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Behavior of Certain Metastatic Malignant Diseases Arising in Urinary Tract
THE JOUH>l'AL OF UROLOGY
·vol. 81, I\"'."o. 5, i1.1ay HJ59 Printed fo U.S.A.
BEHAVIOR OF CERTAIK METASTATIC J\fALIGNANT DISEASES """RISI:'\G IK URINARY TRACT HAY
:u.
BOBBITT, ff AN R. HAHVVOOD
The management nrnl tretttrnent of certltin nmligmrnt n1etastatic· ttrising in the some of tlH,m formerly eonsidererl bopclcss, will be discussed. Also the management of benigu prost:cti<' obstructive disease with malignant di~ettse clse1d1ere ,vill he briefly considcn'
.\,-;n
FRA:'\K l\I. PECK
rmrnrclcd 1Yhen the patients lived with comfort much longer than anticipated. Fnforturrntcly om cxperieuc:e with metastatic lesions arising from the lmYrr tract, Buch as prost:1tic and bladder cancer, htt8 not hc('U happy, and we hiwe usuall,1- ccmfiiwcl the management of tliese cases to 1mlliative measnrr''· HmYe,-er, \Ye have ha
the following casl, reports. CASE REPORTl:i
Case l. aged 2}1 years, ,vns sc'en June 19.",0 at St. Ho~pital ,,ith n Yl"ilms tumor on the rig lit side (figs. 1 and 2). After a course of
l t has b<-'lcll shmn1 rcpeatr:dl)- tlmt solitary metastasis of nmlignaut tumorn could be successfully removed with control of the disease. Tlrns at treatment of acln111cecl 1woplastic lesions or further trC':ctrnent of their extension of metastasis ,in; """""·--·-, justifil'cl despite appm-cmt great odds agairrnt good results. The urologist must make decisions as to the management of maligrnmt nwtastascs which heretofore we lmve bc,eH JJrnne to consider beyoncl help, and simply try to nrnke the patient comfortable palliatiH' means. I-ImYc,-er, ,vith the advances in surgecr:y, radiation and x-ray, we, have been impressed ,,-ith improvement and sometimes ttpparent cure in some of these cases. \Ve have; ha(l severnl case~ referred to us with complete retention of urine due to benign hypertrophy, ,vith ttch-m1cecl malignant disease clse,1-hcre, some of them with metastasis. "With these cxpcricnees in mind, trnnsurethral resections lrn ve been clone on som0 of these patients rather than sc'ntence tl1em to permttnent ca.thRter m· supmpubic drainage. '\Ye lrnve been
"u"'"""', the
good recovery. Fourtr:cn montl1s later x-ray presented a mc,t:11,tasi,; about -.i: inches in dinmc:ter in the nppr:r lobe of tlH, lung (fig. 3) After a carPful eyicJencc; of 1rn,tastases ancl none
Read at annual meeting of American Urological As,ociation, Inc., Xe,y Orlean,, La., April 281\fay l, 1()58,
629
Frn. l. Case 1. Gross specimen of irradia1.e,J \Vil ms tumor.
FrG. 2. Case 1. Photomicrograph of tumor.
Fm. 7. Case 2. Gross specimen shows involvement of renal vein in hypernephroma.
Fm. 3. Case 1. Chest x-ray 14 months later showing metastasis to lung (right upper lobe).
Fm. 8. Case 2. Negative chest x-ray at time of renal surgery.
Fm. 4. Case 1. Gross specimen. Note metastatic lesion.
Fm. 5. Case 1. Photomicrograph shows metastatic lung lesion.
Fm. 9. Case 2. One year later. Note metastatic lesion in right lung.
Fm. 6. Case 1. Chest x-ray 3 years after lung surgery shows no further metastasis.
630
Fm. 10. Case 2. Gross specimen. Note metastatic lesion in right lung.
IlElIXVIOH OF CERTAIN MALIGNANT DISEASES
Fro. 14. Case :-L Photomicrogrnph of 1,hy,md metastases.
F1cL 11. Case 2. Chr;s( x-rnv 6 months later. General condition good. Film· still shows some sugg;c,stion of mGtastase.,. Oli,ervation only.
FICL 12. Case :3. Gro:-,:~ .spce1n1cn :--:ho-\Yr-:; hypcrnephrorrrn,
Fie;. 1'.3. Case :). Gros., qiecimen of thyroid 2 _\·cam later.
,Yhich time further radiation 1nts gin·n, a lobecton\1· was performed am! the clirrgnosis ronfinnccl (figs. 4 and .5). This patient, kc,pt under constant observation since: oprrntion, lrns rrmainrd ,mil am! the clicst x-rnys an' (fig. G).
\Yhilr we L'a1mot classify this as :i c·urc, ,yn· experirnce has been that if further metasbsl'~ 1wrc going to occur in this type of disease it woulcl have bren mud1 sooner. Yi\, ,m: nnnhk to fine! a n,port of a similar casr in the literntHl'l'. Case 2. R.S., St. l\Iarr's Hospital ~os ~liit-i2-7it\ and 14818-56, a 47-ycar-old white woman was first s<"en in June 19.51, complaining of left flank pain ancl hematuria. The diagnosis ,ms renal tumor, ancl a hypenwphroma 1n1s rcmo,-cd in June 19.51. Pathological srctions shmwcl n1vasion of the renal vein and pelvis (fig. 7') Prcoperati\-r x-ray of the chest 1rns negative f~). An x-ray of thr chest on April 1952 ,ms i11kr·prcted as showing bilatnal pulmmmr~- metastasis (fig. 9). In 1953 regression of mctastasi:i 1\'ithout treatment ,1as notrd. Tn 19.5+ a c:111,si:, x-ray was inkrprctrd as negative. Jn Hl5Vi a re· currcncc of bilateral nwtastasis was fmmrL Iii April a segmental lobectomy of the ldt lnng done (fig. 10). At the \\Titing of this paper b<,r 1958) chest x-rn.y is su,;picicnrn or n·r1uT1'nu· of metastasis in the apcx of the right lung 11), but the patient's rnnclition is goo11 and further observation is necr;ssar~Case S. J\LJ., a :'\egress aged 51, m1s scc'n in .Jul~- 1944 becaus<" of painless hematun:1. diagnosis of right n'nal tumor ,,as made a.rn l an advancrcl right h>-perncpluoma ,, as n·mcwc,d (fig. 12). T\\'o years later she rPtmm'cl for examination. A large nodule was found i11 the th>·roid glancl. ,\. thyrnidcctomy \rns done and the pathological study shmn,cl a nwtm;tati(' hypernepliroma (fig~. 13 ,md J.1). Thi:; 1Yas seen C\'Cry six months for a period of five yrarn. ~ o further e,-idence of nwt:rntasrs,, ,,,n:·' noted. She cliccl el~<:\\hrre ~udclenh- in E);36. :\'. u
632
BOBBITT, HARWOOD AND PECK
autopsy was obtained. The death certificate cited coronary thrombosis as the cause of death. CONCLUSIONS
Our experience has led us to believe that metastatic disease often can be treated successfully, that a hopeless prognosis should not be given until every known facility is used, and only then after a long period of observation. Certainly from the pathological study, it is im-
possible to predict the course of moRt malignant tumors. We are indebted to Dr. l\I. Lawrence White, who performed the chest surgery on these cases, and to Dr. Karl Kappes, the thyroid surgery, for their notes on these cases. We also wish to thank Dr. Sigried vVerthammer for his help in the study of pathology.
1139 Fourth Ave., Huntington, TY. Va.
·vol. 81, I\"'."o. 5, i1.1ay HJ59 Printed fo U.S.A.
BEHAVIOR OF CERTAIK METASTATIC J\fALIGNANT DISEASES """RISI:'\G IK URINARY TRACT HAY
:u.
BOBBITT, ff AN R. HAHVVOOD
The management nrnl tretttrnent of certltin nmligmrnt n1etastatic· ttrising in the some of tlH,m formerly eonsidererl bopclcss, will be discussed. Also the management of benigu prost:cti<' obstructive disease with malignant di~ettse clse1d1ere ,vill he briefly considcn'
.\,-;n
FRA:'\K l\I. PECK
rmrnrclcd 1Yhen the patients lived with comfort much longer than anticipated. Fnforturrntcly om cxperieuc:e with metastatic lesions arising from the lmYrr tract, Buch as prost:1tic and bladder cancer, htt8 not hc('U happy, and we hiwe usuall,1- ccmfiiwcl the management of tliese cases to 1mlliative measnrr''· HmYe,-er, \Ye have ha
the following casl, reports. CASE REPORTl:i
Case l. aged 2}1 years, ,vns sc'en June 19.",0 at St. Ho~pital ,,ith n Yl"ilms tumor on the rig lit side (figs. 1 and 2). After a course of
l t has b<-'lcll shmn1 rcpeatr:dl)- tlmt solitary metastasis of nmlignaut tumorn could be successfully removed with control of the disease. Tlrns at treatment of acln111cecl 1woplastic lesions or further trC':ctrnent of their extension of metastasis ,in; """""·--·-, justifil'cl despite appm-cmt great odds agairrnt good results. The urologist must make decisions as to the management of maligrnmt nwtastascs which heretofore we lmve bc,eH JJrnne to consider beyoncl help, and simply try to nrnke the patient comfortable palliatiH' means. I-ImYc,-er, ,vith the advances in surgecr:y, radiation and x-ray, we, have been impressed ,,-ith improvement and sometimes ttpparent cure in some of these cases. \Ve have; ha(l severnl case~ referred to us with complete retention of urine due to benign hypertrophy, ,vith ttch-m1cecl malignant disease clse,1-hcre, some of them with metastasis. "With these cxpcricnees in mind, trnnsurethral resections lrn ve been clone on som0 of these patients rather than sc'ntence tl1em to permttnent ca.thRter m· supmpubic drainage. '\Ye lrnve been
"u"'"""', the
good recovery. Fourtr:cn montl1s later x-ray presented a mc,t:11,tasi,; about -.i: inches in dinmc:ter in the nppr:r lobe of tlH, lung (fig. 3) After a carPful eyicJencc; of 1rn,tastases ancl none
Read at annual meeting of American Urological As,ociation, Inc., Xe,y Orlean,, La., April 281\fay l, 1()58,
629
Frn. l. Case 1. Gross specimen of irradia1.e,J \Vil ms tumor.
FrG. 2. Case 1. Photomicrograph of tumor.
Fm. 7. Case 2. Gross specimen shows involvement of renal vein in hypernephroma.
Fm. 3. Case 1. Chest x-ray 14 months later showing metastasis to lung (right upper lobe).
Fm. 8. Case 2. Negative chest x-ray at time of renal surgery.
Fm. 4. Case 1. Gross specimen. Note metastatic lesion.
Fm. 5. Case 1. Photomicrograph shows metastatic lung lesion.
Fm. 9. Case 2. One year later. Note metastatic lesion in right lung.
Fm. 6. Case 1. Chest x-ray 3 years after lung surgery shows no further metastasis.
630
Fm. 10. Case 2. Gross specimen. Note metastatic lesion in right lung.
IlElIXVIOH OF CERTAIN MALIGNANT DISEASES
Fro. 14. Case :-L Photomicrogrnph of 1,hy,md metastases.
F1cL 11. Case 2. Chr;s( x-rnv 6 months later. General condition good. Film· still shows some sugg;c,stion of mGtastase.,. Oli,ervation only.
FICL 12. Case :3. Gro:-,:~ .spce1n1cn :--:ho-\Yr-:; hypcrnephrorrrn,
Fie;. 1'.3. Case :). Gros., qiecimen of thyroid 2 _\·cam later.
,Yhich time further radiation 1nts gin·n, a lobecton\1· was performed am! the clirrgnosis ronfinnccl (figs. 4 and .5). This patient, kc,pt under constant observation since: oprrntion, lrns rrmainrd ,mil am! the clicst x-rnys an' (fig. G).
\Yhilr we L'a1mot classify this as :i c·urc, ,yn· experirnce has been that if further metasbsl'~ 1wrc going to occur in this type of disease it woulcl have bren mud1 sooner. Yi\, ,m: nnnhk to fine! a n,port of a similar casr in the literntHl'l'. Case 2. R.S., St. l\Iarr's Hospital ~os ~liit-i2-7it\ and 14818-56, a 47-ycar-old white woman was first s<"en in June 19.51, complaining of left flank pain ancl hematuria. The diagnosis ,ms renal tumor, ancl a hypenwphroma 1n1s rcmo,-cd in June 19.51. Pathological srctions shmwcl n1vasion of the renal vein and pelvis (fig. 7') Prcoperati\-r x-ray of the chest 1rns negative f~). An x-ray of thr chest on April 1952 ,ms i11kr·prcted as showing bilatnal pulmmmr~- metastasis (fig. 9). In 1953 regression of mctastasi:i 1\'ithout treatment ,1as notrd. Tn 19.5+ a c:111,si:, x-ray was inkrprctrd as negative. Jn Hl5Vi a re· currcncc of bilateral nwtastasis was fmmrL Iii April a segmental lobectomy of the ldt lnng done (fig. 10). At the \\Titing of this paper b<,r 1958) chest x-rn.y is su,;picicnrn or n·r1uT1'nu· of metastasis in the apcx of the right lung 11), but the patient's rnnclition is goo11 and further observation is necr;ssar~Case S. J\LJ., a :'\egress aged 51, m1s scc'n in .Jul~- 1944 becaus<" of painless hematun:1. diagnosis of right n'nal tumor ,,as made a.rn l an advancrcl right h>-perncpluoma ,, as n·mcwc,d (fig. 12). T\\'o years later she rPtmm'cl for examination. A large nodule was found i11 the th>·roid glancl. ,\. thyrnidcctomy \rns done and the pathological study shmn,cl a nwtm;tati(' hypernepliroma (fig~. 13 ,md J.1). Thi:; 1Yas seen C\'Cry six months for a period of five yrarn. ~ o further e,-idence of nwt:rntasrs,, ,,,n:·' noted. She cliccl el~<:\\hrre ~udclenh- in E);36. :\'. u
632
BOBBITT, HARWOOD AND PECK
autopsy was obtained. The death certificate cited coronary thrombosis as the cause of death. CONCLUSIONS
Our experience has led us to believe that metastatic disease often can be treated successfully, that a hopeless prognosis should not be given until every known facility is used, and only then after a long period of observation. Certainly from the pathological study, it is im-
possible to predict the course of moRt malignant tumors. We are indebted to Dr. l\I. Lawrence White, who performed the chest surgery on these cases, and to Dr. Karl Kappes, the thyroid surgery, for their notes on these cases. We also wish to thank Dr. Sigried vVerthammer for his help in the study of pathology.
1139 Fourth Ave., Huntington, TY. Va.