Small cell neuroendocrine carcinoma of the ureter: A case report and literature review

Neuroendocrine Neoplasms of the Female Genitourinary Tract: A Comprehensive Overview

Simple Summary

Primary neuroendocrine neoplasms (NENs) are a rare, heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. NENs in the urinary tract are observed in <0.05% of individuals, in whom the bladder is the most common site. In this review, we described the epidemiology, pathogenesis, imaging, staging, and management of the genitourinary NENs.

Abstract

Primary neuroendocrine neoplasms are a rare heterogeneous group of tumors that include well-differentiated neuroendocrine tumors, poorly differentiated neuroendocrine carcinoma, and paraganglioma. An extensive literature search was used to compile the data regarding epidemiology, pathogenesis, imaging features, and management of the urinary system NENs. We also included the updated staging of the NENs at various locations of the urinary system.

Primary renal small cell carcinoma: A case report

BACKGROUND

Small cell carcinoma (SCC) is a malignant tumour that is frequently accompanied by extensive metastasis. Primary renal SCC has typical characteristics related to SCC and is extremely rare, with no uniform treatment standard. Clinical treatment is mainly based on the literature. Here we report the diagnosis and treatment of an interesting case of primary renal SCC.

CASE SUMMARY

We report a tortuous course of treatment for a 68-year-old man. Four years before diagnosis, the patient developed continuous gross haematuria, during which he underwent several ureteral biopsies, ureteral stricture relief, and urine exfoliated cell examinations; however, SCC was not confirmed. One month before radical resection of the renal pelvic carcinoma, the severe haematuria recurred. Computed tomography revealed transitional cell carcinoma in the right kidney and right upper ureter. A preoperative examination exluded the possibility of a pulmonary origin of the tumour, and primary renal SCC was diagnosed. The postoperative pathology findings were suggestive of SCC. The patient was treated with combined chemotherapy but died of tumour progression at 7 mo postoperative.

CONCLUSION

Our patient's disease onset in the context of a succession of regular testing and the fact that it occurred so quickly with perirenal encroachment immediately after diagnosis reveals the cruel and unforgiving side of the disease. Furthermore, patients with poor comprehensive treatment results require new treatment regimens.

Hyperprogression After Immunotherapy for Primary Small Cell Neuroendocrine Carcinoma of the Ureter: A Case Report

Background

Primary small cell neuroendocrine carcinoma (SCNEC) in the ureter is extremely rare and has been sporadically reported in case reports. Its incidence, diagnosis, treatment, and outcomes have not yet been thoroughly understood. Here we present a patient with advanced SCNEC in the ureter who was treated by multimodal strategies. To the best of our knowledge, this is the first literature report about the clinical outcomes of the combination of programmed death ligand 1 (PD-L1) immune checkpoint inhibitors (ICIs) and radiotherapy in patient with primary ureteral SCNEC.

Case Presentation

A 71-year old male presented with right flank pain and gross hematuria. A laparoscopic right nephroureterectomy was performed. He was diagnosed with primary ureteral SCNEC, pT3N0M0. Following the surgery, 4 cycles of adjuvant chemotherapy with carboplatin and etoposide (CE) were administered, with disease-free survival (DFS) of 10.1 months. He was then offered 4 cycles of palliative first-line chemotherapy with nedaplatin and irinotecan. The disease was continuously progressed, with progression-free survival (PFS) of 3.7 months. The patient subsequently received second-line treatment with PD-L1 ICI combined with radiotherapy. Unfortunately, hyperprogressive disease was found at the end of treatment. MRI and CT scan showed bilateral pubic bones, right acetabulum, and liver metastases. Without further intervention, the patient died from extensive metastatic disease 2 months after diagnosis, with overall survival (OS) of 18.2 months.

Conclusion

Physicians must be aware of this rare and aggressive carcinoma at its initial presentation. Special attention should be paid to the potential likelihood of hyperprogression during the treatment.

Primary small cell carcinoma of the ureter with hydronephrosis: A case report

Small cell carcinoma in the ureter is extremely rare, with few cases reported in the literature. The current report describes the case of a 63-year-old man who presented with right-side back pain. A mass was identified in the right ureter. A nephroureterectomy was performed. Subsequent microscopic examination revealed that the mass comprised a monotonous population of small cells and that the carcinoma cells were positive for cluster of AE1/AE3 and synaptophysin. The tumor was diagnosed as a ureteral small cell carcinoma. Adjuvant chemotherapy was administered with 80 mg/m² intravenous cisplatin on day 1 and 100 mg/m² etoposide on days 1–3, every 21 days for 2 cycles. The patient has remained disease-free 6 months after surgery.

Clinicopathologic features of the ureteral neuroendocrine tumors

BACKGROUND

Neuroendocrine tumors of the ureter are extremely rare. There are only a few case reports in the past decades. Their clinicopathologic features, therapy and prognosis are not that clear.

METHODS

5 cases of ureteral neuroendocrine tumors were collected and reviewed of the literature. Histomorphology, immunophenotype and ultrastructural features were observed by HE, immunohistochemistry, special staining and electron microscopy. The clinical pathological data were retrospectively analyzed and followed up.

RESULTS

Among the 5 patients, 1 was female and 4 were male, aged 62-82 years. 2 cases manifested intermittent hematuria, 1 had lower abdominal pain with frequent urination and dysuria, 1 with hydronephrosis, and 1 had no manifestations. All the 5 patients were treated with nephroureterectomy, 3 of which were also treated with excision of bladder cuff, 1 also had lymphadenectomy. On presentation, 2 cases in T2N0M0 (stage II), 2 cases in T3N0M0 (stage III), and 1case in T3N2M0 (stage IV). 2 cases were small cell neuroendocrine carcinoma, 1 was large cell neuroendocrine carcinoma and 2 were atypical carcinoid. The tumor cells were positive for neuroendocrine markers (CD56, CgA, Syn). 1 case of vimentin-positive small cell neuroendocrine carcinoma has a very good prognosis. Grimelius stain and electron microscopy observation showed numerous neuroendocrine granules in the cytoplasm.

CONCLUSION

Ureteral neuroendocrine tumors are extremely rare. Neuroendocrine markers (CD56, CgA, Syn) and epithelial markers (CKpan, CK7) are usually helpful. Grimelius special staining and electron microscopy observation can help to make a final diagnosis. Radical surgery together with postoperative adjuvant chemotherapy can improve the survival of patients. Vimentin may play a role in predicting the prognosis.

Primary small cell carcinoma of the upper urinary tract: A case report

Small cell carcinoma of the urinary tract is an aggressive malignancy that comprises less than 1% of urinary bladder cancers. The renal pelvis and ureter, also lined by urothelium, are rare sites for small cell carcinoma. The diagnosis and staging of upper tract cancer are difficult due to the need for small, atraumatic instrument to access the upper tract. There are fewer than 40 reported cases of upper urinary tract small cell carcinoma. These include both pure and variant histologies. We present the management of a 72 year old male with small cell carcinoma of the upper urinary tract.

Incidental finding of a small cell neuroendocrine carcinoma of the ureter

The ureter is an extremely rare site for small cell neuroendocrine carcinoma. We present a case of this disease in a patient who presented without urological symptoms. The multidisciplinary team proposed nephroureterectomy (if fit) or watchful waiting as management. After discussion with the patient a decision in favour of watchful waiting was made. We report her case including a review of the literature, and emphasise that although small cell neuroendocrine carcinomas can be very aggressive, they can remain asymptomatic.

Primary large-cell neuroendocrine carcinoma of the upper ureter: A case report

RATIONALE

The incidence of primary large-cell neuroendocrine carcinoma (LCNEC) is extremely rare in the urinary tract. In the present study, we investigated a case of primary LCNEC associated with the upper ureter.

PATIENT CONCERN

A 58-year-old Korean female patient with right ureter mass, which was accidentally detected. An enhancing mass measuring 3.3 cm in size was found in the computed tomography (CT) scan. No definitive evidence of lymph node and distant metastasis was observed.

DIAGNOSIS

Histopathological analysis revealed large atypical epithelial cells in upper ureter mass, based on neuroendocrine morphology. Immunohistochemistry was positive for synaptophysin, CD 56, and cytokeratin. Accordingly, the upper ureter mass was finally diagnosed as LCNEC stage III, pT3 cN0 cM0.

INTERVENTION

Right nephroureterectomy was conducted.

OUTCOMES

Multiple metastatic lesions were detected in the right adrenal, paracaval, and right pararenal space of the patient in a CT scan 3 months post-surgery. The patient chemotherapy and radiation therapy were proceeded for metastatic and recurred mass. But patient died by multiorgan failure LESSONS:: In summary, this case study demonstrated that LCNEC can develop even in the upper ureter for the first time, despite the absence of neuroendocrine cells in the normal urothelium. The occurrence of LCNEC in the ureter is still very rare but is possible. Therefore, further studies are needed to establish appropriate treatment strategies.

Atypical Carcinoid Neuroendocrine Tumor of the Ureter: A Case Report and Literature Review

Neuroendocrine tumors (NETs) of the ureter are rare, with less than 40 cases described in the literature. A majority of tumors described are poorly differentiated tumors with a poor prognosis. We present the case of a moderately differentiated atypical carcinoid NET of the ureter with a good postoperative outcome. A literature review was also performed to identify similar cases to compare their management and postoperative outcomes.

Systematic review and two new cases of primary upper urinary tract neuroendocrine carcinomas

BACKGROUND

Upper urinary tract neuroendocrine carcinoma (UUT-NEC) is extremely rare and has a poor prognosis. Although a few cases of successful treatment have been reported, no treatment has shown established efficacy.

PATIENTS AND METHODS

We analyzed 70 UUT-NEC patients, including 68 with small cell neuroendocrine carcinoma (SCNEC) and large cell neuroendocrine carcinoma (LCNEC) reported between 1985 and 2017 and 2 treated at our hospital.

RESULTS

Median patient age was 66 years, 58.6% were men, and 60% were of Asian descent. Most UUT-NECs were SCNEC (68; 95.7%), whereas LCNEC was very rare (2; 2.9%). More than half of the patients had accompanying other histological components, the most common being urothelial carcinoma (51.5%), whereas 41.4% had NEC alone. Of the 70 patients, 27 underwent additional therapy (e.g., chemotherapy and radiotherapy) along with surgery. Median survival was 15 months. In univariate analysis, stages T1-2 disease showed better prognosis than stages T3-4 (P < 0.001). Additional treatment (e.g., chemotherapy and radiotherapy) significantly improved prognosis (P = 0.014). Moreover, platinum-based chemotherapy also was associated with improved prognosis (P = 0.017). For platinum-based chemotherapy, multicollinearity with additional treatments was strong, and, thus, these data were not included in the analysis. Multivariate analysis revealed pathological stage (T1-2 vs. T3-4; P = 0.003) and additional treatment (P = 0.028) to be independent predictors of improved prognosis.

CONCLUSION

Although UUT-NEC has a poor prognosis, additional treatment along with surgery and therapeutic intervention and stage T1-2 disease are independent factors to improve prognosis.

Primary small cell carcinoma of the ureter: Case report and review of the literature

RATIONALE

Primitive small cell carcinoma of the ureter is extremely rare, in this case report is meticulously described its aggressive clinical course and the pathological clues that help with the diagnosis. Also, a detailed table with the clinico-pathological features of analogous case reports in literature is provided.

PATIENT CONCERNS

A 79-year-old female presented with gross hematuria and flank pain.

DIAGNOSES

Small cell carcinoma of the ureter. The surgical specimen showed a mixed histology of small cell carcinoma and transitional cell carcinoma; the common neuroendocrine markers (chromogranin A, synaptophysin, CD56) were positive, and vimentin and thyroid transcription factor 1 were negative. The patient had an advanced stage at presentation with regional nodes involvement (pT3N1).

INTERVENTIONS

Segmental ureterectomy was performed but it was only possible to administer 1 cycle of platinum-based adjuvant chemotherapy due to the rapid decline of her clinical parameters.

OUTCOMES

The disease rapidly spread locally and metastasized.

LESSON

The clinicians must be aware of this aggressive tumor with silent clinical course and advanced stages at presentation.

Primary Upper Urinary Tract Small Cell Carcinoma: A Case Series and Literature Review

Background: Primary upper urinary tract small cell carcinoma (SCC) is exceedingly rare with < 30 cases reported in the literature. Little is known about the incidence, diagnosis, treatment, and outcomes in these patients. We present a series of three patients with primary upper tract SCC. Case Presentation: Patient 1 is an 89-year-old Caucasian male who presented with hydroureteronephrosis and a mass in the proximal right ureter. Biopsy revealed SCC. Without further intervention, the patient died 2 months after his diagnosis. Patient 2 is a 67-year-old Caucasian female who underwent left laparoscopic nephroureterectomy for primary distal ureteral SCC, pT4N1M0. She developed lymphadenopathy and completed external beam radiation to the pelvis and four courses of cisplatin-based chemotherapy. She died from metastatic disease 7 months after diagnosis. Patient 3 is a 45-year-old female who underwent open right radical nephrectomy, retroperitoneal lymph node dissection, and hepatic metastasectomy for metastatic primary upper tract SCC, pT3N1M1. She underwent two subsequent retroperitoneal debulking procedures for recurrence followed by treatment with octreotide. She developed widespread metastasis and was treated with temozolomide and capecitabine before her death 80 months after diagnosis. Conclusion: This series contributes to the limited knowledge of the management and natural course of primary upper tract SCC. Patient 1 represents the first disease-specific mortality reported in a patient who received no therapy. Patient 3 represents the longest reported survival with metastatic disease, and the first treated with octreotide. The patient was managed with aggressive repeat surgical resection and exhibited 2 years of progression-free survival on octreotide. Emphasis should be placed on aggressive resection of all visible disease combined with the use of multimodal adjuvant chemoradiation for selected patients in this rare disease.

Clinicopathologic characteristics, therapy and outcomes of patients with primary ureteral small cell carcinoma: a case series and systematic review of the literature

Purpose

The aim of this case series was to review the standard diagnosis and treatment procedures of primary small cell carcinoma (SCC) in our institution and discuss the clinicopathologic characteristics, treatments and outcomes of patients with primary ureteral SCC.

Patients and methods

Patients diagnosed with ureteral SCC in Peking University First Hospital, Beijing, China, from January 2007 to December 2016 were included. In addition, we performed a systematic literature review, in October 2016, on case reports and case series of ureteral SCC. The clinicopathologic characteristics, treatments and outcomes of this rare disease were analyzed.

Results

A total of 32 patients were included in our analysis (4 cases from our institution and 28 cases from the literature). Most patients (71.0%) were male with an average age of 66.6 years (range 48–80 years). The most common symptoms were hematuria (n=14, 48.3%) and flank pain (n=14, 48.3%). All patients underwent surgery, with 12 (37.5%) patients undergoing multimodality therapy. Regional or distant recurrences developed in 11 patients, among which only 1 patient had bladder recurrence. The overall median survival of the patients was 17 months, with 1- and 3-year survival rates of 51.9% and 30.3%, respectively. In a univariate analysis, female (P=0.009), pure SCC (P=0.03) and advanced T stage (P=0.04) were associated with worse overall survival.

Conclusion

Ureteral SCCs are extremely rare neoplasms with aggressive natural history and poor prognosis. T stage, tumor components and gender may be important factors influencing prognosis. A multimodality treatment is recommended for management. However, further studies are needed to improve the treatment strategy.

Primary Neuroendocrine Tumors of the Ureter: A Short Review

Neuroendocrine tumors represent 0.05% of urinary tract malignancies, and most originate in the bladder. Their pathogenesis is debated, since ureters are thought to lack neuroendocrine cells. Morphologically, most ureteral neuroendocrine tumors demonstrate the typical small cell neuroendocrine appearance, are immunohistochemically positive for synaptophysin/chromogranin A/CD56, and show electron-dense granules by electron microscopy. Clinical presentation is similar to that of other more common ureteral neoplasms. Prognosis is usually dismal, but a multimodal treatment approach including platinum-based adjuvant or neoadjuvant chemotherapy seems to be beneficial.

Neuroendocrine Tumor of the Ureter: A Zebra Among Horses

Primary neuroendocrine tumors of the upper urinary tract are extremely rare. We report a case of de novo small cell carcinoma of the ureter that presented masquerading as a distal ureteral stone. A 55-year-old lady presented to our clinic with 1 month history of right lower back pain and hematuria. Her history was notable for stage 1B mixed clear cell-endometroid cancer of the uterus status post radical abdominal hysterectomy with adjuvant radiotherapy, 7 years before the current episode. The patient had no evidence of recurrence. Initial noncontrast imaging suggested a 2.5 mm calculus in the distal right ureter and hydronephrosis; however, ureteroscopy revealed a large fleshy mass at the location. Histopathologic evaluation demonstrated the lesion to be primary small cell carcinoma of the ureter, without evidence of it being a derivative of the prior gynecologic malignancy. Metastatic work-up revealed high burden retroperitoneal adenopathy. The patient was started on Cisplatin-based neoadjuvant chemotherapy with plan for nephroureterectomy in the future. At 3 months follow-up, the patient was doing well with significant shrinkage of retroperitoneal adenopathy and no evidence of disease progression.

Neuroendocrine carcinoma of the ureter: A case report and literature review

Primary neuroendocrine carcinoma (NEC) of the ureter is a rare entity, with few cases reported in the literature. These tumors are usually locally aggressive and are associated with a poor prognosis due to the thin walls of the ureter. This is the case report of a 69-year-old male patient who presented with left flank pain and gross hematuria. Following diagnosis of ureteral carcinoma, nephroureterectomy was performed. Postoperatively, the patient refused chemotherapy and radiotherapy, and succumbed to extensive metastases after 12 months of follow-up. The aim of the present study was to provide a literature review of NEC and its clinical and pathological characteristics, diagnostic methods and latest modifications in therapy.

Primary Ureteral Thyroid Transcription Factor 1-Positive Small Cell Neuroendocrine Carcinoma: Case Report and Review of the Literature

Upper urinary tract neoplasms comprise only 5% of urinary malignancies overall, the overwhelming majority showing an urothelial histology. Nonurothelial lesions represent 1.9% of upper tract neoplasms, and small cell carcinomas (SmCCs) only account for a minute fraction of them, with few cases reported in the literature to date. In the genitourinary tract, these lesions are most frequently found in the urinary bladder, where they tend to show a mixed histology with a characteristic small cell neuroendocrine component that is positive for chromogranin A, synaptophysin, and CD56 immunostains. Urinary SmCCs are almost invariably aggressive, with a propensity to infiltrate surrounding tissues and vascular structures. Unfortunately, clinical stage at presentation is often advanced, with early dissemination to lymph nodes or distant organs in a significant proportion of patients. For the most part, prognosis is dismal and can be predicted by the pathologic stage at diagnosis. Recently, new chemotherapeutic regimens have shown some potential benefit for the treatment of urinary SmCC, albeit not achieving curative results. Here we present the case of a 71-year-old male patient with a history of treated bladder urothelial carcinoma that presented with subacute flank pain and was diagnosed with a primary pure SmCC of the ureter. Besides the usual neuroendocrine immunomarkers, this tumor showed intense positivity for TTF-1 (thyroid transcription factor-1), a phenomenon that has been described for extrapulmonary SmCC of other locations.