Lamovec, Janez

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THE INSTITUTE OF ONCOLOGY, LJUBLJANA ADENOCARCINOMA OF THE COLON FOLLOWING URETEROSIGMOIDOSTOMY REPORT OF A NEW CASE WITH AUTOPSY FINDINGS Lamovec J. Abstract - A new case of an autopsied 40-year old patient with adenocarcinoma arising at the site of ureterosigmoidostomy performed 26 years earli er for bladder extrophy is reported. It was also associa­ted with a benign polyp of the rectum distally to the uninvolved right ureteric outlet. The possible mechanisms including the recent findings of abnormal mucin secretion in the colonic mucosa in the regions of urine diversion are briefly discussed. UDC: 616.348-006.66 Key words: colonic neoplasms, adenocarcinoma, ureterosigmoidostomy Case report Radiol lugosl 1989; 23: 59-62. lntroduction - Ureterosigmoidostomy used to be the procedure of choice tor urinary diver­sion. It has been largely substituted by ileal conduit introduced by Bricker (5) and its well known complications, i.e. hyperchloremic aci­dosis, chronic renal infections and urinary cal­culi were thus avoided or reduced although the long-term results of this operation are far from ideal (21 ), and other operative procedures, e.g. colon conduit without reflux are gaining increa­sed popularity (2). However, one serious and very late sequel may stili appear in patients who had ureterosigmoidostomy perfomed many years previously when the procedure was popu­lar, namely neoplastic growth at the site of anas­tomosis. The first to describe the occurence of colonic neoplasm was Ham mer in 1929 (1 O). Since then over 50 such cases were described in English literature, most of them being carcinomas and benign polyps in the minority of cases (1, 3, 4, 7, 8 11, 12, 14-20, 22-24). This is a new report of an adenocarcinoma arising in the colonic mucosa at the site of urete­rosigmoidostomy performed for extrophy of the urinary bladder 27 years before. Case report - A 40-year-old man was refer­red to our institution from another hospital where he had a palliative transversosigmoidostomy per­formed because of inoperable tumor in the upper part of sigmoid colon involving the right retrope­ritoneum and bilateral paraaortic lymph nodes. His main complaints for the last two years were inappetence, periodic obstipation and colics in the left lower abdomen. When he was 14 years old he had had a ureterosigmoidostomy done because of bladder extrophy. Since then he was in good health until for the past two years, except for the bout of acute alcoholic hepatitis 4 years ago and acute appendicitis 15 years ago. On physical examination, no mass was palpa­ted in his abdomen, however, palpation was painful in the region of the left mesogastrium along the postoperative scar. No other abnorma­lities were found except for the stili persistent epispadia and poorly corrected bladder extro­phy with vesico-cutaneous fistula. Digital rectal examination was negative. On rectoscopy a 0.7 cm sessile polyp was found on the anterior rectal wall 17 cm above the anus, few centime­ters distally to the right ureteric outlet. Barium enema examination showed oval filling defect in the region of the implanted left ureter in the proximal sigmoid colon with enema barely pas­sing stenotic area but freely filling transverse colon through transversosigmoidostomy. Ultra-Received: November 7, 1988 -Accepted: November 21, 1988 59 Lamovec J.: Adenocarcinoma of the colon following ureterosigmoidostomy report of a new case with autopsy findings sound of the abdomen showed dilated calices, pelvis and ureter of the left kidney with shorte­ning of the latter. Chest X-ray and liver scan failed to show any evidence of metastases. Re­nography showed afunctional left kidney. The patient was palliatively irradiated to the left meso- and hypogastric region (total dose 4000 cGy); his condition improved and abdomi­nal pains completely ceased. However, he was readmitted two months later with bilateral upper abdominal pain, was irradiated again, this tirne to bilateral paraaortic lymph nodes (total dose 2700 cGy) but his condition deteriorated, and he died 5 months after first admission to our institu­tion. At autopsy, the patient appeared cachectic. The distal part of the descending colon and the proximal part of the sigmoid colon were »bur­ried« in the dense fibrous tissue in the left retro­peritoneum. The lumen of the intestine in this area was replaced by an irregular cavity without identifiable muscular wall, its wall consisted of dense fibrous tissue and necrotic white-yellow neoplastic tissue on the luminal surface. A 7 cm long markedly dilated left ureter was implanted into this wall with complete obstruction of the outlet and extreme dilatation of the excretory system of the left kidney with compressive atro­phy of its parencyma. The outlets of the descri­bed cavity were narrowed by fibrotic and / or neoplastic tissue and led into slightly dilated descending and sigmoid colon on the opposite sides. The obstruction was by-passed by sig­moido-transversoanastomosis. The right ureter which was implanted into the sigmoid colon dis­tally to the left one was slightly dilated with wi­dely patent outlet (Fig. 1 ). No metastatic colic Fig. 1 - Gross specimen showing contracted and dilated left ureter with neoplastic infiltration and fibro­sis at the site of ureterosigmoidostomy. 60 lymph nodes were found. Paraaortic tissue was markedly fibrotic with no identifiable lymph nodes. No distant metastases were seen. Other pertinent autopsy findings included bilateral bronchopneumonia, pulmonary congestion and edema. The cause of death appeared to be a complex one: cachexia, dehydration, bronchop­neumonia, and possible action of multiple pain­killing drugs on patient's CNS may have contri­buted to it. Histology of the site of the left ureterosigmoi­dostomy showed infiltrating moderately differen­tiated adenocarcinoma of the colonic type invol­ving the superficial portion of the fibrosed intes­tinal wall (Fig. 2). Dense hyalinized fibrous tissue Fig. 2 - Adenocarcinoma infiltrating the ureterosig­moidostomy with uninvolved colonic mucosa in the right lower corner of the picture (HE X 1 O). lnset shows moderately differentiated adenocarcinoma (HE X 40). of the deeper part of the wall which also massively involved the left retroperitoneum showed no microscopic foci of carcinoma. Mucosal lining of the ureteral part of the anastomosis was necro­tic, deeper layers fibrotic, with no carcinomatous growth. The right ureterosigmoidostomy was microscopically unremarkable. The fibrotic pa­raaortic tissue had only few completely hyalini­zed microscopic lymph nodes without metas­tases. Other relevant histologic findings included chronic pyelonephritis with nephrosclerosis on the left side and chronic pyelonephritis on the right side. In summary, the patient had a residual infiltra­ting adenocarcinoma of the colon at the site of left ureterosigmoidostomy without lymph node metastases and severe postirradiative retroperi­toneal fibrosis. Discussion - The occurence of large bowel neoplasia following ureterosigmoidostomy has Radiol lugosl 1989; 23: 59-62. Lamovec J.: Adenocarcinoma of the colon following ureterosigmoidostomy report of a new case with autopsy findings been reported on several occasions (1, 3, 4, 7, 8, 10-12, 14-20, 22-24). The neoplasms arisingin this location were either benign polyps or car­cinomas, predominantly adenocarcinomas.There were over 30 cases of carcinoma reportedto date (1, 15). Most of them were seen in patientswho were operated upon for nonmalignantcondition, minority of these patients had the ure­terosigmoidostomy performed after cystectomyfor bladder carcinoma (22). The median age atthe outset of the colonic carcinoma in the form ergroup was 33 years and in the latter group 63years respectively (20, 22). The latent period fromureterosigmoidostomy and the development ofcolonic neoplasm ranged from 7 to 46 years inpatients operated upon for nonmalignant condi­tion but was substantially shorter in the bladdercarcinoma group (22).It is thought that the association of colonic neoplasm and ureterosigmoidostomy is unlikely to be fortuitous (9, 24). The carcinoma of the colon occuring before the age of 40 is rare (25, 26), while most cases of carcinomas at uretero­sigmoidostomy site occured before this age (14, 15, 20, 22-24). It was calculated that the inci­dence of colonic neoplasia in patients with ure­terosigmoidostomy to be 500 times greater than normally expected for this age group (24). Howe­ver, this number was estimated to be much lower by other authors and put into the range of 80-100 (23). The etiology of the neoplasms ari­sing at ureterosigmoidostomy site is as yet un­known. The fact that most of the tumors are colo­nic adenocarcinomas speaks in favor of causa­tive agent acting upon colonic mucosa. The ex­perimental data suggest that a fecal stream isnecessary for carcinogenesis, and that local ac­tivation of fecal carcinogens by diverted urine, orof urinary carcinogens by fecal bacteria may bethe cause of cancer after ureterosigmoidostomy(9). On the other hand, there was a report ofadenocarcinoma complicating colon conduit 26years after the diversion which contradicts theabove hypothesis, since there had never beenany mixture of urine and feces in the conduit inthe reported case (6). It has been recently repor­ted that the pattern of mucin secretion in colonicmucosa is definitely abnormal in patients whohave undergone urinary diversion (13). lf this isan indicator of preneoplasia remains to be esta­blished.It is of interest to note that the present case showed also a benign polyp of the rectum in association with colonic carcinoma. They may or may have not been etiologically related. The mucosal proliferation in this polyp was only slight but unusual presence of smooth muscle Radiol lugosl 1989; 23: 59-62. bundles was not unlike to the case described by Ali et coworkers (1 ), (Fig. 3). Fig. 3 - A benign polyp of the rectum. Slightly hyper­plastic mucosa with proliferation of smooth muscle bundles is seen (HE X 13). Conclusion - This case once again shows that patients who have had ureterosigmoidos­tomy should be followed tor the rest of their lives to discover the earliest neoplastic change in their colonic mucosa which may appear many years after the operation. Povzetek V članku poročam o novem obdukcijskem primeru adenokarcinoma na ureterosigmoidostomi pri štiride­setletnem bolniku. Operacija je bila napravljena pred 26 leti zaradi ekstrofije sečnega mehurja. Bolnik je bil obsevan na Onkološkem Inštitutu, kjer je umrl v kahek­siji. Poleg karcinoma na ureterosigmoidostomi je bil v rektumu še manjši benigni polip. V diskusiji razprav­ljam o možnih mehanizmih za nastanek karcinoma na ureterosigmoidostomi, vključno o novejših odkritjih abnormalne mucinske sekrecije v črevesni sluznici na mestih urinske preusmeritve. Re fe rences  1. Ali M .  H., Satti M .  B., AI-Nafussi A.: Multiple be­nign colonic polypi at the site of ureterosigmoidos­tomy. Cancer 53: 1006-101 O, 1984. 2. Althausen A. F., Hagen-Cook K., Hendren W. H. 111:Nonrefluxing colon conduit: experience with 70 cases. J. Urol. 120: 35-40, 1978.3. Amar A. D.: Neoplastic obstruction of the uretero­sigmoid anastomasis. J. Urol. 86: 334-335, 1961. 4. Ansell l. D., Vellacott K. D.: Colonic polyps com­plicating ureterosigmoidostomy. Histopathology 4: 429-436, 1980.5. Bricker E. M.: Bladder substitution after pelvicevisceration. Surg. Ciin. Norih Am. 30: 1511-1521, 1950. 6. Chiang M. S., Minton J. P., Clausen K., ClatworthyH. W., Wise H. A. II: Carcinoma in a colon conduiturinary diversion. J. Urol. 127: 1185-1188, 1982.7. Dunn M., Roberts J. B. M., Smith P. J. B.: Benigntumors developing at the site of ureterosigmoidostomy. Br. J. Urol. 51: 260-263, 1979. 61 Lamovec J.: Adenocarcinoma of the colon following ureterosigmoidostomy report of a new case with autopsy findings 8. Gillman J. C.: Adenomatous polyp of bowel follo­wing ureterocolic anastomosis. Br. J. Urni. 36: 264-270, 1964.9. Gittes R. F., Ruegg C., Kerr S., Wilson L.: Adeno­carcinoma of ureterosigmoidostomy and of bladder extrophy: pathophysiology and experimental studies. J. Urol. 131: 278 A, 1984. 1 O. Ham mer Em. M.: Cancer du colon sigmoide dixans apres implantation des ureters d'une vesse exs­trophiee. J. Urol. Nephrol. (Paris) 28: 260-263, 1929. 11. Haney M. J., McGarity, W. C.: Ureterosygmoidos­tomy and neoplasms of the colon. Arch. Surg. 103: 69-72, 1971. 12. Harford F. J., Fazio V. W., Epstein L. M., Hewitt C. B.: Rectosigmoid carcinoma occurring after uretero­sigmoidostomy. Dis. Colon Rectum 27: 321-324, 1984. 13. lannoni C., Marcheggiano A., Pallone F., FrieriG., Gallucci M., DiSilverio F., Caprilli R.: Abnormal pat­terns of colorectal mucin secretion after urinary diver­sion of different types: histochemical and lectin bin­ding studies. Hum. Pathol. 17: 834-840, 1986. 14. Lasser A., Acosta A. E.: Colonic neoplasmscomplicating ureterosigmoidostomy. Cancer 35: 1218-1222, 1975. 15. Leadbetter G. W. Jr., Zickerman P., Pierce E.:Ureterosigmoidostomy and carcinoma of the colon. J. Urol. 121: 732-736, 1979. 16. Macgregor A. M. C.: Mucous secreting adeno­matous polyp at the site of ureterosigmoidostomy. A case report and review of the literature. Br. J. Surg. 55: 591-594, 1968. 17. Mogg R. A.: Neoplasms at the site of ureterocolic anastomosis. Br. J. Surg. 64: 758-761, 1977. 18. Narayana A. S., Kelly D. G., Duff F. A.: Benign polypi at the site of uretero-rectal anastomosis. Post­grad. Med. J. 54: 348-350, 1978. 19. Recht K. A., Belis J. A., Kandzari S. J., Milam D. F.:Ureterosigmoidostomy followed by carcinoma of the colon. Cancer 44: 1538-1542, 1979. 20. Rivard J. Y., Bedard A., Dionne L.: Colonic neo­plasms following ureterosigmoidostomy. J. Urol. 113: 781-787, 1975. 21. SchmidtJ. D., Hawtrey C. E., Flocks R. H., Culp D.A.: Complications, results and problems of ileal conduit diversion. J. Urol. 109: 210-217, 1973. 22. Soorijaarachi G. H., Johnson R. O., Carbone P.P.: Neoplasms of the large bowel following uretero­sigmoidostomy. Arch. Surg. 112: 1174-1177, 1977. 23. Stewart M., Macrae F. A., Williams C. B.: Neopla­sia and ureterosigmoidostomy: a colonoscopic survey. Br. J. Surg. 69: 414-416, 1982. 24. Urdaneta L. F., Duffell D., Creevy C. D., Aust J. B.: Late development of primary carcinoma of the colon following ureterosigmoidostomy: report of three cases and literature review. Ann. Surg. 164: 503-513, 1966. 25. Winawer S. J.: Screening tor colorectal cancer: an overview. Cancer 45: 1093-1098, 1980. 26. Winawer S. J., Sherlok P.: Surveillance tor colo­rectal cancer in average-risk patients, familial high­risk groups, and patients with adenomas. Cancer 50: 2609-2614, 1982. Author's address: Janez Lamovec. M. D., The Insti­tute of Oncology, 61000 Ljubljana O knjigotisk O ofset O knjigoveznica kaeevje 62 Radiol lugosl 1989; 23: 59-62. 

Adenocarcinoma of the colon following ureterosigmoidostomy report of a new case with autopsy findings

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Adenocarcinoma of the colon following ureterosigmoidostomy report of a new case with autopsy findings

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