Ureteral metastasis incidentally found from primary breast cancer: A case report and review of the literature

Abstract

Breast cancer metastasis to the ureter has been rarely reported and is typically diagnosed by autopsy or radiographically rather than by pathological inspection. We present the rare case of a 60-year-old female in which computed tomography urography imaging during nephrolithiasis revealed an incidental ureteral mass. Pathology workup following mass biopsy was estrogen receptor positive, progesterone receptor negative, and HER2 negative. The patient was ultimately diagnosed with metastatic lobular carcinoma of breast origin based on pathology from the axillary lymph node tissue. This case adds to the body of literature of a rare presentation of ureteral involvement from primary breast cancer.

1 Introduction

Ureteral involvement of metastases typically results from prostate, bladder, colorectal, and lymphoma cancers. Breast cancer metastasis to the ureter has been rarely reported and is typically diagnosed by autopsy or radiographically rather than by pathological inspection. Less than ten cases have been reported of primary breast cancer metastasizing to the ureters in the twenty-first century. Breast cancer is the most common malignancy in adult females and typically metastasizes to the brain, lungs, liver, and bones. Metastases to the ureter typically present with flank pain, oliguria, or hematuria and usually involves the lower ureteral segment. Given the rarity of ureteral metastases from primary breast cancer, we present a case report of this rare presentation and the work up.

2 Case report

A 60-year-old female presented to the urology office with a history of recurrent nephrolithiasis to establish care. Surveillance renal ultrasound was obtained which showed left hydronephrosis so a computed tomography urography (CTU) was performed. This revealed urothelial thickening and abnormal enhancement in the left renal pelvis and in the left renal collecting system which extended along the proximal to mid left ureter ( Fig. 1 ). The CTU also noted ill-defined soft tissue thickening and enhancement in the retroperitoneum and in the periaortic region especially on the left side with suspected confluent lymph nodes which appeared to encase segments of the proximal ureters and enlarged external iliac node. Given the unusual left-sided upper tract enhancement and left hydronephrosis, ureteroscopy in the operating room was performed for direct visualization which revealed a distal ureteral neoplasm. The lesion seen did not appear consistent with typical urothelial carcinoma. Left upper tract biopsy performed at this time revealed scant, detached, denuded fragment of tissue with infiltrating carcinoma with signet ring cell/plasmacytoid features. Intra-operatively, vaginal speculum exam revealed a thickened white anterior cervix which was biopsied and resulted as rare, atypical cells, indefinite for carcinoma. Cytology was negative for high grade urothelial carcinoma. Immunohistochemical stains were positive for AE1/3, CK7, GATA3 and negative for CK20, p63, CD163, estrogen receptor, progesterone receptor, and HER2.