic c o lic , hype rthe rmia a nd pyuria during the pa st 2 0 ye a rs a nd ha d re c e ive d tre a tme nt fo r urina ry infe c tio ns a numb e r o f time s. The p a tie nt w a s w e ll c linic a lly a nd ro utine la b o ra to ry e xa mina tio ns sho w e d unc o mp li-c a ted urina ry infeli-c tio n, whili-c h wa s underg o ing suc c e ssful tre a tme nt. Exc re to ry uro g ra p hy sho w e d la rg e c o ra rifo rm c a lc ulus a nd mo d e ra te hyd ro ne p hro sis in the rig ht-sid e kidne y; sig ns o f re pe titio n pye lo ne phritis in the le ft-sid e kid ne y; e limina tio n o f simulta ne o us a nd d e la y-fre e c o ntra st. Ultra so no g ra p hy sho we d a 2 5 mm c o rte x in the rig ht kidne y a nd a 5 mm c o rte x in the le ft kidne y. C ysto sc o py w a s p e rfo rme d a nd a p ig ta il c a the te r w a s
ABSTRACT
Contex t: The a sso c ia tio n o f prima ry c a rc ino ma o f the ure te r a nd lithia sis is e xtre me ly ra re . W e repo rt a rare case o f a primary carcino ma o f the ureter with co rarifo rm calculus.
Ca se Report: 6 0 -ye a r-o ld pha e o de rma l fe ma le , re po rte d a histo ry o f rig ht-side ne phritic c o lic ,
hype rthe rmia a nd pyuria during the pa st 2 0 ye a rs a nd ha d re c e ive d tre a tme nt fo r urina ry infe c tio ns a numb e r o f time s. The first clinical presentatio n was related to lithiasis and the tumo r had no t been sho wn up by excreto ry uro g raphy, cysto sco py o r ultraso no g raphy. Two mo nths after the calculus had been eliminated, the patient beg an to have serio us sympto ms and a g rade III transitio nal cell carcino ma o f the ureter was disco vered. To tal
nephro ureterecto my and M.V.A.C. (Meto trexate + Vinblastina + Do xo Rubicina + Cisplatina) chemo therapy were tried unsuccessfully. In this repo rt we emphasiz e the diag no stic difficulty caused by the co nco mitant presence o f the two patho lo g ies. In o ur o pinio n, the rapid evo lutio n in this case is directly related to the hig h g rade o f the tumo r.
Key W ords: Carcino ma. Ureter. Struvite. Calculi. Lithiasis.
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Fig. 1 - Ureter: transitional cell carcinoma (Hematoxylin Eosine: 10.0 x 2.5 x 3.0).
Fig. 2 - Pulmonary(A) and tibia(B) metastasis. po sitio ne d to the rig ht witho ut a lte ra tio ns to the te st. Fo ur a pplic a tio ns o f e xtra c o rpo re a l sho c k wa ve litho tripsy we re a dministe re d o ve r a 5 0 da y pe rio d with to ta l e limina tio n o f the c a lc ulus.
Two mo nths la ter, the pa tient presented hematuria, acute urinary retentio n and nephritic c o lic s o n the rig ht sid e . Ultra so no g ra p hy sho wed sma ll hydro nephro sis witho ut c a lc uli in the rig ht kidney, and larg e dilatatio n o f the pelvis thro ug ho ut the c o urse o f the ureter a ro und the left kidney. Cysto sc o py sho wed a pa pillifo rm lesio n g o ing o ut thro ug h the left ureteral meatus. Bio psies o f the mea tus rim a nd vic inities were no rma l, while tho se o f the lesio n sho wed g ra de III transitio nal cell carcino ma attacking the entire uretera l wa ll (Fig . 1 ).
C o mpute riz e d to mo g ra phy did no t sho w inva sio n o f the b la d d e r o r o the r o rg a ns, a ltho ug h the to ta l ne p hro ure te re c to my w ith
e xc isio n o f the pe rio rific ia l b la dde r c o uld ha ve b e e n inc o mple te due to the e xte nt o f the tumo r inva sio n.
M . V. A . C . (Me to tre xa te + Vinb la stina + Do xo Rubicina + Cisplatina) c hemo thera py wa s re so rte d to . Ho we ve r, the pa tie nt unde rwe nt a me ta sta sis in the ta lus, b ra in, lung s a nd le ft tib ia (Fig . 2 ), a nd she die d 5 mo nths la te r.
DISCUSSION
The etio patho g enesis o f upper urinary tract tumo rs is e xte nsive . C hro nic irrita tio n o f the uro thelium ma y o c c ur thro ug h infla mma tio ns, infe c tio ns a nd p ro lo ng e d c o nta c t w ith carcino g ens resulting fro m the struvite calculus. These appear to be asso ciated with scaly cell c a rc ino ma .1 , 2 This a sso c ia tio n c a n no t b e c o nfirme d in the c a se o f tra nsitio na l c e ll carcino ma.
Dia g no sis o f the tumo r wa s de la ye d due to the la te a ppea ra nc e o f sympto ms a sso c ia ted with the tumo r, suc h a s pa in, he ma turia a nd hydro nephro sis,4 a nd furthermo re, the a b sence o f a lte ra tio ns in e x c re to ry uro g ra p hy, cysto sco py and ultraso no g raphy all co ntributed to this de la y.
The tumo r g ra de , whic h is re la te d to the DN A c e ll c o nte nt, wa s in o ur o pinio n de c isive in the e vo lutio n o f this c a se .3
C o mp ute riz e d to mo g ra p hy d id no t c o ntrib ute in this c a se to the study o f tumo r inva sio n in the pe lvic re g io n.
REFERENCES
1. Maze m an E, Gillio t P. Uppe r urinary tract tum o rs. In: Krane RJ, Siro ky MB, Fitzpatrick JM, ed ito rs. Clinical Uro lo gy. Philade lphia: Lippinco tt 1994;26:374-98.
2. Catalo na WJ. Uro the lial Tum o rs o f the Urinary Tract. In: Walsh PC, Re tik AB, Stam e y TA Jr, Danaco tt V, e d ito rs. Cam pb e ll’s Uro l-o gy (6th e ditil-o n). Philade lphia: W.B. Saunde rs 1992;28,2:1094-144.
3. AAb adi H, Nage l R. Transitio nal ce ll carcino m a o f the re nal pe l-vis and ure te r: Pro gno stic re le vance o f nucle ar de o xyrib o nucle ic acid plo idy study b y slide cyto metry: An 8-year survival time study. J Uro l 1992;148:31-7.
4. Mills C, Vaughan ED. Carcino m a o f the ure te r: natural histo ry, m anage m e nt and 5-ye ar survival. J Uro l 1983;129:275.
Sao Paulo Med J/Rev Paul Med 1999; 117(3):129-31.
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Da nielo Ga rcia de Freita s - MD. Po stg raduate Student at Uro lo g y Divisio n. Universidade Federal de São Paulo .
Adria no Sca ff Ga rcia - MD. Unive rsida de Fe de ra l de Ub e rlâ ndia .
O sva ldo de Freita s Filho - MD. Pro fesso r and Chair o f Discipline o f Uro lo g y. Universidade Federal de Uberlândia.
RESUMO
Contex to: A asso ciação de carcino ma primário de ureter e litíase é muito rara, sendo o bservado em 3 0 a 5 0 % o carcino ma de células escamo sas. Relatamo s um caso raro de carcino ma de células transicio nais e cálculo de estruvita. Rela to de Ca so:
Descreve-se caso raro de carcino ma primário de ureter asso ciado a cálculo co rarifo rme. A apresentação clínica inicial estava predo minantemente lig ada ao quadro de litíase renal, não detectando -se o tumo r pela uro g rafia excreto ra, cisto sco pia o u ultrasso no g rafia. Do is meses apó s a eliminação do cálculo , a paciente evo luiu co m alteraçõ es clínicas impo rtantes, sendo então diag no sticado carcino ma de células transicio nais de ureter, g rau III. N efro ureterecto mia radical e quimio terapia M.V.A.C. fo ram tentadas, sem sucesso . Enfatiz amo s a dificuldade diag nó stica na co nco mitância das duas pato lo g ias e a rápida evo lução do caso , ao no sso ver, diretamente lig ada ao g rau tumo ral.
Sources of Funding: N o t de c la re d
Conflict of interest: N o t de c la re d
La st received: 2 6 o cto ber 1 9 9 8
Accepted: 1 1 december 1 9 9 8
Address for correspondence:
Da nie lo G a rc ia de Fre ita s
Rua Dr. Altino Ara nte s 9 5 8 , Apto 8 4 C EP 0 4 0 4 2 -0 0 4 - Sã o Pa ulo / SP - Bra sil
