Mucinous adenocarcinoma of renal pelvis and villous adenoma of bladder after a caecal augmentation of bladder

De Novo Secondary Adenocarcinoma in the Colon Used as Urinary Diversion Not in Contact with the Fecal Stream: Systematic Review and Meta-analysis

BACKGROUND

A systematic review with a meta-analysis was performed to determine the prevalence and risk factors for secondary de novo adenocarcinoma in the colon used as a urinary diversion not exposed to the fecal stream.

METHODS

The systematic review of the literature identified 47 patients with secondary adenocarcinoma in a colonic urinary diversion not exposed to the fecal stream.

RESULTS

The diagnosis of secondary adenocarcinoma was determined due to the presence major local symptoms and because the cancer in half of the patients was detected at an advanced stage. Diagnosis at an earlier stage was associated with long-term cancer-free survival.

CONCLUSIONS

The authors concluded that cystoscopy-colonoscopy screening as suggested by the American Gastroenterology Society for the general population should be applied to patients who have colon urinary diversion not exposed to the fecal stream. For patients with active high-grade inflammation, difficulty with self-catheterization, or symptoms, cystoscopy should be performed earlier. Resection of the tumor at an early stage offers better clinical outcomes with longer survival rates.

Villous adenoma coexistent with focal well-differentiated adenocarcinoma of female urethral orifice: A case report and review of literature

BACKGROUND

Villous adenomas of the urinary tract are uncommon. They are morphologically similar to and difficult to differentiate from their counterpart in the colon. The histogenesis and malignant potential are uncertain.

CASE SUMMARY

A 63-year-old woman was admitted to our hospital with a mass in the urethral orifice. Gross and microscopic pathological examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma. The whole urethra and part of the bladder were excised. No further treatment was offered. Carcinoembryonic antigen, cytokeratin 7, cytokeratin 20, epithelial membrane antigen, and p53 protein were positive, and the ratio of Ki-67 was 60%. After follow-up at 11 mo, the patient was cured and had no recurrence.

CONCLUSION

Immunohistochemistry is important for differential diagnosis of villous adenoma of the urinary system. Complete surgical resection of the urinary tract is curative.

A case of tubular adenoma developing after bladder augmentation: Case report and literature review

INTRODUCTION

We encountered a rare case of tubular adenoma developing after bladder augmentation. We here report our case as well as summarize reports in the literature on adenomas developing after bladder augmentation.

PRESENTATION OF CASE

A 23-year-old man came to our hospital for routine surveillance cystoscopy. He was born with a lipomyelomeningocele and neurogenic bladder with low bladder compliance, and hence his bladder was routinely emptied by clean intermittent catheterization. He was also treated with anticholinergic agents. However, because the patient's neurogenic bladder was unstable, he underwent sigmoidocolocystoplasty when he was 8-years old. After the bladder augmentation, he was examined annually by surveillance cystoscopy. On cystoscopy, a 5-mm pedunculated polyp was found on the front side of the sigmoid colon cap. Therefore, we performed snare polypectomy together with electrocoagulation under cystoscopy. The patient's final diagnosis was tubular adenoma (mild atypia) with no malignancy, as assessed by histopathology. There has been no evidence of recurrence after the polypectomy on routine surveillance cystoscopy.

DISCUSSION

To the best of our knowledge, there have been 11 cases of adenoma occurring after bladder augmentation reported in the literature, including our present case. There are several carcinogenic pathways associated with colorectal oncogenesis. Adenomas that are larger than 1.0cm in diameter with a marked villous component have a high risk of oncogenesis.

CONCLUSION

We believe that the early detection of carcinoma or adenoma and their treatment at an early stage is crucial. Therefore, we recommend routine surveillance cystoscopy for patients after bladder augmentation.

Primary mucinous adenocarcinoma of the renal pelvis with elevated CEA and CA19-9

Primary adenocarcinoma of the renal pelvis is rarely reported in the literature. Here we present a case of primary mucinous adenocarcinoma of the renal pelvis with elevated serum carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) levels. A 56-year-old woman was referred to our center with intermittent fever and left-sided back pain for 1 month. Computed tomography showed bilateral nephrolithiasis, mild right hydronephrosis and left pyonephrosis accompanied with ambiguous soft tissues. A radionucleorenogram showed that the glomerular filtration rate of the left and right kidney was 0 and 79 ml/min, respectively. Left nephrectomy was performed without lymph node dissection. Histopathology revealed mucinous adenocarcinoma and elevated serum CEA and CA19-9 levels were found. She died of multiorgan metastasis after 5 months. A review of the literature is also reported.

Serum carcino-embryonic antigen (CEA) and its possible use as tumor marker for secondary tumors in urinary intestinal reservoirs

OBJECTIVES

Serum carcino-embryonic antigen (CEA) has become a useful tumor marker in patients with colorectal adenocarcinoma. Patients who undergo uroenteric reconstruction, such as urinary diversion (UD), have an increased risk of developing malignant changes in their UD. We compared serum CEA levels in patients with different types of UD, evaluating long-term CEA changes and assessing its potential for use as a tumor marker of malignant transformation in the UD.

MATERIALS AND METHODS

Serum CEA was evaluated 3 to 122 months after surgery in 177 patients with different types of UD and retrospectively analyzed. The normal range for CEA was 0.2-3.4 μg/l. No patient had a history of colorectal cancer.

RESULTS

A total of 443 CEA samples from 177 patients were evaluated. CEA was elevated (up to 32 μg/l) in 122 samples (27.5%) from 59 patients (33.3%). Patients with Mainz Pouch II had significantly higher CEA levels (P = 0.037) than patients with other forms of UD. CEA levels increased significantly in the study population during follow-up (P = 0.0000007). Five of the patients (2.8%) developed a secondary neoplasm, 4 of whom had elevated CEA. Three neoplasms (urothelial cancer) were located outside the UD. Only 2 tumors were actually located in the UD: an urothelial cancer at the uretero-colonic anastomosis of the UD with normal CEA levels, and a colonic adenoma at the bottom of the UD with elevated CEA levels. No patient had adenocarcinoma in the UD.

CONCLUSION

Elevated serum CEA is a common finding in patients with UD using bowel segments (33.3%), especially in patients with rectal reservoirs. Serum CEA has a tendency to increase over time in patients with UD but is not a valuable marker of secondary neoplasms in these patients.

Villous adenoma of the ureter with manifestation of mucus hydroureteronephrosis

Ureteral tumor is prone to result in lumen obstruction. Villous adenoma is most frequently found in the colon and rectum, seldom in the urinary tract and even more rarely in the ureter or pelvis. Herein, we present a case of bilateral renal stones of more than 10 years' duration with the chief complaint of right flank pain. Obstruction of the right upper ureter with hydroureteronephrosis was observed on sonography, computed tomography and retrograde pyelography. Ureteroscopy revealed papillary tumor obstructing the upper third of the ureter and inducing hydroureteronephrosis with abundant mucoid content. The ureteral tumor proved to be villous adenoma by pathologic examination. It should be noted that ureteral villous adenoma may be related to previous enteric-type metaplastic mucosa or ureteritis glandularis, demonstrates profuse production of mucus, and may eventually undergo malignant transformation.

SECONDARY MALIGNANCIES IN DIFFERENT FORMS OF URINARY DIVERSION USING ISOLATED GUT

PURPOSE

Tumor development following ureterosigmoidostomy is a worldwide accepted late complication. In contrast, tumor risk in other forms of urinary diversion with the separation of urine and feces is still unclear. We present a complete and detailed analysis of all reported tumors following urinary diversions using isolated gut segments in the literature. We estimated the tumor risk in comparison to ureterosigmoidostomies and to the general population.

MATERIALS AND METHODS

We reviewed the world literature up to April 2003 via MEDLINE for secondary tumors in urinary diversions using isolated intestinal segments.

RESULTS

We found 81 tumor case reports following urinary diversion using isolated intestinal segments. Tumors developed in 18 conduits, 45 cystoplasties, 5 rectal bladders, 3 neobladders, 6 colonic pouches and 4 ileal ureter replacements.

CONCLUSIONS

All urinary diversions using bowel with or without separation of urine and feces carry a significantly higher tumor risk for intestinal tumor development compared to the general population. The tumor spectrum and tumor location in isolated gut segments are different than tumors following ureterosigmoidostomies but the total tumor risk is probably similar. The latency period depends on the initial diagnosis with malignant diseases leading to a shorter induction time. Concerning etiology, many theories exist but the exact mechanism remains unclear. Regular endoscopic control beginning with postoperative year 3 for early detection of secondary malignancies is mandatory.

Tumour formation within intestinal segments transposed to the urinary tract

Patients and their urologists are quite rightly concerned about the possibility of neoplastic change within intestinal segments transposed to the lower urinary tract. This fear arises from the occurrence of latent adenocarcinoma arising from the urocolic anastomosis in approximately 10% of patients who underwent ureterosigmoidostomy in childhood. The present text provides an update of previous reviews and details work published since 1990 on epidemiological, experimental and clinical studies. Consideration of the collected evidence confirms the increased risk of colonic neoplasia following mixing of the faecal and urinary stream by ureterosigmoidostomy or its more recent variants. In contrast, the occurrence of tumours within transposed intestinal segments appears more likely to be related to the underlying urinary tract disease for which the surgery was performed rather than exposure of the intestinal mucosa to urine. This conclusion is, however, based on low level evidence and, despite the reassuring findings, caution is advised until more robust data are available to provide a confident risk assessment.

Muconephrosis

We report a case of a mucus-filled kidney (muconephrosis) encountered during laparoscopic nephrectomy for presumed xanthogranulomatous pyelonephritis. Conversion to open nephrectomy and en-bloc right hemicolectomy were necessary because of severe perinephric fibrosis and suspected renal-enteral fistula. Pathologic examination revealed a renal pelvic villous adenoma and diffuse intestinal metaplasia of the urothelium; no enteral communication or gastrointestinal pathologic features were found. Urothelial villous adenoma is extremely rare, and one should consider neoplastic etiologies, including appendiceal mucinous cystadenocarcinoma and mucus-secreting adenocarcinoma of the renal pelvis, in directing the appropriate management of muconephrosis.