333
CASE REPORTS
and transfixed with 2/0 chromic catgut. There was no pathology in the sigmoid colon. The patient made an uneventful recovery and was free from dysuria. Histologically the kidney showed features of xanthogranulomatous pyelonephritis and the ureter showed chronic inflammatory fibrosis.
Comment
The classical symptoms of ureteroenteric fistula, such as pneumaturia, faecaluria and diarrhoea (Heney and Crooks, 1984), were not seen in our patient, probably because of the impacted ureteric calculus. References Heney, N. M. and Crooks, K. K. (1984). Ureterocolic fistula. Br. J. Urol., 56,225-226. Kar, A., Angwafo, F. F. and Jhunjhuwala, J. S. (1984). Ureteroarterial and ureterosigmoid fistula associated with polyethylene ureteral stents. J. Urol., 132,755-757. Requests for reprints to: K. P. Patil, Department of Urology, Asir Central Hospital, P.O. Box 34, Abha, Saudi Arabia.
Fig. Retrograde ureteropyelogram showing fistulous tract and the ureteric stone.
dysuria. There were no other urinary symptoms and clinical examination was unremarkable. The urine contained significant gram-negative bacteria but no acid fast bacilli. Investigations revealed a non-functioning left kidney, with a 5-cm renal stone and a 1.5-cm ureteric stonejust below the left sacroiliac joint. The right kidney showed compensatory hypertrophy. Ultrasonography revealed a small left kidney with a dilated collecting system. At cystoscopy a 6 F ureteric catheter was passed into the left ureter and was initially held up at the 8-cm level, but subsequently could be advanced up to the kidney. The retrograde ureteropyelogram showed a dilated pelvicaliceal system with a calculus in the upper major infundibulum. The ureter was dilated up to the calculus (Fig.), just proximal to which the dye was seen passing medially into the colon. A barium enema showed that the sigmoid loop was tethered at the level of the ureteric calculus. Sigmoidoscopy was normal. On exploration, the kidney was found to be adherent to the surrounding tissue and the ureter was dilated and thickened up to the site of the calculus. A small fistulous tract was seen communicating with the sigmoid colon. Nephrectomy was performed with excision of the ureter distal to the impacted stone. The tract was disconnected
Choriocarcinoma Arising in Transitional Cell Carcinoma of the Bladder A. L. FOWLER, ELIZABETH HALL and G. REES, Departmentsof Pathology and Oncology,Royal United Hospital, Bath
Case Report A 74-year-old man was referred for radical radiotherapy for a T3 transitional cell carcinoma. After the start of radiotherapy he complained of breast tenderness and was noted to have bilateral gynaecomastia (Campo et al., 1989). The serum beta-HCG concentration was 15,000 iu/l. His gynaecomastia became more prominent and shortly after completing radiotherapy there was evidence of distant metastases and consequent rapid decline in his condition. Owing to the possibility of this being a germ cell tumour he was treated with etoposide but with no response. At this stage his beta-HCG had risen to 75,000 iu/l. At autopsy there was evidence of spread to neck nodes, thyroid, lungs and mediastinum, gut, kidney, adrenal glands and liver as well as spinal involvement, scalp, meningeal and choroidal spread. The overall tumour bulk was extremely large.
334
BRITISH JOURNAL OF UROLOGY
Comment About 12 cases of choriocarcinoma arising in bladder tumour have been reported since 1904. A suggested mechanism is “retrodifferentiation” (Abratt et al., 1959) during progression of the tumour. This is not the same as primary choriocarcinoma arising in the bladder from germinal rests. Non-gestational choriocarcinoma does not show the excellent response to chemotherapy seen in the gestational type. Various combinations, including platinum compounds, have not been effective in previously reported cases (Burry et al., 1986). Measurement of beta-HCG may be a useful way of detecting these aggressive tumours early so that treatment can be suitably adjusted, and for deciding prognosis.
References Fig, Poorly differentiated urothelial carcinoma of bladder with cells producing HCG (arrows). (Anti-human chorionic gonadotrophin (Avidin Biotin Complex) x 128).
A serial increase in Positive staining for beta-HCG, together with the appearance of choriocarcinoma cells, was demonstrated in successive biopsies (Fig.). The original biopsy showed absence of both.
Abratt, R. P., Temple-Camp, C. R. E. and Pontin, A. R. (1989). Choriocarcinoma and transitional cell carcinoma of the b1adder-a case report and review of the clinical evolution of disease in reported cases. Eur. J. Surg. Oncol., 15, 149-153. Burry,A. F.,Munn,S. F.,Arnold, E. P.eial. (1986).Trophoblastic metaplasia in urothelial carcinoma of the bladder. Br. J. Urol., 58, 143-146. Camp, E., Algaba, F., Palacin, A. e t d . (1989). Placental proteins 63,2497-2504. in high-grade urothelial neoplasms, cancer, Requests for reprints to: A. L. Fowler, 42B Cautley Avenue, Clapham, London SW4 9HU.
CASE REPORTS
and transfixed with 2/0 chromic catgut. There was no pathology in the sigmoid colon. The patient made an uneventful recovery and was free from dysuria. Histologically the kidney showed features of xanthogranulomatous pyelonephritis and the ureter showed chronic inflammatory fibrosis.
Comment
The classical symptoms of ureteroenteric fistula, such as pneumaturia, faecaluria and diarrhoea (Heney and Crooks, 1984), were not seen in our patient, probably because of the impacted ureteric calculus. References Heney, N. M. and Crooks, K. K. (1984). Ureterocolic fistula. Br. J. Urol., 56,225-226. Kar, A., Angwafo, F. F. and Jhunjhuwala, J. S. (1984). Ureteroarterial and ureterosigmoid fistula associated with polyethylene ureteral stents. J. Urol., 132,755-757. Requests for reprints to: K. P. Patil, Department of Urology, Asir Central Hospital, P.O. Box 34, Abha, Saudi Arabia.
Fig. Retrograde ureteropyelogram showing fistulous tract and the ureteric stone.
dysuria. There were no other urinary symptoms and clinical examination was unremarkable. The urine contained significant gram-negative bacteria but no acid fast bacilli. Investigations revealed a non-functioning left kidney, with a 5-cm renal stone and a 1.5-cm ureteric stonejust below the left sacroiliac joint. The right kidney showed compensatory hypertrophy. Ultrasonography revealed a small left kidney with a dilated collecting system. At cystoscopy a 6 F ureteric catheter was passed into the left ureter and was initially held up at the 8-cm level, but subsequently could be advanced up to the kidney. The retrograde ureteropyelogram showed a dilated pelvicaliceal system with a calculus in the upper major infundibulum. The ureter was dilated up to the calculus (Fig.), just proximal to which the dye was seen passing medially into the colon. A barium enema showed that the sigmoid loop was tethered at the level of the ureteric calculus. Sigmoidoscopy was normal. On exploration, the kidney was found to be adherent to the surrounding tissue and the ureter was dilated and thickened up to the site of the calculus. A small fistulous tract was seen communicating with the sigmoid colon. Nephrectomy was performed with excision of the ureter distal to the impacted stone. The tract was disconnected
Choriocarcinoma Arising in Transitional Cell Carcinoma of the Bladder A. L. FOWLER, ELIZABETH HALL and G. REES, Departmentsof Pathology and Oncology,Royal United Hospital, Bath
Case Report A 74-year-old man was referred for radical radiotherapy for a T3 transitional cell carcinoma. After the start of radiotherapy he complained of breast tenderness and was noted to have bilateral gynaecomastia (Campo et al., 1989). The serum beta-HCG concentration was 15,000 iu/l. His gynaecomastia became more prominent and shortly after completing radiotherapy there was evidence of distant metastases and consequent rapid decline in his condition. Owing to the possibility of this being a germ cell tumour he was treated with etoposide but with no response. At this stage his beta-HCG had risen to 75,000 iu/l. At autopsy there was evidence of spread to neck nodes, thyroid, lungs and mediastinum, gut, kidney, adrenal glands and liver as well as spinal involvement, scalp, meningeal and choroidal spread. The overall tumour bulk was extremely large.
334
BRITISH JOURNAL OF UROLOGY
Comment About 12 cases of choriocarcinoma arising in bladder tumour have been reported since 1904. A suggested mechanism is “retrodifferentiation” (Abratt et al., 1959) during progression of the tumour. This is not the same as primary choriocarcinoma arising in the bladder from germinal rests. Non-gestational choriocarcinoma does not show the excellent response to chemotherapy seen in the gestational type. Various combinations, including platinum compounds, have not been effective in previously reported cases (Burry et al., 1986). Measurement of beta-HCG may be a useful way of detecting these aggressive tumours early so that treatment can be suitably adjusted, and for deciding prognosis.
References Fig, Poorly differentiated urothelial carcinoma of bladder with cells producing HCG (arrows). (Anti-human chorionic gonadotrophin (Avidin Biotin Complex) x 128).
A serial increase in Positive staining for beta-HCG, together with the appearance of choriocarcinoma cells, was demonstrated in successive biopsies (Fig.). The original biopsy showed absence of both.
Abratt, R. P., Temple-Camp, C. R. E. and Pontin, A. R. (1989). Choriocarcinoma and transitional cell carcinoma of the b1adder-a case report and review of the clinical evolution of disease in reported cases. Eur. J. Surg. Oncol., 15, 149-153. Burry,A. F.,Munn,S. F.,Arnold, E. P.eial. (1986).Trophoblastic metaplasia in urothelial carcinoma of the bladder. Br. J. Urol., 58, 143-146. Camp, E., Algaba, F., Palacin, A. e t d . (1989). Placental proteins 63,2497-2504. in high-grade urothelial neoplasms, cancer, Requests for reprints to: A. L. Fowler, 42B Cautley Avenue, Clapham, London SW4 9HU.
