TRANSITIONAL CELL CARCINOMA OF ILEAL LOOP FOLLOWING

ZEW WAJSMAN,

CYSTECTOMY

M.D.

GEORGE

BAUMGARTNER,

CLAUDE

MERRIN,

M.D

M.D.

From Department of Urology, Roswell Park Memorial Institute, New York State Department of Health, and State University of New York at Buffalo, New York

ABSTRACT in an ileal loop.

This is the second case reported in the literature involving The case is described and the literature reviewed.

Metastasis of transitional cell carcinoma in the ileal mucosa is rare, and no mention of this has been found in the English literature until very recently when Grabstald’ reported transitional cell metastasis in the stoma of an ileal loop. We report a second such case of metastasis following cystectomy and nephroureterectomy for carcinoma of the renal pelvis and bladder. Case Report In 1963 transitional cell carcinoma of the bladder developed in a fifty-seven-year-old white

transitional

cell carcinoma

woman. She was treated with transurethral resection until 1965 when, in view of progression of her disease, she received radiation therapy (6,400 rads) to the bladder. In February, 1967, because of postradiation recurrence, she was referred to Roswell Park Memorial Institute. In April, 1967, she underwent total cystectomy with ileal loop diversion. In July, 1970, follow-up intravenous pyelogram and loopogram revealed a filling defect in the right renal pelvis (Fig. 1A). The patient was explored, and a right nephroureterectomy was performed. The pathologic report was papillary

FIGURE 1. Loopogram showing (A) big filling defect in ureteropelvic junction of right kidney; (B)filling defect in loop.

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transitional cell carcinoma, grade I. The distal part of the ureter was free of tumor. In April, 1972, transitory gross, painless hematuria developed. A complete re-evaluation failed to demonstrate any lesion. In October, 1973, another episode of gross, painless hematuria occurred. This time the work-up revealed a space-occupying lesion in the loop (Fig. 1B). Exploratory laparotomy revealed a mass inside the loop. No evidence of metastatic disease outside the loop was apparent. The loop was opened, and a papillary lesion measuring 2 cm. by 2 cm. was found. The part of the loop bearing the tumor was excised and the loop closed. Pathologic examination revealed papillary transitional cell carcinoma, grade II, implanted in the ileal mucosa with clumps of tumor cells invading the muscle. The patient was started on chemotherapy, cyclophosphamide (Cytoxan) and adriamycin, and is clinically free of tumor twelve months postoperatively.

time of anastomosis, and the second is that ureteral manipulation produced implantation of tumor cells in the ileal mucosa at the time of the nephroureterectomy. The fact that the distal ureter was free of tumor at the time of the nephroureterectomy indicates that the most probable mechanism was the second one. This case is an illustration of the theory expressed by Wallace6 regarding the likely possibility of transitional cell involvement of the ileal loop at the ureteroileal junction. It also emphasizes the importance of: (1) a high index of suspicion for ileal loop tumor involvement when hematuria is present postcystectomy for cancer. (Loopogram should be obtained to rule out such an occurrence.) (2) Th e need for careful tissue handling and wound washing at the time of surgery.

Comment

References

The occurrence of transitional cell carcinoma at the level of ureterocolonic anastomosis is not new. Amar,’ Riches and Page,3 Sugg,4 and Shapiro et al. 5 have reported such findings. On the contrary, transitional cell carcinoma in the ileal mucosa always has been considered uncommon. To date only 1 case has been reported. l Our case emphasizes the possibility of ileal loop involvement in bladder tumor. There are two possible mechanisms which may explain the development of such a metastasis. The first is that a residual tumor was left in the distal ureter at the

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1. GRABSTALD,H. : Carcinoma of ileal bladder stoma, J. Urol. 112:332 (1974). 2. AMAR,A. D. : Neoplastic obstruction at the ureterosigmoid anastomosis, ibid. 86: 334 (1961). 3. RICHES, E. W., and PAGE, B. H. : Transitional cell carcinoma of the colon following cystectomy and ureterosigmoidostomy for carcinoma of the bladder, Br. J. Urol. 28: 288 (1956). 4. SVGC, W. L.: Tumor at site of uretero-sigmoidostomy, Ann. Surg. 155: 572 (1962). 5. SHAPIRO, S. R., BAEZ, A., COLODNY, A. H., and FOLKMAN,J. : Adenocarcinoma of colon at ureterosigmoidostomy site 14 years after conversion to ileal loop, Urology 3: 229 (1974). 6. WALLACE, D. M.: Total cystectomy. An editorial overview, Cancer 32: 1078 (1973).

UROLOGY /

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VOLUME V, NUMBER 2

Transitional cell carcinoma of ileal loop following cystectomy.

This is the second case reported in the literature involving transitional cell carcinoma in an ileal loop. The case is described and the literature re...
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