隱藏在輸尿管狹窄和淋巴細胞浸潤的泌尿上皮癌：常見臨床困境

唐慈翊^1-2、溫聖辰^1,2

高雄醫學大學附設醫院²泌尿科

 高雄醫學大學醫學院³泌尿學科

From Lymphoid Cells to UTUC: A Case of Urothelial Carcinoma Masked by Ureteral stricture

Tsz-Yi Tang^1-2, Sheng-Chen Wen ^1,2

¹Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan;

²Department of Urology, Kaohsiung Medical University, Kaohsiung, Taiwan

Introduction 

            This case report presents a 65-year-old female who was initially evaluated for incidental left hydronephrosis, suspected to be due to simple stenosis or lymphoma. However, further assessments ultimately revealed a diagnosis of high-grade urothelial carcinoma.

Case Report 

            A 65-year-old female without any underlying disease was admitted with incidentally discovered left hydronephrosis. Initial evaluation included a left ureteroscopic (URS) tumor biopsy, which revealed dysplasia and did not find papillary tumor during URS survey. A repeat URS biopsy showed only lymphoid cell infiltration, and there was no significant increase in hydronephrosis during these two months. Further abdominal CT demonstrated a soft tissue lesion in the left upper ureter, likely causing hydronephrosis and hydroureter, with suspicion of a urothelial tumor (Figure 1A, 1B). Differential diagnoses included hematoma; however, no lymphadenopathy was noted. After discussion, the plan was to perform ureteroureterostomy with intraoperative frozen section analysis. During surgery, severe adhesions between the left ureter and the abdominal aorta, along with fibrotic tissue encasing the ureter, were observed. Therefore, the procedure was changed to nephroureterectomy and excision of the bladder cuff. Pathology revealed infiltrating high-grade urothelial carcinoma, high grade tumor, staged as pT3N0, with invasion into the periureteric fat. Kidney pathology showed focal global glomerulosclerosis, tubal thyroidization, interstitial fibrosis, and chronic inflammation with lymphoid aggregation. Same lymphoid cell filtration pattern was noted as previous URS biopsy specimen. The patient subsequently received adjuvant chemotherapy post-surgery.

Conclusion 

This case underscores the importance of considering malignancy in the presence of lymphocytic infiltration in the ureter, particularly when severe adhesions surrounding the ureter. In such scenarios, nephrectomy may be indicated rather than subjecting the patient to multiple survey and biopsies, which may compromise the timely initiation of appropriate treatment.