PTRF independently predicts progression and survival in multiracial upper tract urothelial carcinoma following radical nephroureterectomy

OBJECTIVES

Polymerase I and transcript release factor (PTRF) has been implicated in cancer biology but its role in upper tract urothelial carcinoma (UTUC) is unknown. From a pilot transcriptome, we identified PTRF was significantly upregulated in high stage UTUC. Bladder cancer transcriptome from The Cancer Genome Atlas (TCGA) supported our finding and high PTRF level also predicted poor survival. We, therefore, investigated the correlation of PTRF with patients' clinicopathologic characteristics and outcomes in a multiracial UTUC cohort.

MATERIALS AND METHODS

By immunohistochemical staining, PTRF expression was determined using H-score. PTRF expression of 575 UTUCs from 8 institutions, including 118 Asians and 457 Caucasians, was compared with various clinicopathologic parameters. Human urothelial cancer cell lines were used to evaluate the level of PTRF protein and mRNA expression, and PTRF transcript level was assessed in fresh samples from 12 cases of the cohort. The impact of PTRF expression on disease progression, cancer-specific death and overall mortality was also examined.

RESULTS

High PTRF expression was significantly associated with multifocality (P = 0.023), high pathologic tumor stage (P < 0.00001), nonurothelial differentiation (P = 0.035), lymphovascular invasion (P = 0.003) and lymph node metastasis (P = 0.031). PTRF mRNA expression was also markedly increased in advanced stage UTUC (P = 0.0003). High PTRF expressing patients had consistently worse outcomes than patients with low PTRF expression regardless of demographic variation (all P < 0.005). In multivariate analysis, high PTRF expression was an independent predictor for progression-free survival (hazard ratio [HR] 1.70, 95% confidence interval [CI] 1.07-2.69, P = 0.025), cancer-specific survival (HR 2.09, 95% CI 1.28-3.42, P = 0.003), and overall survival (HR 2.04, 95% CI 1.33-3.14, P = 0.001).

CONCLUSIONS

Results indicate that PTRF is a predictive biomarker for progression and survival and an independent prognosticator of UTUC. Elevated PTRF could probably propel clinically aggressive disease and serve as a potential therapeutic target for UTUC.

Primary carcinosarcoma of the ureteropelvic junction associated with ureteral duplication: A case report

RATIONALE

Primary carcinosarcoma of the upper urinary tract is rare. Ureteral duplication is one of the most common urinary tract malformations. Additionally, the association between ureteral duplication and malignancy is unknown. To the best of our knowledge, no cases of malignant tumors diagnosed as carcinosarcoma with ureteral duplication have been reported. We herein report the case of a patient with carcinosarcoma of the ureteropelvic junction associated with incomplete ureteral duplication.

PATIENT CONCERNS

A 60-year-old Japanese woman presented with painless gross hematuria. She had a history of total hysterectomy and chemotherapy for endometrioid carcinoma 5 years before. She had no history of occupational chemical exposure.

DIAGNOSES

Radiographic imaging revealed right incomplete ureteral duplication, hydronephrosis, and a polypoid tumor in the ureteropelvic junction of the lower moiety of the right kidney. Urine cytology showed a small amount of degenerated atypical epithelial and nonepithelial cells. The transureteral biopsy specimen showed dysplastic urothelial cells and atypical myoid spindle cells. These findings were indefinite for malignancy.

INTERVENTIONS

The patient underwent right nephroureterectomy. Pathological examination of the resected tumor showed a biphasic neoplasm composed of carcinomatous and sarcomatous components. The sarcomatous component was immunohistochemically positive for vimentin, desmin, h-caldesmon, and α-SMA and negative for pancytokeratin (AE1/AE3), low molecular weight cytokeratin (CAM 5.2), EMA, E-cadherin, GATA3, uroplakin 2, and p63. Based on these findings, we diagnosed the tumor as carcinosarcoma.

OUTCOMES

The postoperative course was uneventful. No additional therapy was administered. The patient has remained alive without recurrence for 21 months since surgery.

LESSONS

Carcinosarcoma can arise from ureteral duplication. Although the majority of carcinosarcomas of the upper urinary tract are diagnosed at an advanced stage and have a poor prognosis, some can have a less aggressive course. Further studies are needed to determine the association between ureteral duplication and malignancy.

Primary small cell carcinoma after renal transplant: A case report

INTRODUCTION

Primary small cell carcinoma (SCC) after renal transplantation is very rare. Here, we reported 1 case of primary SCC after renal transplantation and analyzed its clinical and pathological characteristics.

CASE PRESENTATION

A 55-year-old female underwent renal transplantation in our hospital 2 years ago and had been using tacrolimus for immunosuppressive therapy. Because of abdominal distention, the patient was admitted to our hospital. Computed tomography (CT) showed a malignant tumor of left kidney. Patient underwent surgical treatment and radical nephrectomy and lymph node dissection were selected. Postoperative pathological diagnosis was primary renal parenchyma and ureteral SCC. The patient has been treated with combination chemotherapy of lowpol (100 mg per day) and etoposide (10 mg per day). His vital signs are stable now, and he is receiving further treatment in our hospital.

CONCLUSION

Because of immunosuppressive drugs use, the incidence of malignancies has increased significantly after renal transplantation. This case highlights the difficulty of diagnosis of primary SCC and the necessity of checking for neuroendocrine tumor after organ transplantation.

Significant Role of Lifetime Cigarette Smoking in Worsening Bladder Cancer and Upper Tract Urothelial Carcinoma Prognosis: A Meta-Analysis

PURPOSE

Although cigarette smoking is a well established risk factor for urothelial cancer, its role in urothelial cancer prognosis is still undetermined. In this meta-analysis we quantify the role of lifetime smoking history in bladder cancer recurrence, progression and survival by pooling available data on nonmuscle invasive bladder cancer, muscle invasive bladder cancer and upper tract urothelial carcinoma.

MATERIALS AND METHODS

A total of 24 studies, comprising data from 13,114 patients with bladder cancer and 2,259 patients with upper tract urothelial carcinoma, were included in this meta-analysis. Publication bias was addressed through Egger's test, and the heterogeneity among studies was assessed by the I(2) test statistic and subgroup analyses.

RESULTS

Current smokers at diagnosis are at increased risk for local recurrence in nonmuscle invasive bladder cancer (HR 1.27, 95% CI 1.09-1.46) and smokers with muscle invasive bladder cancer have an increased risk of dying of bladder cancer (HR 1.23, 95% CI 1.02-1.44). In the upper tract urothelial carcinoma population smokers have an increased risk of recurrence in the operative bed (HR 1.57, 95% CI 1.19-1.95) and of death from upper tract urothelial carcinoma (HR 1.53, 95% CI 1.13-1.92). We did not identify significant heterogeneity among included studies.

CONCLUSIONS

The body of evidence is limited due to the absence of prospective studies. However, the results from this meta-analysis unambiguously support the hypothesis that lifetime cigarette smokers are at increased risk for a more malignant type of urothelial carcinoma associated with a worse prognosis.

Uroepithelial and kidney carcinoma in Lynch syndrome

Increased risk for urological tumors has been observed in mutation carriers with Lynch syndrome (LS). In this study, we evaluated the clinical features of uroepithelial (bladder and ureter) and kidney cancers in 974 Finnish mutation carriers. Altogether 30 patients had a total of 34 urological tumors: 12 ureter, 12 bladder, and 10 kidney cancers. Urological tumor was the only tumor in 9 (30 %) patients, and metachronous other tumor occurred in 21 (70 %). The occurrence of uroepithelial cancers was significantly higher in MSH2 mutation carriers (6 %; 95 % CI, 2.7-11.0) than in MLH1 carriers (2 %; 95 % CI, 1.1-3.2) and MSH6 mutation carriers (0 %) (p = 0.014). The mean ages of patients at the time of diagnosis were: bladder cancer, 57 years; ureter cancer, 58 years; and kidney cancer, 64 years. Overall 5-year survival rates were 70 % (95 % CI, 0.32-0.89) in bladder cancer, 81 % (95 % CI, 0.45-0.95) in ureter cancer, and 75 % (95 % CI, 0.31-0.93) in kidney cancer. Cancer-specific 5-year survival rates were 70 % (95 % CI, 0.32-0.89) in bladder cancer, 91 % (95 % CI, 0.51-0.98) in ureter cancer, and 100 % in kidney cancer. In conclusion, early age of onset was observed in patients with uroepithelial tumors, but not in patients with kidney cancer. The frequency of uroepithelial tumors was significantly higher in MSH2 mutation carriers than in MLH1 carriers. Further studies with larger numbers of patients, however, are needed to evaluate the potential benefit of surveillance of urological tumors in LS.

[Urothelial carcinoma after renal transplantation : a case report]

We report a case of urothelial carcinoma (UC) in a 69-year-old man that occurred after renal transplantation. He had started receiving hemodialysis therapy in 2004 due to diabetic nephropathy and underwent living related renal transplantation from his brother in 2005. He was referred to our hospital in May 2009 with asymptomatic microscopic hematuria. Cystoscopy findings revealed multiple bladder tumors, and transurethral resection of bladder tumor (TUR-BT) followed by intravesical instillation of pirarubicin was performed. Histopathological findings revealed UC (G1>G2, pTa). Cytology findings after the operation did not become negative; urine specimen from the native right ureter was positive, and abdominal computed tomography (CT) demonstrated a right pelvic tumor. In January 2010, a laparoscopic right nephroureterectomy was performed and pathological examination findings revealed UC in the right pelvis (G3>G2, INFβ, pT3). In March 2010, recurrence of the bladder tumor was demonstrated as carcinoma in situ (CIS) of the bladder and left native ureter. In June 2010, a radical cystectomy with left nephroureterectomy and ileal conduit diversion were performed. One week after that operation, laboratory results revealed abnormal hepatic function and CT showed multiple liver metastases. The patient died in August 2010, 2 months after surgery.

Upper urinary tract urothelial cancers: where it is A:T

Despite a ban on the use of plants of the Aristolochia genus in herbal medicine, as they contain known carcinogens, urothelial carcinoma attributable to the use of this plant seems to be more common than previously thought.

Transitional cell carcinoma of the upper urinary tract after cystectomy

OBJECTIVE

To assess the incidence, characteristics and outcome of upper urinary tract tumors (UUTTs) that developed in patients who underwent radical cystectomy for urothelial carcinoma.

METHODS

We performed an analysis of original and review articles that were related to post-cystectomy UUTTs. The articles were published from 1984 through 2011 and were identified by searching the Pub Med database.

RESULTS

The incidence of post-cystectomy UUTT ranges from 2-6% and is stable over time. The primary risk factors include a tumor in the distal ureter in the cystectomy specimen and signs of multifocal disease (e.g., multiplicity, a history of non-muscle-invasive bladder tumor, diffuse carcinoma in situ and the presence of a tumor in the prostatic urethra). The median time between cystectomy and UUTT exceeded three years in 70% of the reviewed cases. Even with regular radiological follow-up visits, over 50% of cases were diagnosed after clinical onset, and over 70% were in an advanced stage. Currently, a multidetector computed tomography urography is the standard technique for studying the upper urinary tract. In patients with urinary diversion, the maximum yield of cytology can be obtained when this technique is used to confirm a clinical or radiological suspicion of UUTT. Nephroureterectomy is the treatment of choice for these tumors. The high prevalence of high-grade and stage UUTT results in endourological treatment being restricted to only selected cases. Despite surgery, fewer than 30% of post-cystectomy UUTT patients experience prolonged survival.

CONCLUSIONS

Post-cystectomy UUTT is rare and usually has a late onset. A distal ureteral tumor and the presence of multifocal disease are its primary risk factors. Most cases of post-cystectomy UUTT are diagnosed clinically and in advanced stages.

[Increased risk of cancer in the urinary tract in patients with hereditary colorectal cancer]

During screening of 20 selected patients with hereditary non-polyposis colorectal cancer (HNPCC) (Lynch syndrome) carried out in the Department of Urology of Odense University Hospital from 2001 to 2010, two patients without urologic symptoms with cancer in the ureter were found. The purpose of the present case report is to underline the importance of referring those patients with HNPCC that have increased risk of urologic cancer to screening of the urinary tract. Furthermore, this paper seeks to point out the necessity of further investigation in the risk of urologic cancer in the different mutations causing HNPCC, as well as the effects of the different screening methods in order to find the optimal screening population and the optimal screening method.

[Clinical analysis of urothelial cancer after renal transplantation]

OBJECTIVE

To analyze and summarize the risk factors of malignant tumor after renal transplantation.

METHODS

We retrospectively analyzed 435 renal recipients who underwent renal transplantation in our institute from May 1991 to March 2011, and found 14 patients developed malignant tumor, of which 12 were from our institute, and the other 2 were referred from other institute. We analyzed the risk factors of those tumors for their incidence, classification, time of final diagnosis, immunity suppression therapy and prognosis.

RESULTS

The incidence of malignant tumors after renal transplantation in our hospital was 2.8%.Of the 14 cases, 11 were urothelial tumor (6 cases developed both in pelvis and ureter, 2 cases of primary ureter cancer and 3 cases of primary bladder cancer), and the other 3 were thyroid carcinoma, colon carcinoma and lymphoma. We carried out radical corrections in 13 patients,of whom 10 were in good status, 2 underwent the secondary operation in 1 year due to relapse (one patient died in half a year due to tumor size expansion), and 1 died from repeated relapse in 3 years. Chemotherapy was used for the patient with lymphoma.

CONCLUSION

Immunity suppression and surgery are associated with the high incidence of maglinant tumor (78% were urinary tract tumors) after renal transplantation. The risk of tumor is strongly associated with the recipient's survival. The key point of management is early diagnosis and treatment. Further attention should be emphasized to painless gross hematuria, unconfirmed back pain, hydronephrosis, hydroureter and infections.

[Primary adenocarcinoma of a ureteral remnant stump after nephrectomy]

AIM

Adenocarcinomas of the upper urinary tract are very rare malignancies often related to primary genitourinary and extraurinary tumours. Primary adenocarcinomas are even rarer. There are no clinical guidelines for the management of primary ureteral adenocarcinoma. Our objective is to propose a management algoritm of this sort of tumours.

METHODS

We report a case of adenocarcinoma affecting a ureteral stump in a patient who previously underwent a nephrectomy. A review of literature is performed.

RESULTS

After the ureterectomy the pathologist diagnosed a ureteral adenocarcinoma. We performed an extension study in order to discard an extraurinary origin.

CONCLUSIONS

Adenocarcinoma of the ureteral stump is a very rare malignancy. About the clinic and pathologic characterization, there is no an established reference due to the short number of previous reports. Clinical presentation may include previous nephrectomy, flank pain, dysuria, urgency and/or gross hematuria. It seem necessary the complete resection of the urinary tract when a nephrectomy is performed. Adjuvant chemotherapy can be employed with uncertain results.

[Tumour in the ureter stump 13 years after nephrectomy--a rare case of endometriosis]

Endometriosis is found in the urinary tract in 1-2% of women suffering from this disease. The most common site is urinary bladder (81%). In the ureter it is found in only 15% of cases and it mainly involves the pelvic part. The authors present a case of 49-year old woman who was diagnosed with an endometriotic tumour in the stump of the ureter, 13 years after left nephrectomy performed for hydronephrosis and lack of the kidney's function confirmed in renal scintigraphy. After laser ablation and hormonal therapy the tumour burden was diminished and symptoms resolved.

[Ureteral tumor occurring from remaining stump: a case report]

Primary tumor originated from ureteral stump following nephrectomy for benign disease is extremely rare. A 79-year-old male was referred to our department for asymptomatic macroscopic hematuria. He had undergone left simple nephrectomy for renal tuberculosis 52 years ago. Cystoscopic examination revealed a ureteral tumor on the residual ureteral orifice. Under the diagnosis of left ureteral stump tumor, which was subsequently enhanced on computer tomographic scan and magnetic resonance imaging, he received partial cystectomy and excision of the left ureteral stump. The histological examination revealed grade 2 to 3 urothelial carcinoma with muscle invasion (pT2). He received no adjuvant chemotherapy. He is now alive and free from recurrence 2 months post-operatively. This is the 21st case reported in the Japanese literature.

Ureteral mullerian carcinosarcoma (mixed mullerian tumor) associated with endometriosis occurring in a patient with a concentrated soy isoflavones supplementation

Malignant transformation and particularly malignant mixed mullerian tumor arising in extragenital endometriosis is extremely rare and occurs in the majority of cases after estrogen replacement therapy. We present a case of a 75-year-old woman who developed a ureteral malignant mullerian carcinosarcoma in a context of florid endometriosis. The patient had a history of total hysterectomy with bilateral salpingo-oophorectomy 30 years earlier for extensive endometriosis. Since 5 years, the patient has been on phytoestrogen supplementation consisting of 72 mg/day of superconcentrated soy isoflavones. This is the first case of ureteral mullerian carcinosarcoma arising in endometriosis foci after extensive phytoestrogen supplementation. Our data suggest that phytoestrogens at least in concentrated form may play a role not only in maintenance of endometriosis but also in its malignant transformation. Given the extraordinary popularity and availability of these dietary supplements, several studies are indispensable regarding their safety particularly in women with extensive endometriosis.

Long-Term Follow-Up of Ureteral Stump Tumors after Nephrectomy for Benign Renal Disease

OBJECTIVE

The occurrence of primary carcinoma of the ureteral stump after nephrectomy is rare. In this study, we evaluated the clinical characteristics of ureteral stump tumors after nephrectomy for benign renal disease.

METHODS

During a 16-year period, 318 consecutive patients underwent simple nephrectomy for benign renal disease (216 cases) or for donation (102 cases). Eight of these 318 patients diagnosed as having an ureteral stump tumor were treated by ipsilateral ureterectomy with cuff excision of the bladder. Pathologic findings, tumor stages, and clinical characteristics were analyzed.

RESULTS

The eight ureteral stump tumors comprised; 6 transitional cell carcinomas (TCCs) and 2 squamous cell carcinomas (SCCs). The mean interval between nephrectomy and ureteral stump tumor diagnosis was 76.5 months. Six of the 8 patients had pyonephrosis and two renal tuberculosis as original renal diseases. Four of the 6 TCCs were stage T1 and 2 stage T2. There was no concomitant bladder tumor at stump tumor diagnosis. Hematuria was the major presenting symptom in 3 of the 8 patients and 4 patients were diagnosed by follow-up imaging study. Two of the 6 ureteral stump TCC patients developed bladder TCC during follow-up. The 5-year survival rate of patients with ureteral stump tumor was 37.5%. T1G1 TCC was associated with a better survival than T2 or G2 TCC. No ureteral stump tumor occurred in cases of donor nephrectomy.

CONCLUSION

This study demonstrate, that long-term closed observation is needed to detect ureteral stump tumor, particularly in patients that have undergo nephrectomy for a long-standing inflammatory renal disease such as pyonephrosis or tuberculosis. Hematuria is a major presenting symptom of ureteral stump tumor. However, a follow-up imaging study is also important for ureteral stump tumor detection. The prognosis is poor in cases developing ureteral stump SCC, bladder tumor recurrence, or a high-grade ureteral tumor.

A possible case of Werner syndrome presenting with multiple cancers

The treatment of a man with six metachronous primary cancers is described. The primary lesions were in the soft palate, both edges of the tongue, the hard palate, the esophagus, and the right ureter. Pathologically, all of the first five tumors in the head and neck and esophagus were proven to be squamous cell carcinoma with various grades of differentiation, and the last one was transitional cell carcinoma. The cancers were found in the early clinical stage, and were completely controlled one by one except for the ureteral tumor under treatment. His characteristic medical history and physical findings, i.e. bilateral cataracts, short stature, baldness, diabetes mellitus, high-pitched voice, and multiple malignancies, met the clinical criteria for possible Werner syndrome, a genetic premature aging disorder, though the possibility of phenocopy of this syndrome has not been ruled out. We have followed him carefully because he might be vulnerable to malignant tumor formation.

Synchronous bilateral ureteral and renal pelvic carcinomas

BACKGROUND

Synchronous bilateral urothelial tumors of the upper urinary tract are very rare. The authors reported baseline and long-term follow-up data for all patients in western Sweden during a 28-year period.

METHODS

The authors performed a clinical and histopathologic study of all patients in western Sweden who were diagnosed with a malignant neoplasm in the renal pelvis or ureter between 1971 and 1998.

RESULTS

Of 936 patients, 15 (1.6%) had synchronous bilateral tumors. The incidence of such tumors decreased in each successive decade. Abuse of phenacetin-containing analgesics by patients also decreased during the study period, as did the incidence of renal papillary necrosis. The median age at diagnosis of bilateral tumors was 68 years, and 80% of the patients were male. Eleven patients had bilateral tumors of the renal pelvis, two had bilateral ureteral tumors, and two had tumors of the renal pelvis and contralateral ureter. Partial renal pelvic, ureteral, or kidney resection on at least one side was possible in eight patients, and four patients were left untreated on at least one side. Only three patients underwent bilateral nephroureterectomy. Twelve patients (80%) had bladder carcinoma diagnosed either before or after diagnosis of the upper tract tumors. The median survival period for the 11 patients who received surgery for their bilateral tumors was 84 months.

CONCLUSIONS

The decreasing incidence of synchronous bilateral upper tract tumors may be related to the prohibition of phenacetin-containing analgesics in the 1960s. Partial resection with preservation of the renal parenchyma was possible in the majority of patients. Survival for patients with bilateral tumors did not differ from that of patients with unilateral tumors.

DNA adducts and p53 mutations in a patient with aristolochic acid-associated nephropathy

BACKGROUND

Aristolochic acid-associated nephropathy (AAN) is a specific type of renal disease that predisposes patients to a high risk of urothelial carcinoma. The authors have analyzed DNA from a patient who had urothelial malignancy 6 years after presenting with AAN and later had a breast carcinoma that metastasized to the liver.

METHODS AND RESULTS

DNA was isolated from the primary breast tumor, the liver tumor, and the original urothelial malignancy and assayed for aristolochic acid (AA)-DNA adducts and mutations in the p53 gene. The adduct detected was the adenosine adduct of aristolochic acid I 7-(deoxyadenosin-N6-yl)aristolactam I (dA-AAI). In DNA from the breast and liver tumors the authors showed the same missense mutation in codon 245 (GGC-->GAC; Gly-->Asp) of exon 7 of p53. In contrast, DNA extracted from the urothelial tumor showed an AAG to TAG mutation in codon 139 (Lys-->Stop) of exon 5.

CONCLUSION

A to T transversions, as observed here, are the typical mutations observed in the H-ras gene of tumors induced when rodents are treated with AA and correspond with DNA adduct formation at adenosine residues. These data indicate the probable molecular mechanism whereby AA causes urothelial malignancy.

[Metachronous bilateral ureteral cancer in patient with hereditaly nonpolyposis colorectal cancer]

Hereditary nonpolyposis colorectal cancer (HNPCC) is an autosomal dominant disorder characterized by an excess of extracolonic malignancies including those of the urinary tract. We report a case of metachronous bilateral ureteral cancer associated with HNPCC. A 51-year-old man was referred to Nara National Hospital for further examination of left hydronephrosis on excretory urography performed on the periodical follow-up for colon cancer. Computed tomography showed a mass in the left lower ureter and urine cytology was demonstrated class V. The operation was performed under the diagnosis of left ureteral cancer. The histopathological diagnosis was transitional cell carcinoma, grade 2, pT1. After 4 months of the operation, he presented with gross hematuria. Retrograde pyelography demonstrated tumors in the right side (ureter and renal pelvis) and the histopathological diagnosis of the biopsy specimens revealed transitional cell carcinoma, grade 2. We performed 4 times of BCG instillation followed by laser ablation of the tumor. The reported case was compatible for Japanese clinical criteria, group B for HNPCC.

The development of bladder tumors and contralateral upper urinary tract tumors after primary transitional cell carcinoma of the upper urinary tract

BACKGROUND

Contralateral, metachronous upper urinary tract (UUT) tumors after primary transitional cell carcinoma (TCC) of the UUT are reported rarely, and to the authors' knowledge the risk factors have not been determined to date. In addition, few reports have described the characteristics of recurrent bladder tumors and contralateral UUT tumors and any relation between theses tumor types.

METHODS

Statistical analysis of data from 223 patients with documented primary UUT-TCC was undertaken. After excluding bilateral involvement and distant metastases, 12 variables were analyzed by multivariate analysis in 189 patients to determine the risk factors for recurrent urothelial tumors.

RESULTS

The incidence rates of recurrent bladder tumors and contralateral UUT tumors were 31.2% and 5.8%, respectively. Multiplicity was determined as a risk factor for recurrent bladder tumors. Renal insufficiency, uremia, and concurrent bladder tumors significantly predisposed patients to develop contralateral UUT tumors after primary UUT-TCC. The time intervals and stage distributions differed significantly between recurrent bladder tumors and contralateral UTT tumors. Patients who had recurrent bladder tumors had earlier stage tumors and had a shorter time to recur compared with patients who had contralateral, metachronous UUT tumors.

CONCLUSIONS

For patients with primary UUT-TCC, regular follow-up by cystoscopy is necessary to detect recurrent bladder tumors. Intravenous urography or retrograde pyelography should be performed for patients who have a high risk of developing contralateral UUT tumors.

Transitional cell carcinoma of the ureter and renal pelvis

Transitional cell carcinoma (TCC) of ureter and renal pelvis is relatively uncommon. Smoking, occupational carcinogens, analgesic abuse, Balkan nephropathy are the risk factors. Cytogenetic studies revealed that the most frequent aberration is the partial or complete loss of chromosome 9. Approximately 20-50% of patients with upper urinary tract (UUT) TCC have bladder cancer at some point on their course, whereas the incidence of UUT TCC after primary bladder cancer is 0.7-4%. Excretory urography and retrograde pyelography are the conventional diagnostic tools; however, ureteropyeloscopy combined with cytology and biopsy is more accurate. Grade and stage of the disease have the most significant impact on survival. Nephroureterectomy with bladder cuff excision has been the mainstay of treatment. Local resection may be appropriate for distal ureteral lesions especially when the disease is low grade and stage. Advances in endourology have made it possible to treat many tumors conservatively. Ureteroscopic and to a certain extent percutaneous surgical approaches are widely used today especially in patients with low grade, low stage disease. Endoscopic close surveillance is mandatory for these patients. Adjuvant topical therapies appear to be safe but confirmation of any benefits awaits the results of further large studies. More recently, laparoscopic techniques have become a viable alternative to open surgery, but long term cancer control data are lacking. Aggressive surgical resection does not affect the outcome of patients with advanced disease. Adjuvant radiotherapy is ineffective, and systemic chemotherapy results in a low complete response rate for patients with metastases.

Clinical and urographic presentation of transitional cell carcinoma of the ureter in a blackfoot disease endemic area in southern Taiwan

We reviewed the clinical, radiographic, and pathologic findings of ureteral transitional cell carcinoma (TCC) in a blackfoot disease (BFD) endemic area in southern Taiwan to increase understanding of tumor behavior in this area, which has a high incidence of urothelium carcinoma. From August 1995 to February 2002, 28 histologically proven ureteral TCCs from this area were eligible for study. There was an unusual female predominance (male:female ratio, 1:1.333). The urographic filling defects in the 28 ureteral TCCs were classified into four categories. An ovoid filling defect was significantly associated with non-invasive tumors (p = 0.003) and a trend toward low tumor grades (p = 0.073). The risk of ureteral TCC in this BFD endemic area of southern Taiwan remained high between August 1995 and February 2002. Urographic surveillance provides a simple, clear, inexpensive method to study the extent, location, and morphology of the ureteral mass. Detailed assessment of the image could be useful for preoperative planning and predicting prognosis. Large-scale, randomized, prospective clinical trials are needed to validate our results.

[Ureteral inverted papilloma: a case report]

A 43-year-old man presented with left hydronephrosis, incidentally found by ultrasonography. He had undergone transurethral bladder tumor resection when he was 29 years old. Cystoscopy revealed a tumor protruding from the left ureteral orifice. Left partial ureterectomy was performed, and its histopathological diagnosis was ureteral inverted papilloma. He has remained free of disease for 18 months after the surgery.

[Carcinosarcoma of the renal pelvis and ureter: a case report]

We report a case of carcinosarcoma of the renal pelvis and ureter arising in an 89-year-old man who presented at our hospital with gross hematuria. Abdominal computed tomography, excretory pyelography, and retrograde pyelography demonstrated that left hydronephrosis was caused by an ureteral tumor. Left urine cytology indicated transitional cell carcinoma. The patient underwent chemotherapy and radiation therapy. However, gross hematuria recurred, and the patient underwent left nephroureterectomy. The surgical specimen showed carcinosarcoma in the renal pelvis and ureter histologically. He has been free of cancer for 1.5 years.

Ureteral fibroepithelial polyp associated with urolithiasis induced by steroid therapy in a child: a case report

A 14-year-old boy complained of left flank pain. He had been given high-dose corticosteroid therapy for chronic inflammatory demyelinating polyneuropathy (CIDP). Retrograde pyelography revealed irregular defects at the left ureteropelvic junction (UPJ), and ureteroscopy demonstrated ureteral polyp. The polyp was removed and histologically diagnosed as fibroepithelial polyp. Hypercalciuria due to the corticosteroids and bedridden was assumed to have been a causative factor in the stone formation. To our knowledge, this is the first report of a ureteral fibroepithelial polyp in children associated with urolithiasis, and associated with CIDP.

[Adenocarcinoma of the renal pelvis and transitional cell carcinoma of the ureter occurring 11 years after radical cystectomy for bladder cancer: a case report]

We report a case of upper urinary tract carcinoma which recurred 11 years after total cystectomy. A 52-year-old man presented with complaints of a sense of residual urine and terminal miction pain. Urinary cytology, cystoscopic examination and intravenous pyelography revealed normal findings. Twenty months later, because class V urinary cytologic findings were detected, transurethral biopsy was performed. Carcinoma in situ was diagnosed pathologically. Therefore, total cystectomy and ileal conduit urinary diversion were performed. The pathological diagnosis was transitional cell carcinoma, grade 3, pTis. At 127 months postoperatively, laboratory examination revealed an extremely high serum level of LDH (3,084 U/l). The right kidney was not visualized on IVP and computed tomography revealed a right renal irregular mass. On the suspicion of a renal pelvic tumor, right total nephroureterectomy was done. The pathologic diagnosis was renal pelvic adenocarcinoma and ureteral transitional cell carcinoma. The patient was treated postoperatively with 3 cycles of systemic chemotherapy and radiotherapy. The serum level of LDH returned to normal. However, one year later, the serum level of LDH elevated to 1,118 U/l. He died of retroperitoneal lymph node, left adrenal gland and pulmonary metastases.

[Risk factors for urothelial carcinoma: drinking measures, smoking and other life style-related risk factors--results of the Berlin Urothelial Study (BUS)]

With the exception of smoking and several occupational exposures there is little knowledge about risk factors for urothelial cancer. A case control study in the area of former West Berlin was performed from 1990-1995 to investigate the role of several lifestyle risk factors, such as smoking, drinking behaviour and regular intake of analgesics and laxatives. The study includes 647 hospital-based incident cases with bladder cancer (n = 571), renal pelvis cancer (n = 51), and ureter cancer (n = 25), and 647 population-based controls which were matched individually by sex and age. Data analyses were carried out using standard methods for case control studies (conditional multiple logistic regression analysis). Odds ratios (OR) and 95% confidence intervals (CI) were applied as effect parameter. Statistically significantly increased odds ratios were observed for current smoking (OR: 3.46, 95% CI: 2.50-4.78), previous but now abandoned smoking (OR: 1.51, 95% CI: 1.09-2.81), and for regular intake of laxatives (OR: 2.52, 95% CI: 1.56-4.09). Furthermore, an increased risk for urothelial cancer was observed for daily consumption of three and more litres of cold drinks (OR: 2.65 95% CI: 1.12-6.24). The results underline that lifestyle factors other than smoking may contribute to a higher risk of urothelial cancer.

Urothelial cancer at different tumour sites: role of smoking and habitual intake of analgesics and laxatives. Results of the Berlin Urothelial Cancer Study

BACKGROUND

In Germany about 20000 new cases of urothelial cancer (UC) and about 7500 deaths from bladder cancer alone occur each year. Among the manifold risk factors, little research has been done on the role of smoking and the habitual intake of analgesics and laxatives-practices that are common in parts of the German population. The aim of this study is to define the proportion of risk derived from these preventable habits for the development of UC at its different sites. Subjects and methods. A case-control study in the area of the former West Berlin was performed from 1990 to 1995 including all newly diagnosed incident cases of UC from the eight hospitals of the study area. Study subjects and population-based controls individually matched by age (+/-2 years) and sex were evaluated by a standardized face-to-face interview about the lifelong exposure to cigarette smoking, analgesics, and laxatives. Adjusted risk analysis was carried out for the main exposure variables in relation to the different sites of UC in the bladder, ureter, and renal pelvis.

RESULTS

Six hundred and forty-seven cases of UC (571 bladder, 25 ureter, and 51 renal pelvis) and an identical number of controls were included in the analysis (response rate in cases, 84.6%; in controls, 70.2%). Smoking increased the risk of bladder cancer (BC) by an odds ratio (OR) of 3.22 (95% confidence interval (CI) 2.29-4.52), that of ureter (URC) or renal pelvis cancer (RPC) together by OR 6.20 (95% CI 2.04-18.81), and that of RPC alone by OR 5.91 (95% CI 1.47-23.66). Ex-smoking was associated with an increased risk for BC (OR 1.55, 95% CI 1.10-2.19). Intake of more than 1 kg of phenacetin in analgesic mixtures was associated with an OR of 5.28 for RPC (intake of > or = 1 kg paracetamol, OR 3.27; > or = 1 kg pyrazolones, 1.12) and 0.75 for BC (not significant). Laxatives significantly increased the risk of BC (OR 2.14, 95% CI 1.26-3.63) and RPC/URC (OR 9.62, 95% CI 1. 01-91.24) in both sexes.

CONCLUSION

Habitual risks from smoking and intake of laxatives significantly contribute to the development of UC, especially of the renal pelvis and ureter cancer. Intake of at least 1 kg of analgesic substances (anilides, pyrazolones) as calculated from this study base is associated with increased but not significant risks for RPC. These data underline that restrictive and educational measurements focusing on common habits would have a strong impact on preventing UC in Germany.

Transitional cell carcinoma of ureteral stump after radical nephrectomy for renal cell carcinoma

A 68-year-old male presented with microscopic hematuria during a routine checkup after undergoing a radical nephrectomy for renal cell carcinoma. Retrograde ureterography demonstrated a ureteral stump tumor. The ureteral stump was completely resected with a bladder cuff and histologic diagnosis was grade 2 to 3 transitional cell carcinoma of the ureteral stump. He is doing well and has been tumor-free for 2 years. The ureteral stump must be correctly evaluated using retrograde ureterography in any patient with a prior history of bladder cancer. Even if a patient had no history of ureterial cancer, whenever hematuria is present in the follow-up period after nephrectomy for renal cell carcinoma, a retrograde pyelogram should be performed.

Lambert-eaton myasthenic syndrome in association with transitional cell carcinoma: a previously unrecognized association

The Lambert-Eaton myasthenic syndrome is known to occur with, or precede, a variety of malignancies, most commonly oat cell carcinoma of the lung. We report the first case of this syndrome associated with transitional cell carcinoma of the bladder and ureter. A brief review of published reports on the presentation, diagnosis, and treatment is included.

[A clinical study on renal pelvic and ureteral tumor associated with bladder tumor with special reference to risk factors of subsequently recurrent bladder tumor]

PURPOSE

The purpose of this report is to analyze the clinical feature of renal pelvic and/or ureteral tumor (RUT) associated with bladder tumor (BT) with special reference to risk factors of subsequently recurrent BT.

METHODS

Of the 49 patients with RUT who underwent surgery and were diagnosed pathologically as transitional cell carcinoma at the Department of Urology, Osaka National Hospital from April 1986 to October 1996, 20 patients (40.8%) had associated BTs. These patients were categorized to the following 4 groups, Group 1: 5 patients with BT preceding RUT, Group 2: 5 patients with concomitant BT, Group 3: 10 patients with subsequent BT following RUT operation and Group 4: 29 patients without any associated BT. The clinical course of these 4 groups were studied and compared with each other retrospectively.

RESULTS

In group 1, the first BTs preceded RUTs by 19 to 81 months (mean 54.6 months). And during this relatively long period, the preceding BTs were treated by TUR for each recurrence, 1 to 9 times (mean 5.2 times). Two of 5 were bilateral RUT cases, which were observed only in this group. In group 2, the prognosis were relatively poor (5-year survival rate: 0%), because all RUTs of this group were high stage. And also the concomitant BTs were showing invasive feature during the observation period, despite they were superficial at first. Thus 3 of 5 underwent radical cystectomy. On the other hand, in group 3, the subsequent BTs, which developed at 2 to 26 month (mean 13.4 month) after RUT operation, were all superficial and resectable by TUR. The 5-year disease specific survival rate was 50% in group 1, 0% in group 2, 63.5% in group 3, 64.9% in group 4. Group 2 had the most poor prognosis. However there was no significant difference in prognosis among the 4 groups. Incidence of preoperative urine positive cytology was significantly higher in group 3, than in group 4 (87.5% vs. 44.8%).

CONCLUSIONS

These results indicated that the RUTs with associated BTs have distinct clinical features depending on the sequence of association with the BTs. Especially the RUTs with concomitant BTs should be watched carefully as a high risk group with poor prognosis and possible development of invasive BTs. Positive urine cytology prior to RUT operation may reflect biological activity of tumor cell for dissemination in the lower urinary tract and we suggested preoperative urine cytology was possible predictor of subsequently recurrent BTs after RUT operation in this study.

[Improved tumor stent for internal palliative urinary diversion]

The disadvantages of high flexible endoureteral stents (DJ) in case of tumorinduced extrinsic ureteral compression are due to an insufficient vertical stability of the used stents leading to stent-compression and consecutive hydro- or pyonephrosis. The new developed tumor-stent used in case of tumor-induced ureteral compression is available from 6 to 8 French in diameter and 24 to 32 cm in length. The corpus consists of a combination of high-stability plastics but is of sufficient elasticity in length. Both ends consist of extremely elastic J-parts guaranteeing an exact fixation. As against common DJ's with the same outside-diameter the new stent has a comparable interior diameter and compared to used "old" tumor stents promises a higher interior flow in case of extrinsic diseases. The application can be undertaken in well-known technique, needs no special instrumentation and no learning-curve. To date 52 stents at our urologic departments were placed without any problems, the latest remaining for 15 months. Tumor-induced compression or a higher rate of encrustation could not be seen. All patients tolerated these stents well. In our opinion the new stabilized endoureteral stent can be seen as a better solution instead of percutaneous nephrostomy or frequent stent changing in patients with tumor induced extrinsic ureteral compression.

Primary tumor of the ureteral stump following a nephrectomy for renal cell carcinoma

BACKGROUND

A 64-year-old man presented with asymptomatic macroscopic hematuria during a follow up for a localized renal cell carcinoma (RCC), which was treated by a right radical nephrectomy 6 years earlier.

METHODS

X-rays and a ureteroscopic examination revealed multiple papillary tumors filling the right ureteral stump. Surgery was performed to excise the ureteral stump and bladder cuff. The tumor was histologically a grade 2-3 transitional cell carcinoma without muscle invasion.

RESULTS/CONCLUSIONS

Only four patients with a ureteral stump carcinoma, including the present case, have been reported after a nephrectomy for RCC. Considering that this patient had a past history of multiple cancers, genetic or environmental factors may have contributed to the etiology of the ureteral stump tumor.

[Myelodysplastic syndrome (RAEB in T) developed in a renal allograft recipient]

A 46-year-old man who had been treated with azathioprine (150 mg/day) and prednisolone (7.5-10 mg/day) for 16 years after allogeneic renal transplantation was admitted to our hospital in July 1996 for evaluation of pancytopenia. Three years earlier he had been given a diagnosis of renal pelvic and ureteral cancer, and underwent left nephrectomy with total uretectomy. His bone marrow was normocellular with excess of blasts (27.6%), and displayed trilineage myelodysplasia. A chromosomal analysis of the bone marrow revealed 43-45, XY with del (1) (p13), -5, del (7) (q22), -17, -18, and -19. The patient was given a diagnosis of refractory anemia with excess of blasts in transformation (RAEB in T), and treated with idarubicin and cytosine arabinoside. Two months later, overt acute leukemia developed and reinduction chemotherpay was started, but the patient died of cerebral hemorrhage in October. This case suggests that immunosuppressive agents such as azathioprine might play an important role in the pathogenesis of MDS (RAEB in T) and renal pelvic and ureteral cancer after renal transplantation.

[Kidney-sparing surgery for recurrent ureteral and bladder cancers in an aged patient with functionally solitary horseshoe kidney]

A 79-year-old woman was admitted with recurrent ureteral and bladder cancers. She had a horseshoe kidney with a non-functioning right renal unit. Fifteen months earlier, multiple urothelial tumors had first developed in the left upper ureter and bladder. Transurethral resection of bladder tumor (TUR-Bt) and partial ureterectomy (2 cm) had been performed. Presently, the recurrent tumors were located at the left lower ureter and bladder. Considering the high age of the patient, TUR-Bt and partial ureterectomy (5 cm) were performed. Besides urothelial cancers, she had been operated for carcinomas of the colon, uterus and stomach. Kidney-sparing therapy has successfully maintained her quality of life.

Should we get routine urothelial biopsies in every stone surgery?

Physical traumas have been implicated as intrinsic risk factors for the progression of urothelial tumours. In stone disease, histologic changes of the urothelium have a wide spectrum. We want to show the importance of biopsies for identification of these changes. In this study, we investigated the histologic changes of the urothelium in stone patients. There were 16 squamous metaplasia, 14 pyelitis follicularis, 5 pyelitis or ureteritis cystica, 4 polypoid pyelitis or ureteritis, 2 encrusted pyelitis in 43 stone patients, and 5 calcium, 2 long-standing struvite and 2 mixed calculi histories were found in 9 of 14 upper urothelial tumour patients. According to our results, it is important to identify the histologic changes of the upper urothelium during stone surgery for possible neoplastic progression in the future. If any suspicious finding is demonstrated, the patients should be enrolled in a follow-up programme or should be transferred to tumour treatment programme. Therefore, we propose to take biopsies of the urothelium in every stone surgery.

[Tumors of the upper excretory tract]

Most tumors of the upper urinary tract are epithelial tumors from transitional cell origin. They are more frequent in the renal pelvis than in the ureter. They may be single or multiple and rarely bilateral. Gross hematuria is the most common presenting form. Computed tomography is useful both in the diagnosis and staging and is much more contributive than intravenous pyelography. Nephroureterectomy with a bladder cuff is the standard treatment for upper tract tumors. In selected cases are low grade and low stage tumors, conservative surgery can be discussed with similar longterm results than radical surgery.

Radiation-induced urothelial carcinoma

Four cases of urothelial carcinoma following pelvic irradiation for carcinomas of the cervix uteri (n = 3) and the ovary (n = 1) are reported. The urothelial carcinomas developed 26.8 (mean) years after radiotherapy and invaded the bladder in 3 patients and the ureter in 1. Despite radical surgery, the patients died of metastatic cancer.

Transitional cell carcinoma of the ureteral stump 13 years after nephrectomy for benign disease

A case of primary carcinoma of the ureteral stump occurring 13 years after nephrectomy for benign disease is reported. The literature is reviewed.

[Squamous cell carcinoma of the ureter as a late complication of ureterocutaneostomy--a case report]

A case of squamous cell carcinoma of the ureter was reported. A 62-year-old woman, who underwent left nephrectomy and right ureterocutaneostomy at the age of thirty-one because of tuberculosis of the urinary tract, visits our hospital periodically for an ureteral catheter change. An urgent nephrostomy was performed because of ureteral stricture on March 8, 1994. Three months later tenderness and induration appeared at the former ureteral stoma. The resected specimen was histologically diagnosed as squamous cell carcinoma. Right palliative ureterectomy did not produce the desired effects due to the invasion of the tumor into the surrounding organs. In this rare case, it is suggested that chronic infection and irritation of the indwelling catheter might be causative of squamous cell carcinoma of the ureter.

[Pseudodiverticula of the ureter: a precancerous lesion?]

Ureteral diverticula belong to the group of acquired diverticula even though their pathogenesis and clinical significance are still debated. They are occasionally detected during urography or retrograde pyelography and appear as small spicular or saccate wall outpouchings, single or more often multiple, mostly limited to the upper third of the ureter. The frequent association of these lesions with transitional cell carcinoma of the urinary tract is a problem of great clinical interest since they might represent a preneoplastic manifestation. The authors report on 16 patients with pseudodiverticula, 6 of whom (37.5%) affected with benign prostatic hyperplasia, 4 (25%) with synchronous or metachronous vesical neoplasm and 3 with renal stones. The remaining three patients were affected respectively with vesicoureteral reflux, neurogenic bladder and ureteropelvic junction obstruction. All patients were men over 46 years old. Ureteral involvement was bilateral in 50% of patients. The radiologic pattern consisted of small marginal outpouchings 1-3 mm in diameter, whose demonstration requires good contrast opacification and ureter distension. Pseudodiverticula were always localized in the upper third of the ureter and were multiple in 15/16 cases. Anatomical-histologic studies showed that pseudodiverticula result from hyperplastic-type proliferation of lung epithelium in the ureteral submucosa. Our observations do not confirm literature data on the frequent association between pseudodiverticula and transitional cell carcinoma because of the common presence, in our patients, of other non-neoplastic urinary conditions. The patients with benign hyperplasia of the ureteral epithelium cannot be excluded to be a risk group for cancer, even though no precise confirmation exists. The best advice is to carefully follow-up the patients with ureteral pseudodiverticula, clinically and with IVP.

[Carcinoma of the renal pelvis and ureter following bladder carcinoma]

We followed 135 primary bladder carcinoma patients for at least 3 years. Subsequent carcinomas of the upper urinary tract were found in 5 patients (3.7 per cent) an average of 67 months after an initial treatment of the bladder tumors. Two patients underwent radical cystectomy and the remaining 3 patients received transurethral resections or partial cystectomy five to seven times for bladder lesions. Primary bladder tumor was multiple in all and one of them was accompanied by carcinoma in situ in the bladder and urethra. Except for one patient who presented with gross hematuria, four patients had no symptoms referable to the upper urinary tract tumor. However two of them had high stage disease. Positive urinary cytology was observed in only one patient. All patients underwent nephroureterectomy and the four got well but one died of acute heart failure. Regular urinary cytology and IVP should be done for an extended period of time for early detection of renal pelvic and ureter cancers in patients who had multiple and recurrent bladder cancers.

Fibroepithelial ureteral polyps and urolithiasis

Fibroepithelial polyps are the most common benign tumor of the ureter. Most of the literature regarding their cause ascribes it to chronic infection. These publications, however, show that the majority of such cases never were associated with a documented urinary tract infection. Fibroepithelial polyps appear with equal frequency in male and female subjects and are found in all age groups including children, in contrast to what would have been expected with an infectious cause. Four histologically confirmed cases of fibroepithelial polyps were associated with chronic inflammation of the upper urinary tract related to the presence of calculi and/or Double J ureteral stents. All patients were managed successfully by endoscopic means, preserving renal function. Fibroepithelial ureteral polyps may be associated with urolithiasis, which serves as a source of chronic inflammation. A review of the literature is presented and supports these observations.

Adenomatous polyp at the ureterocaecal anastomosis

A case of adenomatous polyp occurring at a ureterocaecal anastomosis, 25 years after urinary diversion following a total cystectomy for carcinoma of the bladder, is reported. Bilateral nephrectomy for chronic pyelonephritis was carried out 25 years after the initial surgery and, following this, a sinus formed at the incision at the right loin. A sinogram showed contrast filling the right ureter and caecum, and outlined a lobulated filling defect at the ureterocaecal anastomosis. Subsequent histology revealed a dysplastic tubulovillous adenoma. The clinical presentation and management of tumours at the ureterointestinal junction are discussed.

[Carcinoma of the residual ureter many years after nephrectomy: an evasive cause of hematuria and a high risk tumor]

Any of the diseases of the upper urinary tract (lithiasis, tumor or fistula) can develop in the residual distal ureteral stump after simple or radical nephrectomy. It may take months or years before they manifest since this segment of the ureter is not involved in urinary function and is generally not visible on the IVP or US. These circumstances lead to difficulties and diagnostic errors and considerable delay in instituting appropriate treatment. Two patients with tumor of the residual ureteral stump are described. One had undergone simple nephrectomy for renal tuberculosis 38 years earlier and the other for a urothelial tumor 10 years ago. The delay in diagnosing the cause of these patients' symptoms prompted us to review the literature on the diseases of the ureteral stump, a subject that is little known and represents a challenge to the urologist.

[Nephrogenic adenoma of the ureter: a case report]

A 27-year-old male with nephrogenic adenoma of the ureter complicating urolithiasis is reported. Nephrogenic adenoma of the ureter is extremely rare, and this case is the sixth reported in Japan. The lesion was found at the site of the stone in the left ureter. Histopathologically, the tumor consisted of ducts resembling uriniferous tubules, and no signs of malignancy were noted. The cause of nephrogenic adenoma is considered to be metaplastic reaction to stimulation by stones and inflammation.

[Primary squamous cell carcinoma of the ureter: report of a case]

A case of squamous cell carcinoma of the ureter in a 63-year-old female is reported. Right hydronephrosis was found by examination of duodenal ulcer. Ureteroscopy and biopsy revealed squamous cell carcinoma (SCC) of the lower ureter. Total nephroureterectomy with a bladder cuff was performed. Pathological diagnosis was SCC pT3 G2 INF beta pL1 pV0 pR0. Three cycles of chemotherapy were performed postoperatively with bleomycin, methotrexate and cisplatin. Fifty-three cases of primary ureteral squamous cell carcinoma from the Japanese literature are reviewed and characteristic clinical figures of the tumor are discussed.

[Primary tumor of the ureteral stump following nephrectomy for non-malignant disease. A case report]

Primary tumor in the ureteral stump is rare. A 66-year-old woman visited our hospital because of microscopic hematuria. She had undergone right nephrectomy for the contracted kidney 36 years ago. Intravenous pyelography and cystoscopy showed no positive findings for hematuria. But urine cytology indicated class V. The flexible ureterorenoscopy disclosed a nonpapillary sessile tumor in the ureteral stump. We also did the biopsy of the tumor under the direct vision before open surgery. The specimen showed transitional cell carcinoma, grade 3. The ureteral stump was successfully removed. The flexible ureterorenoscopy was most useful for the diagnosis in this case.