個案報告:尿路上皮癌

蔡宏偉¹ 、李致樵 ¹

¹台灣基督長老教會馬偕醫療財團法人馬偕紀念醫院泌尿科

Urethral carcinoma: a case report

Hung Wei Tsai¹、Chih Chiao Lee ¹

¹Department of Urology, MacKay Memorial Hospital, Taipei, Taiwan

Introduction:

Upper urinary tract carcinomas (UTUCs) make up only 5-10% of urothelial tumors. The majority of UTUCs are presented in a single renal unit, although up to 5% of patients have bilateral disease. Disease recurrence after treatment involves the bladder in 22-47% of cases and the contralateral upper tract in 2-6%. Patients treated with bladder-sparing surgeries and intravesical immunotherapy with bacillus Calmette-Guérin (BCG) had a 7.5% possibility of developing a UTUC. Conversely, the incidence of UTUC in patients, who underwent radical cystectomy because of muscle-invasive bladder cancer is 3-5% [1].

Case description:

This 68-year-old female with history of ESRD under H/D, left putamen ICH, and hypertention was first presented with gross hematuria off and on for several months. Urine analysis showed RBC: Numerous/HPF. Kidney echo revealed bilateral renal stones and right hydronephrosis. Abdominal CT was arranged. Irregular mucosal thickening of the almost whole urinary bladder and about 9mm enhancing soft tissue in right middle ureter were found, suspected urothelial carcinoma of right ureter and bladder. Cystoscopy was done and diffused bladder tumor were found in bladder. Thus, laparoscopic right nephroureterectomy was done first. Pathology showed invasive urothelial carcinoma. After 3 months, open cystectomy with right distal ureterectomy was done. However, a followed-up abdominal CT 6 months later revealed one new developed 2.6cm soft tissue nodule in distal left ureter and left hydronephrosis and hydroureter. Laparotomy left nephroureterectomy was arranged and the pathology also showed invasive urothelial carcinoma. She was under OPD follow-up now.

Discussion and Summary:

Tumors that originate in the upper ureter occasionally can be managed endoscopically, if low-grade, but more commonly are treated with nephroureterectomy with a bladder cuff, with or without perioperative intravesical chemotherapy, plus regional lymphadenectomy for high-grade tumors. Neoadjuvant chemotherapy should be considered in select patients, including patients with retroperitoneal lymphadenopathy; bulky (>3 cm) high-grade tumor; sessile histology; or suspected parenchymal invasion. A portion of the bladder is removed to ensure complete removal of the entire intramural ureter. Tumors that originate in the mid portion may also be managed differently depending on grade. Low-grade tumors may be managed by endoscopic resection or excision, with or without perioperative intravesical chemotherapy, followed by ureteroureterostomy, or segmental or complete ureterectomy, or ileal ureter interposition may also be an option in highly selected patients. High-grade lesions are generally managed with nephroureterectomy with a bladder cuff, with or without perioperative intravesical chemotherapy, and regional lymphadenectomy. Neoadjuvant chemotherapy can be considered in select patients. Distal ureteral tumors may be managed with a distal ureterectomy and regional lymphadenectomy if high grade followed by reimplantation of the ureter (preferred if clinically feasible), with or without perioperative intravesical chemotherapy. Other primary treatment options include endoscopic resection for low-grade tumors, or, in some cases, a nephroureterectomy with a bladder cuff, and regional lymphadenectomy if high grade. Neoadjuvant chemotherapy can be considered for select patients with distal ureteral tumors following distal ureterectomy or the nephroureterectomy with bladder cuff [2].