Late-Onset Distant Metastatic Upper Urinary Tract Urothelial Carcinoma Mimicking Lung Adenocarcinoma
A 50-year-old man was referred to our hospital with presumed lung cancer. He reported blood-tinged sputum for 5 days but was otherwise well. He had a 40-pack-year history of cigarette smoking. Twelve years earlier, after two episodes of gross hematuria, a diagnosis of UC of the renal pelvis had been made at our hospital. Right nephroureterectomy with bladder cuff excision was performed. Pathological examination revealed a UC in the renal pelvis (T1N0M0, grade 2) (), and a tumor involving the ureteral margin. The patient underwent adjuvant chemotherapy (methotrexate, vinblastine, doxorubicin, and cisplatin: three cycles for 3 months). Thereafter, he was followed up through regular cystoscopy and/or abdominal computed tomography (CT) at the urology clinic for 10 years, and no additional tumors were identified.\nAt admission, the serum level of carcinoembryonic antigen was 9.73 ng/mL (reference range, 0.0-6.0 ng/mL). Other laboratory test results were normal. A chest CT scan showed a mass lesion in the left lower lobe of the lung and lymphadenopathy in the left lower paratracheal and subcarinal areas. Bronchoscopic examination revealed no endobronchial lesions. A CT-guided fine-needle biopsy of lung demonstrated histologic features suggestive of adenocarcinoma (). No other primary lesions were found by 18F-fluorodeoxyglucose positron emission tomography/computed tomography, digestive endoscopy, abdominal CT or urine cytology. Brain magnetic resonance imaging revealed brain metastases. Therefore, we diagnosed the patient with advanced lung adenocarcinoma. After brain CyberKnife radiosurgery, he underwent two cycles of cisplatin-based combination chemotherapy, which had no effect. After chemotherapy, a small nodule in the mid-trachea was noted on bronchoscopic examination. Pathological analysis of a bronchoscopic biopsy showed a poorly differentiated carcinoma (). Immunohistochemical analysis showed the tumor cells to be positive for cytokeratin 7 and p63 (), and negative for thyroid transcription factor 1 (TTF-1). These findings suggested possible metastatic UC. All histopathological samples, including the previous UC of the renal pelvis (), CT-guided fine-needle biopsy of the lung (), and tracheal biopsy (), were reviewed. The results of pathologic analysis revealed a high-grade metastatic UC following a previous low-grade UC of the renal pelvis. Systemic re-evaluation revealed concomitant aggravation of lung, esophagus, and bone metastases (). In spite of radiotherapy and supportive care, the patient died as a result of aggravation of multiple metastasis.