卵巢癌合併輸尿管侵犯：案例報告及文獻回顧

陳冠宇^1,2、陳順郎^1,2、陳文榮^1,2、謝佐宜^1,2、楊旻鑫^1,2、宋文瑋^1,2、王紹全^1,2、何承儒^1,2

¹中山醫學大學附設醫院泌尿科；²中山醫學大學醫學院

Ovarian cancer with ureter invasion: a case report and literature review

Kuan Yu Chen^1,2, Sung Lang Chen^1,2, Wen Jung Chen^1,2, Tuzo Yi Hsieh^1,2, Ming Hsin Yang^1,2, Wen Wei Sung^1,2, Shao Chuan Wang^1,2, Cheng Ju Ho^1,2

¹Department of Urology, Chung Shan Medical University Hospital, Taichung, Taiwan.  ²School of Medicine, Chung Shan Medical University Hospital, Taichung,

Introduction:

Ovarian cancer, particularly clear cell carcinoma, is known for its potential to spread beyond the ovaries, often involving the peritoneal cavity and adjacent structures. While direct invasion of the ureter is relatively rare, it can lead to complications such as hydronephrosis, significantly impacting patient prognosis and treatment options. The clinical manifestations of ureteral invasion often include symptoms related to obstructive uropathy, such as flank pain, hematuria, and, in severe cases, acute kidney injury. However, due to the insidious nature of ovarian cancer, these symptoms may be absent or masked by other abdominal complaints. Diagnostic evaluation typically involves imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI), which can reveal the extent of pelvic disease, hydronephrosis, and direct tumor invasion of the ureter. In cases where hydronephrosis is present, a retrograde pyelogram or ureteroscopy may be necessary for further assessment, and a biopsy can confirm malignancy within the ureteral wall. Recent advances in diagnostic imaging, such as positron emission tomography (PET) combined with CT, have improved the detection of small metastatic lesions, aiding in more precise surgical planning.

Management of ovarian cancer with ureteral invasion requires a multidisciplinary approach. Primary treatment often involves cytoreductive surgery, aiming to remove as much tumor as possible. When ureteral involvement is identified, options include segmental ureterectomy with reimplantation or ureteroneocystostomy in cases of extensive disease. Adjuvant chemotherapy with agents such as carboplatin and paclitaxel is typically indicated, given the aggressive nature of these tumors. In instances where direct surgical resection is not feasible, palliative measures, including ureteral stenting or percutaneous nephrostomy, can alleviate symptoms and preserve renal function.

Here we are going to present a case diagnosed with ovarian cancer with ureter invasion.

Case presentation:

  This is a 43-year-old woman with a past medical history of endometrioma status post laparoscopic cystectomy in 2023-03. Her obstetrics and gynecology history with gravidity 1 and parity 1 (via Cesarean delivery), menarche at 12 years old, last menstrual period on 2024-9-23. This time, she noticed a palpable abdominal mass for two months and went to a local hospital for evaluation where sonography showed an ovarian tumor. She was referred to our hospital for further evaluation. Transvaginal ultrasound showed a uterus sized 7.80 x 4.60 cm, and bilateral ovarian tumors that a left complex ovarian tumor sized 8.9*6.0 cm without flow and a right complex ovarian tumor sized 11.2*8.9 cm without flow. She denied fever, dizziness, dyspnea, chest pain, chest tightness, abdominal pain, change of bowel habits, bloody or tarry stool, hematuria, flank pain, dysuria, urinary frequency, urinary urgency, or urinary incontinence. After discussion with the patient, she had laparoscopic right salpingo-oophorectomy, left ovarian cystectomy, and adhesiolysis on 2024-09-19. A frozen section of ovary biopsy was performed and showed suspected malignancy. The formal pathology report showed ovarian clear cell carcinoma, pT1bNxMx. The tumor maker on 20240930 showed CA19-9:45.1 U/mL and CA-125:89.5U/mL. She received one course of chemotherapy with Paclitaxel and carboplatin on 113/10/1. Abdomen CT scan on 2024-10-09 showed hydroureteronephrosis of the right kidney above the middle-third ureter and a cystic lesion at the left adnexa with marginal enhancement, high-density sedimentation and fluid-fluid level of about 4.6cm with focal calcified lesion along the right pelvic wall [Figure 1-3]. After discussion with the patient and her family, a secondary debulking operation and bilateral diagnostic ureteroscopy were arranged on 2024/10/11. Torture of the right lower third ureter was noticed during ureteroscopy and rupture of the ureter was found along the Terumo guidewire [Figure 4-6]. Laparotomy debulking surgery confirmed the tumor invaded the right ureter and ruptured of the right ureter was noted. In addition, a suspicious tumor invasion of the sigmoid colon was found, and an excision biopsy was performed. After an explanation to the family, right ureterovesical reimplantation and psoas hitch were performed

Discussion:

We explore documented cases of ovarian cancer with ureteral invasion, examining the clinical presentations, diagnostic methods, management strategies, and outcomes associated with this condition. An early study explored the role of urinary tract surgery in ovarian cancer treatment. Berek et al. ^[1] analyzed 24 patients with advanced ovarian cancer who underwent lower urinary tract resection as part of their cytoreductive surgery between 1960 and 1979. Ureteroneocystostomy (ureteral reimplantation) was performed in two cases. Patients without preoperative ureteral obstruction had a mean survival of 27.6 months, whereas those with obstruction had a mean survival of only 8.9 months. This study suggests that pre-existing hydronephrosis may be a poor prognostic factor. Complications occurred in about 25% of cases, including ureteral stricture, pyelonephritis, and urinary leaks.

  Kim et al.^[2] reviewed data from 3226 ovarian cancer patients who underwent cytoreductive surgery between 2000 and 2021. Out of these, 56 patients (1.7%) required ureteral reconstruction. Ureteroneocystostomy with direct reimplantation was the most common procedure (51.8%), followed by ureteroureterostomy (32.1%) and psoas hitch (8.9%). Complete cytoreduction was achieved in 83.9% of cases. The 5-year overall survival was 89.5% in primary ovarian cancer cases and 64.0% in recurrent cases. Notably, postoperative complications included hydronephrosis (33.9%), urinary tract infections (35.7%), and ureteral strictures (3.6%). While complications like ureteral anastomotic leaks and renal failure were observed, they were managed successfully with interventions such as stenting and antibiotic therapy. There was no significant impact on the timing of adjuvant chemotherapy, with most patients beginning treatment within 24 days post-surgery.

  Faidley et al.^[3] examined 2580 ovarian cancer patients treated from 2004 to 2019, identifying 190 patients (7.4%) who developed hydronephrosis due to malignant ureteral obstruction. The 190 patients were treated with retrograde ureteral stents (RUS) in 74.4% of cases and percutaneous nephrostomy (PCN) in 25.6%. Despite treatment, hydronephrosis resolution occurred in only 27% of patients. Resolution was more likely when patients had lower FIGO stages (I/II) and underwent surgical interventions like tumor debulking or ureterolysis. Initial hydronephrosis treatment failed in 28 patients. RUS showed slightly higher failure rates (19.3%) than PCN (16.8%), especially in cases with renal atrophy, which increased failure risk by over threefold. The study highlighted the potential underutilization of ureteral reconstruction during debulking surgery, as only 7 patients underwent reconstructive surgery.

  The prognosis of patients with ovarian cancer involving the ureter is generally poorer compared to those without ureteral involvement, as it signifies a more advanced disease stage and potential for recurrence. Studies suggest that patients with ureteral invasion may have reduced overall survival rates, underscoring the importance of aggressive surgical management and vigilant post-operative follow-up. The role of novel therapies, including targeted agents and immunotherapy, in managing such cases remains an active research area, with early data indicating potential benefits.

Conclusion:

  While ureteral invasion in ovarian cancer is rare, its occurrence poses significant clinical challenges and worsens patient outcomes. Prompt diagnosis and comprehensive management, including advanced surgical techniques, are essential in mitigating the impact on patient prognosis. Further research is warranted to explore the molecular mechanisms underlying ureteral invasion and to develop targeted therapies that may improve survival outcomes in this subset of ovarian cancer patients.