Carcinoma of the Pancreas Causing Ureteral Obstruction

Carcinoma of the Pancreas Causing Ureteral Obstruction

U"F LhOLOG\- © :S7:1 Th2 ':r\!illiams October Printed in \iVilidn:; CARCINOMA OF THE PANCREAS CAUSING URETERAL OBSTRUCTION STUART WANUCK, ROBERT ...

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U"F LhOLOG\-

© :S7:1

Th2 ':r\!illiams

October Printed in

\iVilidn:;

CARCINOMA OF THE PANCREAS CAUSING URETERAL OBSTRUCTION STUART WANUCK, ROBERT SCHWIMMER*

AND

LAZARUS ORKIN

From the Department of Urology, Beth Israel Hospital, New York, New York

There are numerous causes of ureteral obstruction that may be considered anatomically intrinsic or extrinsic, as obstructive diseases of hollow viscera are analyzed in generaL Pathologically, obstruction may be caused by stones, inflammation, injuries, developmental abnormalities and tumors. The most common tumors causing ureteral obstruction are fibroids, which cause extrinsic compression of the ureter, and carcinomas of the cervix, which invade the ureter by contiguous extension. 1 Metastatic tumors of the ureter are an uncommon cause of ureteral obstruction, with less than 100 cases reported in the literature before 1967. 2 Primary tumors of the ureter are more common with about 700 cases now reported. Pancreatic carcinoma is a rare cause of ureteral obstruction. In a series of 10,223 consecutive autopsies, ureteral obstruction metastatic tumor occurred in 0.37 per cent. Only 1 case of adenocarcinoma of the pancreas was noted. 2 Presman and Ehrlich 37 cases of ureteral involvement by metastatic tumors; none was of pancreatic " A case of bilateral ureteral obstruction carcinorna of the pancreas was reported Schmidt.• Herein we report a case of carcinoma of the pancreas, which presented as ureteral obstruction 1u1.d ,n~c,Hv1c,~ masqueraded as primary carcinoma of the ureter until autopsy revealed the true cause of the disease. CASE REPORT

A was

healthy white woman in January J.971 because of flank and fever 1 week in duration. An excretory urogram (IVP) n;o,·tr,n,-,,,11 before revealed left ureternl obstruction. The remainder of the history was unremarkable. The denied a history of renal or ureteral stones. exarn.ination revealed a well wel.l nourished white woman with lOlF temperatt1.re and rnarked left costovertebral tender-6, 1973. Accepted for * Current Blvd., Deh-ay Beach, Florida 33444. 1 Scott, W. W.: Tumors of the ureter. In: Urology. Edited M. F. and J. H. Harrison. Philadelphia: W. Saunders vol. 2, 994, 1970. 2 MacLean, J. T. and Fowler, B.: Pathology of tumors of the renal pelvis and ureter. J. Urnl., 75: 384, 1956. 3 Presman, D. and L.: Metastatic tumors of the ureter. J. Urol., 59: 312, • Schmidt, J. D.: Bilateral ureteral obstruction due to cancer of the pancreas. J. Urol., 106: 652, 1971.

ness. No masses were palpable and the remainder of the physical examination vvas normal. Laboratory data revealed a white blood count of 8,800 with a norm.al differential. Urine culture and sensitivity tests were normal, as were the blood urea nitrogen (BUN) and glucose and electrolytes. Serum glutamic oxaloacetic transaminase was 65 and lactic dehydrogenase was 260. Alkaline phosphatase was 100 and albumin was 2.5 mg. Bilirubin and prothrombin times were normal. The tine test was negative. On January 12 cystoscopy and left retrograde pyelography revealed a narrowing of the left mid ureter which was thought to be an extrinsic pressure defect (fig. 1, A). Sigmoidoscopy, barium enema and upper gastrointestinal series with small bowel examination revealed no abnormalities. The patient continued to have a febrile course. Antibiotics were administered and the 6F ureteral catheter which had been left indwelling for drainage was removed 4 days later. At this time the patient had a fever which spiked to 102F and to intravenous sodium cephalothi.n.t A repeat infusion IVP revealed a normal kidney and ureter on the right side and delayed visualization of the left kidney with calicectasis. The delayed films revealed obstruction at a level corresponding to L4. In this region there appeared to be a smooth naiTowing of the ureter which was thought to be more r'ninnr,,,,with an extrinsic etiology for the obstruction. On 21 the left ureter was explored and a tumor was discovered (fig. 1, B). Left newith excision of a cuff of bladder was performed. The pathological diagnosis was an undifferentiated small cell carcinoma involving the ureter. One week 11usu,r,,,rn,, the side. and examination could not establish a cause. The patient BUN and serum

died. revealed primary carcinoma of the head of the pancreas with diffuse involvement of the retroperitoneum and ureter. Histologically the tumor showed the same undifferentiated small cell pattern as the tumor involving the left ureter.

t Keflin, 46206.

Eli Lilly and Co., Indianapolis, Indiana

WANUCK, SCHWIMMER AND ORKIN

396

FIG. 1 DISCUSSION

This case of carcinoma of the pancreas causing ureteral obstruction is noteworthy in that the patient initially presented with left ureteral obstruction without symptoms or signs to suggest any other pathology. Exploration and subsequent left nephroureterectomy revealed an undifferentiated small cell carcinoma which was thought to be compatible with the diagnosis of ureteral carcinoma. The true nature and the extent of the disease were realized only after autopsy uncovered diffuse retroperitoneal carcinomatosis, with a primary lesion in the head of the pancreas. SUMMARY

Reported herein is a case of carcinoma of the pancreas which initially caused unilateral ureteral obstruction despite the presence of diffuse retroperitoneal involvement.

FIG. 2