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

Ureteral small cell neuroendocrine carcinoma: A case report and short review

INTRODUCTION AND IMPORTANCE

Primary small cell neuroendocrine carcinoma (SCNEC) in the urinary tract represents less than 0.5 % of urinary tract cancers, and bladder or prostate are the most common sites. Early diagnosis and treatment of ureteral SCNECs are challenging due to nonspecific clinical symptoms and radiographic findings.

CASE PRESENTATION

Here, we described a diagnostic and therapeutic challenge of a 56-yearold male with recurrent right flank pain that did not relieve with analgesics alone. The patient underwent several non-invasive to invasive procedures revealing nonspecific inflammation pathology of the ureter that later developed into protruded papillary mucosa resembling polypoid cystitis. Later, an abdominal multi-slice computed tomography examination suggested a malignant mass and was confirmed as SCNEC from the pathological analysis. After several successful chemotherapy cycles and surgical procedures, cancer reoccurred, and the patient's general condition deteriorated. He passed away a year after a radical cystoprostatectomy and nephroureterectomy on his right side.

CLINICAL DISCUSSIONS

The occurrence of primary SCNEC is a highly uncommon phenomenon. As SCNEC arises from pluripotent stem cells that have differentiated into neuroendocrine cells, some patients may exhibit paraneoplastic syndrome. The patient's prognosis of this tumor is poor, even for patients in the earliest phases, because SCNEC is characterized by highly aggressive local invasion and distant metastases.

CONCLUSIONS

This case highlights the importance of accurate early diagnosis and treatment of recurrent flank pain and considering the possibility of a malignant tumor as the cause of obstruction.

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.

Successful management of small cell neuroendocrine carcinoma of the ureter with neoadjuvant chemotherapy and adjuvant chemoradiation: case report and literature review

Neuroendocrine tumours (NETs) of the urinary tract are rare, and the urinary bladder is the the most common primary site. Primary ureteric NET is rarer with under 80 cases reported in the literature thus far. Most of these tumours are of the high-grade small cell neuroendocrine carcinoma subtype, which has a worse prognosis. Neoadjuvant chemotherapy has a proven role in the management of NET of the bladder as it downstages the tumour, which may add to significant recurrence-free survival and overall survival. We report the successful management of a patient with locally advanced small cell neuroendocrine carcinoma of the ureter, who had a pathological complete response after neoadjuvant chemotherapy with etoposide and cisplatin. He subsequently received adjuvant chemotherapy followed by radiation and is recurrence-free at a follow-up of 1 year.

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.

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.

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.

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.