ADENOCARCINOMA OF GALLBLADDER PRESENTING AS URETERAL OBSTRUCTION

DEBA SARMA. M.D. MICHAEL HANEMANN, M.D. From the Departments of Pathology and Radiology, Veterans Administration Medical Center and Louisiana State University Medical Center, New Orleans, Louisiana

ABSTRACTA fifty-five-year-old man presenting with unilateral renal colic and ureteral obstruction was found to have ureteral metastasis from a primary gallbladder carcinoma. This appears to be the second report of such a case in the English literature.

Metastatic carcinoma of the ureter is uncommon. Metastasis to ureters occurs most commonly from primary tumors of stomach, colon, breast, prostate, ovary, and lung. There is only 1 reported case of gallbladder carcinoma that metastasized to ureter.1 Herein we describe a case of primary gallbladder carcinoma that metastasized to ureter and presented a unilateral renal colic due to ureteral obstruction. Case Report A fifty-five-year-old man presented with a few-hour history of acute colicky pain of right flank accompanied by nausea and vomiting. He had no fever, chills, dysuria. or hematuria. He had no history of renal calculi or previous renal disease. Physical examination was essentially normal. Laboratory values were all within normal limits, including blood urea nitrogen and creatinine, and routine urinalysis. An excretory urogram (IVP) revealed right hydronephrosis with a medially deviated, dilated, and tortuous right ureter seen up to the level of the midsacrum (Fig. 1). A right retrograde pyelogram revealed an obstructed ureter in the midsacral area with some passage of the dye through the obstructed segment into a proximal dilated segment of ureter (Fig. 2A).

FIGURE 1.

IVP shows right hydronephrosis.

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2. (A) Right retrograde pyelogram shows segmental obstruction of ureter with proximal dilatation. (B) Intraoperative cholecystogram showing marked irregularity of mucosa suggesting neoplasm.
FIGURE

-' " 3. Ureter showing infiltrating adenocarcinoma in the wall. (Hematoxylin and eosin. original magnification x 24.)
FIGURE

With a working diagnosis of right ureteral obstruction due to calculus or external compression, the patient was surgically explored revealing a 2 by 2-cm hard mass encasing the distal ureter. This segment of ureter was excised with reimplantation of the ureter into the bladder. Frozen section examination of the excised tissue showed metastatic adenocarcinoma in the ureter. A thorough exploration of the abdominal cavity revealed a large, tense gallbladder adherent to the transverse mesocolon. The cystic duct was noted to be obstructed by a tumor growth. An intraoperative cholecystogram showed a markedly irregular mucosal pattern

suggestive of cancer (Fig. 2B). The liver showed metastatic tumor nodules on the surface and at the hilum. Biopsies were taken, and a cholecystostomy with placement of draining catheter was performed. Examination of the other abdominal organs, especially the stomach, colon, and pancreas did not show any tumor. Histologic examination of the resected ureter showed a poorly differentiated adenocarcinoma invading the muscle coat and periureteral adipose tissue (Fig. 3). Biopsies from the hilar tissue near the gallbladder showed similar adenocarcinoma. The patient had an uneventful postoperative course. He received chemotherapy without much benefit and died of extensive carcinomatosis four months after the diagnosis. Comment Common causes of ureteric obstruction include calculi, inflammation, trauma, and developmental anomalies. Primary and metastatic tumors are rare causes of ureteral obstruction. Cohen. Freed, and Hasson 2 found 1 case of ureteral metastasis from primary gallbladder carcinoma among 31 cases of metastatic cancer to the ureter. The first detailed case report of a gallbladder cancer that produced unilateral ureteral obstruction by metastatic spread was by Claire, Cohen, and Rudick.1 Interestingly our patient, like that of Claire and associates, was a man in his fifties
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with right ureteral obstruction where a diagnosis was established only after abdominal exploration. Carcinoma of gallbladder accounts for about 4 per cent of all carcinomas, occurring mainly among women over sixty. By the time a diagnosis is made, most of the cases are hopeless. Ureteral metastasis is a manifestation of widespread systemic metastases. Most of the patients die within a year. This case adds another rare source of cancer that may metastasize to the ureter. Also interesting is the clinical presentation of renal

colic as the first and only manifestation of gallbladder cancer.

1601 Perdido Street New Orleans, Louisiana 70146 (DR. SARMA)
References
1. Claire R], Cohen EL. and Rudick DH: Adenocarcinoma of gallbladder producing unilateral ureteral obstruction. Urology 14: 163 (1979). 2. Cohen WM, Freed SZ, and Hasson J: Metastatic cancer to the ureter: a review of the literature and case presentations, J Urol 112: 188 (1974).

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Sarma DP, Hanemann MS(1985): Adenocarcinoma of gallbladder presenting as ureteral obstruction. Urology 25:60-62. PMID: 3966285 [PubMed - indexed for MEDLINE]