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Ureteric Obstruction From Malignant Melanoma in Both Right Double Moiety and Left Single Moiety Ureters
ARTICLE IN PRESS
Images in Clinical Urology Ureteric Obstruction From Malignant Melanoma in Both Right Double Moiety and Left Single Moiety Ureters Brayden March, Ross John Spero Calopedos, Edward Latif, and Rupert Ouyang We report the first documented case of malignant melanoma obstructing ureters of both moieties of a duplex kidney and contralateral single moiety ureter in a 51-year-old male. The patient presented with fever, coryzal symptoms, and liver function test derangement several years after 2 superficial spreading melanomas were excised with clear margins. Ultrasonography demonstrated hydronephroureter in both moieties of a complete right-sided duplex kidney. Retrograde pyelograms showed bilateral hydronephroureter and filling defects in all 3 ureters. Biopsied tumor cells were positive for S100, Melan A, and HMB45. Cutaneous melanoma metastasizing to ureters is a rare phenomenon and can present a diagnostic challenge to clinicians if clinically silent. UROLOGY ■■: ■■–■■, 2017. © 2017 Elsevier Inc.
Figure 1. Computerized tomography scan in portal venous phase with coronal (A) and axial (B) views demonstrating complete right duplex ureter, right hydroureteronephrosis, and a rounded enhancing urothelial mass in the right distal ureter. A left distal ureteric mass can also be seen on coronal computerized tomography (C) and retrograde pyelography (D). Soft tissue lesions can also be seen in the gallbladder. (Color version available online.)
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51-year-old male presented with a 5-day history of fever, coryzal symptoms, and liver function derangement 2 weeks after returning from West Africa. Background included only 2 superficially spreadFinancial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Gosford Hospital, Gosford, NSW, Australia Address correspondence to: Brayden March, B.Med., Medical Workforce, Gosford Hospital, Holden St, Gosford, NSW 2250, Australia. E-mail: brayden.march@ gmail.com Submitted: November 4, 2016, accepted (with revisions): February 8, 2017
© 2017 Elsevier Inc. All rights reserved.
ing melanomas from the scalp and nape (Clark levels I and III, respectively). Excisional margins and subsequent wide local excisions were both clear. Serum tests for infective etiologies were unremarkable. Ultrasonography demonstrated a right-sided renal duplex with hydronephrosis and proximal ureteric dilatation despite normal serum creatinine. Computerized tomography revealed an enhancing intraluminal mass in the right ureter (Fig. 1A,B). Urine cytology showed pigmented cells suspicious for melanoma. Retrograde pyelograms also demonstrated left hydroureter with associated filling defect http://dx.doi.org/10.1016/j.urology.2017.02.021 0090-4295
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ARTICLE IN PRESS (Fig. 1D), corresponding to a lesion not identified on computerized tomography (Fig. 1C). Right upper moiety ureteroscopy showed a pigmented, obstructing mass (Fig. 2), and 3 double J stents were placed. Biopsy showed densely melanin pigmented cells staining positive for S100, Melan A, and HMB45, consistent with metastatic malignant melanoma (Fig. 3). Genotyping revealed BRAF tumor mutations, and dabrafenib and trametinib were commenced. This is the first documented case of metastatic melanomatous deposits in 3 separate ureters, without bladder and renal parenchymal lesions. This is a highly unusual pattern as melanoma cells are either shed from renal parenchyma or spread hematogenously.1 Furthermore, the most commonly reported symptoms, flank pain and hematuria, were absent, posing a significant diagnostic challenge.2 References Figure 2. Pigmented lesion in the right upper moiety on rigid ureteroscopy (guidewire in foreground). (Color version available online.)
1. Torok P, Kiss T. Multiple metastases of malignant cutaneous melanoma into the upper urinary tract. Orv Hetil. 1997;138:285-287. 2. Lebacle C, Pignot G, Mateus C, et al. Metastatic melanoma in upper urinary tract: three cases and literature review. Prog Urol. 2012;22:736739.
Figure 3. (A) The tumor consisted of normal urothelium with the underlying stroma demonstrating dense pigmentation (hematoxylin and eosin, ×200 magnification). (B) Pigment was confirmed to be melanin by its removal with a melanin bleach histochemical stain (×200 magnification). (Color version available online.)
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UROLOGY ■■ (■■), 2017
Images in Clinical Urology Ureteric Obstruction From Malignant Melanoma in Both Right Double Moiety and Left Single Moiety Ureters Brayden March, Ross John Spero Calopedos, Edward Latif, and Rupert Ouyang We report the first documented case of malignant melanoma obstructing ureters of both moieties of a duplex kidney and contralateral single moiety ureter in a 51-year-old male. The patient presented with fever, coryzal symptoms, and liver function test derangement several years after 2 superficial spreading melanomas were excised with clear margins. Ultrasonography demonstrated hydronephroureter in both moieties of a complete right-sided duplex kidney. Retrograde pyelograms showed bilateral hydronephroureter and filling defects in all 3 ureters. Biopsied tumor cells were positive for S100, Melan A, and HMB45. Cutaneous melanoma metastasizing to ureters is a rare phenomenon and can present a diagnostic challenge to clinicians if clinically silent. UROLOGY ■■: ■■–■■, 2017. © 2017 Elsevier Inc.
Figure 1. Computerized tomography scan in portal venous phase with coronal (A) and axial (B) views demonstrating complete right duplex ureter, right hydroureteronephrosis, and a rounded enhancing urothelial mass in the right distal ureter. A left distal ureteric mass can also be seen on coronal computerized tomography (C) and retrograde pyelography (D). Soft tissue lesions can also be seen in the gallbladder. (Color version available online.)
A
51-year-old male presented with a 5-day history of fever, coryzal symptoms, and liver function derangement 2 weeks after returning from West Africa. Background included only 2 superficially spreadFinancial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Gosford Hospital, Gosford, NSW, Australia Address correspondence to: Brayden March, B.Med., Medical Workforce, Gosford Hospital, Holden St, Gosford, NSW 2250, Australia. E-mail: brayden.march@ gmail.com Submitted: November 4, 2016, accepted (with revisions): February 8, 2017
© 2017 Elsevier Inc. All rights reserved.
ing melanomas from the scalp and nape (Clark levels I and III, respectively). Excisional margins and subsequent wide local excisions were both clear. Serum tests for infective etiologies were unremarkable. Ultrasonography demonstrated a right-sided renal duplex with hydronephrosis and proximal ureteric dilatation despite normal serum creatinine. Computerized tomography revealed an enhancing intraluminal mass in the right ureter (Fig. 1A,B). Urine cytology showed pigmented cells suspicious for melanoma. Retrograde pyelograms also demonstrated left hydroureter with associated filling defect http://dx.doi.org/10.1016/j.urology.2017.02.021 0090-4295
1
ARTICLE IN PRESS (Fig. 1D), corresponding to a lesion not identified on computerized tomography (Fig. 1C). Right upper moiety ureteroscopy showed a pigmented, obstructing mass (Fig. 2), and 3 double J stents were placed. Biopsy showed densely melanin pigmented cells staining positive for S100, Melan A, and HMB45, consistent with metastatic malignant melanoma (Fig. 3). Genotyping revealed BRAF tumor mutations, and dabrafenib and trametinib were commenced. This is the first documented case of metastatic melanomatous deposits in 3 separate ureters, without bladder and renal parenchymal lesions. This is a highly unusual pattern as melanoma cells are either shed from renal parenchyma or spread hematogenously.1 Furthermore, the most commonly reported symptoms, flank pain and hematuria, were absent, posing a significant diagnostic challenge.2 References Figure 2. Pigmented lesion in the right upper moiety on rigid ureteroscopy (guidewire in foreground). (Color version available online.)
1. Torok P, Kiss T. Multiple metastases of malignant cutaneous melanoma into the upper urinary tract. Orv Hetil. 1997;138:285-287. 2. Lebacle C, Pignot G, Mateus C, et al. Metastatic melanoma in upper urinary tract: three cases and literature review. Prog Urol. 2012;22:736739.
Figure 3. (A) The tumor consisted of normal urothelium with the underlying stroma demonstrating dense pigmentation (hematoxylin and eosin, ×200 magnification). (B) Pigment was confirmed to be melanin by its removal with a melanin bleach histochemical stain (×200 magnification). (Color version available online.)
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UROLOGY ■■ (■■), 2017