李宗叡、楊啟瑞

中國醫藥大學附設醫院 泌尿部

Tzung-Ruei Li, Chi-Rei Yan

Department of Urology, China Medical University Hospital, Taichung, Taiwan

 

The gold standard treatment of upper tract urothelial carcinoma(UTUC) is nephroureterectomy. However, in the selected patients like solitary kidney, poor renal function or other conditions, less invasive intervention could be considered. We presented a case of UTUC status post right of nephroureterectomy with left side recurrence. Further ureteral catheterization with BCG was done for the salvage therapy. Prolonged recurrence-free time seemed prominent after BCG-acquired infection.

 

A 68 year-old male with benign prostate hyperplasia came to our clinic due to the persistent painless hematuria in 2014. Cytology showed malignancy, in favor of high grade urothelial cell carcinoma(UC). Further retrograde pyelography showed right pelvis filling defect, and right ureteroscope showed papillary tumor, further biopsy showed high grade UC. He then received right nephroureterectomy with bladder cuff excision as the standard treatment. Further pathology revealed pT3N0M0. However, following up urine cytology showed atypia several times. He then received chemotherapy with Gemcitabine and carboplatin. He had bladder tumor recurrence over dome in 2015, and further transurethral resection of bladder tumor showed non-invasive papillary UC, T1 high grade. He then started BCG intravesical instillation for 2 cycles. However, UC was still found from cytology and biopsy. Further left ureteroscope showed a low third papillary tumor, further pathology showed non-invasive papillary UC, high grade, T1. Left nephroureterectomy with cystectomy was suggest, but he refused the surgery, which would lead to poor life quality. He then received distal ureterotomy and ureteroneocystostomy in 2017/3. However, urine cytology showed positive for malignancy in 2017/10. Further MRI showed left renal pelvis tumor. Due to the tumor recurrence, he started to receive ureteral catheter (5fr) instillation therapy. We inserted the catheter to the pelvis in operation room, and collected cytology. We then fixed the ureteral stent together with the Foley catheter. In the ward, chemotherapy/BCG instillation was performed through the open end of ureteral catheter, and then was removed. He had received 3 times of BCG, 4 times of mitomycin (due to stock out of BCG), 5 times of epirubicin this year. However, cytology still revealed malignancy. He received 2 times of BCG again in 2019/7. Nocturnal fever with sweating happened then. Further urine culture showed acid-fast stain positive, and culture showed Mycobacteria tuberculosis complex. BCG induced infection was favored. Fever was control after antibiotics use, and further series of culture showed no tuberculosis growth. However, series of cytology until now all showed negative (2020/2/18). Further image study also showed no tumor recurrence, with only granulation tissue, which proved by CT guided biopsy. No deterioration of renal function was noted.

The literature regarding the intravesical chemotherapy or immunotherapy to the post tumor resection of UTUC is scarce. Previous studies showed recurrence-free survival time was 6.01 months; and the 1-year progression-free rate was 87%. However, the patient number was in limit numbers. We found the short-term advantage for the disease control of the BCG instillation after BCG infection in this case. Salvage chemotherapy or immunotherapy instillation might be considered in the selected patients.