Stomach Cancer with Ureteral Metastasis: CT Findings and Mode of Metastasis

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1 대한방사선의학회지 1992 ; 28 (3) : 407~412 Journl of Koren Rd iologicl Society. My Stomch Cncer with Ureterl Metstsis: CT Findings nd Mode of Metstsis Hye-young Choi, M. D., Kyoung Sik Cho, M. D., Moon-Gyu Lee, M. D., Youg Ho Auh, M.D, Deprtment of Dignostic Rdiology. Asn Medicl Center. College of Medicine. Unversity of U1sn INTRODUCTION Since the first cse report of ureterl invsion of stomch cncer y Schlginweit in less thn 30 cses hve een documented in the literture. Most of the ureterl invsion hve not een dignosed in living ptients until the new imging modlities. especilly computed tomogrphy. (CT) ecme ville. CT is eing used populrly in the stging workup of stomch cncer. We experienced 19 cses of ureterl metstsis during the period from June 1989 to My Except for four cses. one ech from pncretic cncer. colon cncer. uterine leiomyosrcom nd unknown origin. the rest of the 15 cese were from stomch cncer leding to our supicion tht ureterl metstsis of stomch cncer is much more frequent thn other cncers. Therefore. we nlyzed CT findings nd mode of metstsis to the ureter y stomch cnter. MATERIALS AND METHODS The study group consisted of 15 cses of ureterl The CT exmintions were performed on CT/T 9800(GE. Milwukee. WI, U. S. A.)nd CT imges were otined from the diphrgmtic dome to the ilic crest or symphysis puis with 10mm section thickness t 10mm intervls. After orl dministrtion n of 800 ml of 1.3% solution ofe-z-ct (Brium sulfte suspension. Schering. Kore)ws done to ll ptients. We nlyzed CT findings of these ptients to know the specific findings nd the mode of ureterl metstsis of stomch cncer RESULTS All of our cses hd dvnced stomch cncer with 12 poorly differentited denocrcinom. two signet ring-cell crcinom nd one modertely ditterentited denocrcinom. Regrding the involvement site of the stomch. there were six ntrum. seven ntrum nd ody. nd one ech involving the ody nd entire stomch. There were 11 m1es nd 4 femles. etween 21 nd 82 yers of ge. There were six cses ofright. five left. 없 ld four ofilterl ureterl involvement. Tle 1 summrizes the ssocited CT findings of 15 cses of ureter1 metstsis of stomch cncer. metstsis from histologiclly proven stomch cncer Perigstric lymphdenopthy ws present in ll 15 which were exmined CT scn for 2 yers. cses nd pr-ortic lymphdenopthy in 13 Index Words: Stomch. neoplsms 이 Ureter. neoplsms Adomen. CT Lymphtic system. neplsm 논문은 년 11 월 4 일접수하여 년 2 월 26 일에채택되었음 Recived Novemer 4. Accepted Ferury pticents (Fig. l). Omentl nd mesenteric infiltrtions nd/or scites were found in 11 ptients (Fig.2). Pr-ortic lymphdenopthy ws seen on the right side in one cse. on the left in six. on oth in six. nd

2 Journl of Koren Rdiologic l Society 1992 ; 28 (3) : 407~412 none in two cses. Two cses with non-identifiction of pr-ortic lymphdenopthy hd only involvement of the right ureter. One of them hd signet ringcell crcinom wtih mssive mesensnteric infiltrtions (Fig.3) For the reltionship etween pr-ortic lymphdenopthy nd ureterl involvement. the left pr-ortic lymphdenopthy showed left ureterl involvement in four nd oth ureters involment in two cses. Bilterl pr-ortic lymphdenopthy show- Tle 1. Associted CT Findings of Stomch Cncer with Ureter Metstsis(N = 15) Ureter Perigstric Lymphdenopthy Pr-ortic Lymphdenopthy Omentl & Mesenteric Infiltrtion Ascites Liver metstsis Right Left 80th Totl Fig. 1. Perigstric nd pr-ortic lymphdenopthy. Enhnced CT scn shows conglomerted lymphdenopthy with multipe low-density of centrl necrosis in left gstric group. Right retrocrurl lymphdenopthy is lso seen.. Enhnced CT scn shows m비 tipe ilterl pr-ortic lymphdenopthy with right hydronephrosis Fig. 2. Omentl. mesenteric infiltrtions nd scites.. CT scn shows mtted oment1 cke nd mssive scites. 80th ureters revel thickened enhnced wll with luminl nrrowing in right nd hydroureter in left. CT scn shows disseminted omentl. mesenteric infiltrtions nd scites Left ureter revels nd periureterl infiltrtions Left pr-ortic lymphdenopthy is lso seen

3 Hye- Young Choi. et l : Stomch Cncer with Ureterl Mefástsís ed right ureterl involvem ent in three. left in one. nd \ tht the site of pr-orrtic lymphdenopthy w ere oth in two ptients. However. right pr-ortic lym- corrited with the involving site of the ureter. Tnè phdenopthy reveled only involvement of the right m in findings of ureterl m etstsis on CT were oth ureter in one ptient(tle 2). Therefore it cn e sid thickned enhnced ureterl wll nd periureterl in c Fig. 3. Ureter metstsis without lymphdenopthy.. Enhnced CT scn shows diffuse thickened wll in the entire stomch with omentl infiltrtions nd scites. CT scn t the level of ren l hilum shows right hydronephrosis nd mssive mesenteric infiltrtions without pr -ortic lymph denopthy c. Right mid-ureter revels thickened enhn ced wll nd periuretertic infiltrtion (rrowheds). c Fig. 4. Min findings of metsttic ureter on CT. Left dist1 ureter revels thickened enhnced wll with luminl nrrowing (rrowheds).. Right proximl ureter shows thickened enhnced wll(lrger rrowhed}with periureterl infiltrtions(smller rrowheds). c. Left mid-ureter revels mild hydroureter with slight enhnced wll nd periureteric lymphdenopth y(rroheds}

4 Journl of Koren Rdiologicl Society 1992 ; 28 (3) : 407~412 Tle 2. Correltion Side of Pr.ortic Lym. phdenopthy with Ureter We know tht stomch cncer usully spreds to other sites vi the lymphtics, ut the mechnism Ureter Pr.ortic Lymphdenopthy Right Left Both None Right 1 o 3 2 Left o 4 o Both O Totl Totl filtretions in 14 ptients nd ostructive hydronephrosis nd hydroureter in 15 prients(fig of metstsis to the ureter from stomch is uncler. Kost et l(7)suggested tht the route ofmetstsis to the ureter ws through the perivsculr lymphtic chnnel s their cses reveled perivsculr lym. phtic invsion t the metsttic ureter with prureterl lymph node invsion. There re there mechnisms of cncer spred though the lymphtics. The first is y permetion of perineurllymphtics in which contiguous stnds of cncer cells invde nd grow long lymphtic vessels in lte stges of cncer 4). The one with no identifiction of thickened The second is discontinuous spred y emolism in enhnced ureterl wll hd periureterl infiltrtions nd the other with no periureterl infiltrtions hd thickened enhnced ureterl wll. Ech cse show. ed mssive mesenteric infiltrtions nd m 비 tiple liver metstsis respectively. DISCUSSION Metsttic invsion of the ureter is rre nd hs een dignosed only t utopsy. Seki et l( 1) reported tht the incidence of ureterl invsion of stomch cncer t utopsy ws 1.7%. Fitch et l(2)reviewed the literture on metsttic ureterl tumors. nd found 160 csesnd dded three oftheirown. Jerome et l(3)reviewed pproprite cses for 10 yers t the UCLA hospitl nd found 82 cses of ureterl metstsis. The most common primry sites of ureterl metstsis were rest. stomch, ldder. colon. prostte. lung. nd lymphoid tissue(4.5). We found 19 cses ofureterl metstsis. Among them. 15 cses were from stomch cncer. Apprent1y. d. vnced stomch cncer metstsized to the ureter more frequent1y thn we expected. In 1948, Presmn nd Ehrlich(6). in review of the clinicl nd pthologic fetures of secondry ureterl tumors. hve listed the criteri for true metstsis. Unfor. tuntely we couldn t get pthologic proof t metsttic ureterl portion s none of the our ptients were surgicl cndidtes due multiple lym. phdenopthy nd omentl nd mesenteric infiltr. tion nd they were treted y chemotherpy only with or without pllitive gstrojejunostomy which individul cncer cells re crried through the lymphtics to e rrested in lymph nodes during er. ly stges of cncer. The third is retrogrde spred vi pericpsulr chnnels(8). In this study, most ofthe ptients showed dvnc. ed stomch cncer with multiple perigstric, pr. ortic lymphdenopthy nd diffuse omentl nd mesenteric tumor infiltrtions, suggesting tht the mode of metstsis to the ureter is correlted with lymphtic spred through lymphtic chnnels representing denopthy nd omentl nd mesenteric infiltrtions nd lso with retrogrde sped vi pericps 비 r chnnels repersenting involve. ment of ny level of the ureter. The usul rdiogrphic feture on intrvenous pyelogrphy is either ureterl sticture or intrluminl filling defect with vrying degree of proximl hydronephrosis nd hydroureter (2.5). The most com. mon pttern ws involvement of lllyers of ureterl wll y constricting metstsis nd the next comrnon pttern ws periureterl tumor infiltrtions with con. centric compression ofthe lumen. The ureter cn e involved y murl nd/or periureterl infiltrtions leding to hydronephrosis 잉 ld hydroureter regrdless of which form of the ureterl metstsis is present(9). Untri1 now. to our knowledge. CT findings ofureterl metstsis from stomch cncer hve not documented. The min findings in urinry systems on ureter metstsis were thickened enhnced ureterl wll with periureterl infiltrtions nd ostuctive hydronephrosis nd hydroureter. These findings re lso well relted to findings of in.

5 Hye-Young Choi. et l : Stomch Cncer with Ureterl Metstsis trvenous pyelogrphy. 1n our experience nd knowledge. the most import와1t nd specific findings of ureterl metstsis were thickened enhnced ureterl wll with periureterl infiltrtions. Differentil dignosis of ureterl metstsis includes enign ostructive lesions. such s enign retroperitonel firosis. nonopque ureterl stone. endometril implnts. ureterl firosis to irrdition nd other retroperitonel disese since the enhnced ureterl wll cn lso e identified enign ostructive ureterl lesions. 1n our opinion, periureterl infiltrtion is differentil point etween enign nd mlignnt ostructive lesions. Cohen et Al(9)reviewed 31 cses nd found tht the mjority of the ptients(85 %) were symptomtic nd ureterl metstsis were only discovered t utopsy. Behlf nd Leonrd(lO)demonstrted tht less thn 50% of the ptients with ctul ureterl ostruction hd signs or symptoms relted to the urinry trct. The most common complints re flnk or ck pin nd frequency. Hemturi is not frequent s the mucos of the ureter is left intct nd the min portion of the lesions usully occupy the musculris lyer s the lymphtics in the urter progress through sumucosj, intrmusc비r, nd dventitil p Jexuses which communicte with ech oter( ). 1n our study, two cses reveled decrese of urine output ecuse of simultneous involvem ent ofoth ureters nd three cses complined of frequency, voiding difficulty nd flnk pin. Otherwise, most of our cses represented no specific urinry symptoms. These findings leds us to stress the vlue of CT exmintion which hs importnt role in erly detection of ureterl metstsis in ptients without urinry symptoms nd signs. We conclude y sying tht when evluting generlized metsttic stomch cncers. ureterl metstsis should lso e considered even if there is no urinry symptoms nd CT is the only invlule modlity which cn meet this gol. REFERENCES 1. Seki M, Nishi M, lkw Y. Gstric cncer metstsizing to the ureter. Jp. j. Cncer Clin. 1970; 16(10): Fitch WP. Roinson J R. Rdwin HW. Metsttic crcinom ofthe ureter. Arch. Surg. 1976;111: Richie JP, Withers G. Ehrlich RM. Ureterl ostruction secondry to metsttic tumors. Surgery, Gynecology & Osterics 1979; 148: Alexnder S. Kim K. Pick BD et l. Metsttic ureterl tumors. J. Urol : Johnson RD, Johnson JR. Bnnyn GA. Seminom Metsttic to ureter. 1981; Urology 17: Presmn D. Ehrlich L. Metsttic tumors of the ureter. J. Urol. 1948;59: Kost L V. Le ermen PR. Metsttic crcinom to the ureter. A cse report. J. Urol. 1965;93: Weiss L. Hrvey AG. 않 mul CB. Lymphtic System Metstsis. 1980:VoI.III: Cohen WM. Freed SZ. Hsson J. Metsttic cncer to the ureter. A review of the literture nd cse presenttions. J. Urol. 1974;112: Aeloff MD. Lenhrd RE. Clinicl mngement of ureterl ostruction secondry to mlignnt lymphom. Johns Hopkins Med.J.1974;134: Gross M, Minkowits S. Ureterl metstsis from renl denocrcinom. J. Urol. 1971; 106: Song MY. Lhen JM. Durnd D. et l. Rdiologic fetures of metsttic crcinom to the ureter. Dignostic Imging 1983;52:

6 l J o. urr 떼 따 KonerndEldioJo.gicL Society 1.992; 28(3) : 407~412 국문요약 사뇨관전이에대한고찰 i...:! 니 μ I ( ) 위암의 : 전산화단층소견및전이기전 울산대학교의과대학진단방사선과학교실 앙 { 강?U D;:~ν f - r r.~)g f:'-j! t 1 J.;', '1, 최혜영 조경식 이문규 오용호 지금까지위암의뇨관전이는문헌상드문것으로보고되어있으며대분이부검결과에의한것이었다. 그러나저자들은 1989년 6월부터 1991년 5월까지전산화단충촬영으로예상보다많은위암의뇨관전이환자 15명을발견하였다. 위암의전이소견을보기위해서는전산화단층촬영이가장좋은검사로이때뇨관전이의유무도꼭확인해야할것으로생각되어전산화단충촬영소견을분석하였다. 전산화단충촬영상뇨관전이를나타내주는주소견은뇨관벽의비후와조영증강및뇨관주위의침윤에의한뇨관협착이었으며뇨관폐쇄에의한수신증과수뇨관증을나타내였다. 또한대부분의환자에서위주변부및대동맥주위의임파절증대와복부내의대망및장간막에미세암전이및복수를나타내어위암의뇨관전이는임파절및임파관전이에의한것으로사료되어다른문헌고찰과함께보고하는바이다