International Journal of Clinical Oncology

, Volume 17, Issue 2, pp 185–188

Synchronous and metachronous ureteric metastases from adenocarcinoma of the colon

Authors

  • Maitrey Darrad
    • Department of UrologyDoncaster Royal Infirmary
  • Samuel Harper
    • Department of UrologyDoncaster Royal Infirmary
  • Anju Verghese
    • Department of PathologyDoncaster Royal Infirmary
  • John Leveckis
    • Department of UrologyDoncaster Royal Infirmary
    • Department of UrologyDoncaster Royal Infirmary
Case Report

DOI: 10.1007/s10147-011-0274-7

Cite this article as:
Darrad, M., Harper, S., Verghese, A. et al. Int J Clin Oncol (2012) 17: 185. doi:10.1007/s10147-011-0274-7
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Abstract

Primary adenocarcinoma of the ureter occurs in only <1%. Furthermore, metastatic carcinoma to the ureter is very rare and has been described to occur from breast, lung, stomach and prostate cancers. However, metastases to the ureter from colon cancers are extremely rare, and have been largely reported as incidental post-mortem cases. We describe two cases of asymptomatic ureteric metastases secondary to adenocarcinoma of the colon; one is synchronous, whilst the other is a metachronous ureteric metastasis. With the increasing use of radiological imaging modalities such as CT and MRI (Clin Imaging 2001;25:197–202, 2001), together with increasing survival rates of primary cancers, asymptomatic ureteric metastases are more likely to be diagnosed. In summary, metastatic ureteric carcinoma of colonic origin must be considered as a differential diagnosis when there is a radiological abnormality of the ureter in patients with a history of adenocarcinoma of the colon. This should be considered even in patients with colon adenocarcinoma who have previously undergone adjuvant chemotherapy with curative intent.

Keywords

MetastasesUreterUrothelial cancerColon adenocarinoma

Introduction

Common metastatic sites for adenocarcinoma of the colon are the liver and lungs, whereas the bladder, urethra and ureter are rare sites of colonic metastases [24]. However, most studies describing metastases to the ureter are based on post-mortem cases [5]. With the increasing use of radiological imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) [1], together with increasing survival rates of primary cancers, asymptomatic ureteric metastases are more likely to be diagnosed. We describe two cases of asymptomatic ureteric metastases secondary to adenocarcinoma of the colon; one case is synchronous, whilst the other is a metachronous ureteric metastasis.

Case report 1

A 78-year-old male underwent a combined anterior resection and left nephro-ureterectomy for sigmoid cancer with a synchronous ureteric metastasis in 2008.

He was referred for investigations of persistent, asymptomatic microscopic haematuria. He did not suffer with any lower urinary tract symptoms. His appetite, weight and bowel habit were normal, and his general health was very good. Blood tests showed an elevated creatinine of 175 μmol/l (normal < 110 μmol/l) but haemoglobin was normal. Flexible cystoscopy was unremarkable but ultrasound of the renal tract revealed moderate left hydronephrosis. Unenhanced CT of the pelvis showed an abnormal lower ureter/mass (Fig. 1a). Although retrograde studies of the left ureter were abandoned because there was an obstruction of the lower ureter precluding proximal examination (Fig. 1b), urine cytology revealed atypical cells strongly suspicious of malignancy. His carcinoembryonic antigen (CEA) was elevated at 6 ng/ml (normal < 3 ng/ml). He underwent the combined surgery mentioned above. The histology of the sigmoid tumour was a well-to-moderately differentiated adenocarcinoma with 2 of the 13 lymph nodes positive for metastases, pT3N1M1 (TNM classification). The lower ureter histology showed a similar adenocarcinoma with invasion into the muscularis, pT2 (Fig. 1c, d). Immunohistochemical staining of both the sigmoid and ureteric adenocarcinoma was similar (positive for CEA and CK20 and negative for CK7, prostate-specific antigen (PSA) and thrombomodulin). Subsequently, the patient received 6 cycles of palliative, adjuvant chemotherapy with 5-fluorouracil only (due to elevated creatinine ~150 μmol/l). His recent CEA is 2.2 ng/ml and there is no evidence of disease recurrence at 3 years.
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Fig. 1

Case 1. a Unenhanced CT of the pelvis shows an abnormal lower ureter/mass (arrow). b Retrograde study revealing an obstruction of the left lower ureter (arrow). c Microscopic features of adenocarcinoma in the submucosa of the ureter (low power). d Microscopic features of adenocarcinoma in the submucosa of the ureter (high power)

Case report 2

A 67-year-old male underwent an open left nephro-ureterectomy for a metachronous metastatic adenocarcinoma of the upper ureter in 2009. He was diagnosed with ulcerative colitis (UC) in 1980. He received medical therapy and was under colonoscopic surveillance. Regarding his general health, he suffered from type I diabetes mellitus, Addison’s disease and hypertension. He was a non-smoker.

In 2007, he had undergone a surveillance colonoscopy for his medically controlled UC. He was found to have an incidental caecal tumour; biopsy confirmed a well-differentiated adenocarinoma. Pre-operative tumour marker CEA was elevated at 15 ng/ml. A contrast staging CT scan confirmed the caecal mass but showed no radiological evidence of liver metastases. He underwent an uncomplicated panproctocolectomy with end ileostomy. The histology confirmed adenocarcinoma of the caecum with 7 of the 31 lymph nodes positive for metastatic disease, pT4N2MX, and he therefore received adjuvant chemotherapy (oxaliplatin and 5-fluorouracil) following surgical recovery. He remained well and was under regular follow-up; his CEA was within the normal range. However, his post-surgery CT scan at 24 months revealed an abnormal left upper ureter (Fig. 2a). Microscopic haematuria was present and subsequent retrograde studies and biopsies confirmed high-grade malignant cells. He underwent an open left nephro-ureterectomy. The renal pelvis and upper ureteric histology showed adenocarcinoma with invasion into the muscularis, pT2 (Fig. 2b). Immunohistochemical staining of both the caecal and ureteric adenocarcinoma was positive for CEA and CK20 but negative for CK7, PSA and thrombomodulin. Although he made a good recovery following surgery, he died 12 months later from an unrelated Addisonian crisis.
https://static-content.springer.com/image/art%3A10.1007%2Fs10147-011-0274-7/MediaObjects/10147_2011_274_Fig2_HTML.jpg
Fig. 2

Case 2. a CT scan of the abdomen shows a mass in the left upper ureter. b Microscopic features of adenocarcinoma in the submucosa of the ureter (high power)

Discussion

Although upper tract urothelial cancer accounts for 5% of all urothelial cancers [6], primary adenocarcinoma of the ureter occurs in only <1% [7]. Furthermore, metastatic carcinoma to the ureter is very rare and has been described in gastric and lung cancers [8]. Metastases as a result of adenocarcinoma of the colon have been less frequently described [9]. The bladder, urethra and ureter are rare sites of colonic metastases [24]; however, most studies describing metastases to the ureter are based upon post-mortem cases [5]. With the increasing use of radiological imaging modalities such as CT and MRI [1], together with increasing survival rates of primary cancers, asymptomatic ureteric metastases are more likely to be diagnosed.

Metastatic tumour cell deposition in the ureter has been described as peri-ureteral adventitial infiltration with compression of the ureter, transmural infiltration or, uncommonly, mucosal infiltration [10, 11]. Classically, upper urinary tract tumours present with macroscopic haematuria. However, since the mucosa of the upper tract is rarely involved with metastases to the ureter, haematuria is infrequent and thus asymptomatic [10, 12]. This asymptomatic presentation was seen in our two cases described above.

Immunohistochemical staining plays a pivotal role in supporting the diagnosis of metastatic adenocarcinoma of the ureter secondary to colonic cancer. Typically, colon adenocarcinoma stain positive for CEA and CK20 but are negative for CK7. This staining profile has also been shown to be a reliable identifier of both primary and metastatic colon adenocarcinomas [13, 14]. Thrombomodulin staining is usually positive in bladder adenocarcinoma but negative in adenocarcinoma of colonic origin [14]. In our two cases, negative thrombomodulin staining was observed. Additionally, PSA staining was negative, excluding prostate adenocarcinoma as the primary cancer.

In summary, metastatic ureteric carcinoma of colonic origin must be considered as a differential diagnosis when there is a radiological abnormality of the ureter in patients with a history of adenocarcinoma of the colon. This should be considered even in patients with colon adenocarcinoma who have previously undergone adjuvant chemotherapy with curative intent. Furthermore, nephro-ureterectomy must be considered as the surgical therapeutic option.

Conflict of interest

No author has any conflict of interest.

Copyright information

© Japan Society of Clinical Oncology 2011