Clinical Radiology (1992) 46, 354 356
Case Report: Intra-Ureteric Metastasis From Testicular Teratoma R. J. DAVIES, D. M. K I N G and W. F. H E N D R Y *
Departments of Diagnostic Radiology and * Urology, Royal Marsden Hospital, London The case report of a patient found to have intra-ureteric metastatic tcratoma is presented. This has not to our knowledge previously been reported in the literature. Davies, R.J., King, D.M. & Hendry, W.F. (1992). Clinical Radiology 46, 35:~ 356. Case Report: Intra-Ureteric Metastasis F r o m Testicular T e r a t o m a
CASE R E P O R T A 24-year-old m a n presenting with metastatic malignant teratoma of the testis was admitted for chemotherapy. Staging computed tomography (CT) scans of the abdomen showed para-aortic node disease compressing the inferior vena cava together with dilatation of the right ureter (Fig. 1). Associated right hydronephrosis was attributed to obstruction by the lymph node mass. He was treated by conventional cytotoxic chemotherapy and cystoscopic right ureteric stent insertion. At completion of chemotherapy, cystic para-aortic lymph node enlargement and right hydronephrosis remained. His clinical course was complicated by neutropenia and venous thrombosis and para-aortic lymph node dissection was, therefore, deferred for 4 months. A further pre-operative CT delineated the residual lymph node abnormality and showed persisting dilatation of a thick walled ureter (Fig. 2). At operation a cystic mass was adherent to, and compressing, the right ureter and was resected. There was no record of ureteric trauma during the procedure. The stent was removed at the end of the operation. Histological examination of the resected node mass showed necrotic tissue and differentiated teratoma. Subsequent CT and urography showed no resolution of the hydronephrosis and a filling defect in the right ureter was suspected at this time (Fig. 3). A retrograde ureterogram (Fig. 4) confirmed an irregular filling defect in the upper ureter which was over several centimetres of ureteric lumen but was centred within the ureter a few centimetres below the site of lymph node enlargement. Exploration and open biopsy of the intraluminal mass was performed and, although at operation it was thought to be inflammatory material associated with the stent, the mass proved to be teratoma histologically.
In consequence a nephro-ureterectomy was necessary and pathological examination of the operative specimen confirmed intra-ureteric differentiated teratoma (Fig. 5). The external surface of the ureter appeared normal and there was no breach of the ureteric wall, the t u m o u r being largely free within the ureteric lumen and being adherent only to the mucosa. The patient is currently well 18 months post-operatively and in complete remission.
DISCUSSION Tumours of the ureter are rare and account for only 2.5-5% of all uro-epithelial tumours [1]. Intra-luminal filling defects within the ureter may be missed unless meticulous care is taken to display all parts of both ureters during urography. The value of CT in detecting ureteric tumours is well recognized and is more sensitive than intravenous urography if contiguous narrow sections and pre- and postenhancement scans are obtained [2]. On CT, ureteral tumours often appear as filling defects in the contrastfilled ureter. A b n o r m a l thickening of the wall of the ureter is occasionally visible and tumours sometimes enhance if scans are performed following rapid injection of intravenous contrast [2].
~!~ Fig. 1 - Initial staging C T with contrast showing para-aortic node enlargement between aorta and inferior vena cava (IVC) together with dilatation of the right ureter. Correspondence to: D. M. King, Consultant Radiologist, Royal Marsden Hospital, F u l h a m Road, L o n d o n SW3 6JJ.
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Fig. 2 C T 4 m o n t h s after completion of chemotherapy. A cystic enlarged para-aortic node persists and the right ureter has become more dilated and thick-walled.
I N T R A - U R E T E R I C METASTASIS F R O M T E S T I C U L A R T E R A T O M A
355
The presence of an intra-ureteric mass could have been suspected at an earlier stage in this patient (Fig. 2). Delayed diagnosis resulted from dilatation and low contrast density within the ureter and the features were thought at that time to be caused by extrinsic compression of the ureter by the enlarged para-aortic nodes and associated delayed excretion of contrast. When the hydronephrosis failed to resolve following nodal excision, attention was focussed on the CT appearances of the obstructed ureter which by now had become thick-walled and distended. The true cause was then appreciated (Fig. 2). Metastases to the ureter have been reported uncommonly from primary tumours of prostate, stomach, breast and lung [3]. Metastases from tumours originating outside the renal tract are typically serosal and initially appear on urography as smooth extrinsic impressions although intra-luminal spread can occur later. Direct extension of large carcinomas of the cervix and recto-
Fig. 4 Right retrograde ureterogram confirming an extensive intraureteric mass.
......
Fig. 3 IVU showing right hydronephrosis and a filling defect within the ureter projected below the transverse process of L3.
sigmoid into the lower ureter is also recognized, as is extension of l y m p h o m a into the ureter from adjacent enlarged para-aortic nodes. Adenocarcinoma of the kidney may give intra-luminal deposits in the ureter [4] whilst transitional cell tumours may present with multifocal disease in the bladder and ureters [5]. Whether or not these are metastases or synchronous tumours is not clear. It is interesting to speculate on possible routes by which a testicular teratoma could have metastasised to the right ureter. The proximity of the ureter to the adjacent paraaortic node disease clearly suggests the possibility of direct invasion of the wall of the ureter but there was no involvement or breach of the external surface of the ureter. Therefore blood-borne spread is perhaps most likely. Previous surgical dissection in the area may also be implicated as a factor by virtue of disturbance of adjacent veins and lymphatic anatomy. In conclusion, cases o f testicular teratoma metastasising to the ureter are bound to be extremely rare but
356
CLINICAL RADIOLOGY radiologists involved in staging CT scans in cases of testicular tumour should carefully scrutinize the ureters when hydronephrosis co-exists with lymph node enlargement.
REFERENCES
1 Mills C, Vaughan ED Jr. Carcinoma of the ureter: natural history, management and 5 year survival. Journal of Urology 1983;129:275 277. 2 Kenney PJ, Stanley RJ. Computed tomography of ureteral tumours. Journal of Computer Assisted Tomography 1987; 11(1): 102-107. 3 Ney C, Friedenberg RM (eds). Radiographic atlas of the genitourinary system. Pitman Medical Publishing, 1966:440 450. 4 Sargent JW. Ureteral metastasis from renal adenocarcinoma presenting a bizarre urogram. Journal of Urology 1960;83:97-99. 5 Gracia V, Bradfield EO. Simultaneous bilateral transitional cell carcinoma of the ureter: a case report. Journal of Urology 1958;79:925-928.
Fig. 5 Photograph of operative nephro-ureterectomy specimen showing obstructing tumour mass in lower ureter.
Case Report: Intra-Ureteric Metastasis From Testicular Teratoma R. J. DAVIES, D. M. K I N G and W. F. H E N D R Y *
Departments of Diagnostic Radiology and * Urology, Royal Marsden Hospital, London The case report of a patient found to have intra-ureteric metastatic tcratoma is presented. This has not to our knowledge previously been reported in the literature. Davies, R.J., King, D.M. & Hendry, W.F. (1992). Clinical Radiology 46, 35:~ 356. Case Report: Intra-Ureteric Metastasis F r o m Testicular T e r a t o m a
CASE R E P O R T A 24-year-old m a n presenting with metastatic malignant teratoma of the testis was admitted for chemotherapy. Staging computed tomography (CT) scans of the abdomen showed para-aortic node disease compressing the inferior vena cava together with dilatation of the right ureter (Fig. 1). Associated right hydronephrosis was attributed to obstruction by the lymph node mass. He was treated by conventional cytotoxic chemotherapy and cystoscopic right ureteric stent insertion. At completion of chemotherapy, cystic para-aortic lymph node enlargement and right hydronephrosis remained. His clinical course was complicated by neutropenia and venous thrombosis and para-aortic lymph node dissection was, therefore, deferred for 4 months. A further pre-operative CT delineated the residual lymph node abnormality and showed persisting dilatation of a thick walled ureter (Fig. 2). At operation a cystic mass was adherent to, and compressing, the right ureter and was resected. There was no record of ureteric trauma during the procedure. The stent was removed at the end of the operation. Histological examination of the resected node mass showed necrotic tissue and differentiated teratoma. Subsequent CT and urography showed no resolution of the hydronephrosis and a filling defect in the right ureter was suspected at this time (Fig. 3). A retrograde ureterogram (Fig. 4) confirmed an irregular filling defect in the upper ureter which was over several centimetres of ureteric lumen but was centred within the ureter a few centimetres below the site of lymph node enlargement. Exploration and open biopsy of the intraluminal mass was performed and, although at operation it was thought to be inflammatory material associated with the stent, the mass proved to be teratoma histologically.
In consequence a nephro-ureterectomy was necessary and pathological examination of the operative specimen confirmed intra-ureteric differentiated teratoma (Fig. 5). The external surface of the ureter appeared normal and there was no breach of the ureteric wall, the t u m o u r being largely free within the ureteric lumen and being adherent only to the mucosa. The patient is currently well 18 months post-operatively and in complete remission.
DISCUSSION Tumours of the ureter are rare and account for only 2.5-5% of all uro-epithelial tumours [1]. Intra-luminal filling defects within the ureter may be missed unless meticulous care is taken to display all parts of both ureters during urography. The value of CT in detecting ureteric tumours is well recognized and is more sensitive than intravenous urography if contiguous narrow sections and pre- and postenhancement scans are obtained [2]. On CT, ureteral tumours often appear as filling defects in the contrastfilled ureter. A b n o r m a l thickening of the wall of the ureter is occasionally visible and tumours sometimes enhance if scans are performed following rapid injection of intravenous contrast [2].
~!~ Fig. 1 - Initial staging C T with contrast showing para-aortic node enlargement between aorta and inferior vena cava (IVC) together with dilatation of the right ureter. Correspondence to: D. M. King, Consultant Radiologist, Royal Marsden Hospital, F u l h a m Road, L o n d o n SW3 6JJ.
=9¸ .........
i~ ~ ~: ~ ~ =~¸¸ :~:=
:i:~
~....
Fig. 2 C T 4 m o n t h s after completion of chemotherapy. A cystic enlarged para-aortic node persists and the right ureter has become more dilated and thick-walled.
I N T R A - U R E T E R I C METASTASIS F R O M T E S T I C U L A R T E R A T O M A
355
The presence of an intra-ureteric mass could have been suspected at an earlier stage in this patient (Fig. 2). Delayed diagnosis resulted from dilatation and low contrast density within the ureter and the features were thought at that time to be caused by extrinsic compression of the ureter by the enlarged para-aortic nodes and associated delayed excretion of contrast. When the hydronephrosis failed to resolve following nodal excision, attention was focussed on the CT appearances of the obstructed ureter which by now had become thick-walled and distended. The true cause was then appreciated (Fig. 2). Metastases to the ureter have been reported uncommonly from primary tumours of prostate, stomach, breast and lung [3]. Metastases from tumours originating outside the renal tract are typically serosal and initially appear on urography as smooth extrinsic impressions although intra-luminal spread can occur later. Direct extension of large carcinomas of the cervix and recto-
Fig. 4 Right retrograde ureterogram confirming an extensive intraureteric mass.
......
Fig. 3 IVU showing right hydronephrosis and a filling defect within the ureter projected below the transverse process of L3.
sigmoid into the lower ureter is also recognized, as is extension of l y m p h o m a into the ureter from adjacent enlarged para-aortic nodes. Adenocarcinoma of the kidney may give intra-luminal deposits in the ureter [4] whilst transitional cell tumours may present with multifocal disease in the bladder and ureters [5]. Whether or not these are metastases or synchronous tumours is not clear. It is interesting to speculate on possible routes by which a testicular teratoma could have metastasised to the right ureter. The proximity of the ureter to the adjacent paraaortic node disease clearly suggests the possibility of direct invasion of the wall of the ureter but there was no involvement or breach of the external surface of the ureter. Therefore blood-borne spread is perhaps most likely. Previous surgical dissection in the area may also be implicated as a factor by virtue of disturbance of adjacent veins and lymphatic anatomy. In conclusion, cases o f testicular teratoma metastasising to the ureter are bound to be extremely rare but
356
CLINICAL RADIOLOGY radiologists involved in staging CT scans in cases of testicular tumour should carefully scrutinize the ureters when hydronephrosis co-exists with lymph node enlargement.
REFERENCES
1 Mills C, Vaughan ED Jr. Carcinoma of the ureter: natural history, management and 5 year survival. Journal of Urology 1983;129:275 277. 2 Kenney PJ, Stanley RJ. Computed tomography of ureteral tumours. Journal of Computer Assisted Tomography 1987; 11(1): 102-107. 3 Ney C, Friedenberg RM (eds). Radiographic atlas of the genitourinary system. Pitman Medical Publishing, 1966:440 450. 4 Sargent JW. Ureteral metastasis from renal adenocarcinoma presenting a bizarre urogram. Journal of Urology 1960;83:97-99. 5 Gracia V, Bradfield EO. Simultaneous bilateral transitional cell carcinoma of the ureter: a case report. Journal of Urology 1958;79:925-928.
Fig. 5 Photograph of operative nephro-ureterectomy specimen showing obstructing tumour mass in lower ureter.
