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Primary Neuroendocrine Tumors of the Ureter: A Short Review.

EPIDEMIOLOGY AND PATHOGENESIS

Urothelial carcinoma is relatively frequent in the United States, with 54 000 new patients diagnosed with the disease each year. (1) Most of these tumors arise in the urinary bladder, while primary upper urinary tract urothelial carcinoma represents only 5% of urothelial neoplasms. (2) On the other hand, neuroendocrine tumors (NETs) of the urinary system are extremely rare, accounting for less than 0.05% of primary urinary tract (UT) malignancies. Primary urinary NETs are most commonly located in the bladder, where they account for less than 1% of all bladder malignancies. (3,4) To the best of our knowledge, the first case of ureteral NET was published in 1986, and fewer than 30 cases have been reported since, including tumors with a mixed urothelial/neuroendocrine histology. (5) Even though primary ureteral NETs are believed to show a male predominance, several cases have occurred in women, most often after the sixth decade of life. (6-10) Interestingly, ureteral neuroendocrine neoplasms seem to occur more frequently in Asians than in any other ethnic group (Table). Although some of the reported cases include a history of tobacco consumption, a relationship between smoking and urinary tract NETs has not been well established. (7,9)

The pathogenesis of ureteral NETs is debated, because the normal ureters are thought to be devoid of neuroendocrine cells. Interestingly, a thorough systematic immunohistochemical and histochemical search for neuroendocrine cells in the genitourinary system of the female pig demonstrated that the neuroendocrine cell population density shows a concentration gradient. The highest concentration was found in the vulvar/distal urethral region and decreased steeply toward the proximal genitourinary tract. In fact, this study (11) found only occasional neuroendocrine cells in the bladder, and none in the ureters. Therefore, 4 different hypotheses have been formulated to explain the origin of ureteral NETs. The first one posits that the original lesion is a urothelial carcinoma, which undergoes neuroendocrine metaplasia. The next 2 hypotheses suggest that ureteral NETs are derived either from neuroendocrine cells normally residing in the ureter (which has not been demonstrated yet) or from neural crest cells abnormally entrapped during embryonic migration. Finally, similar to NETs arising in other organs that lack neuroendocrine cells, some authors (6,10,12,13) support a cancer stem cell theory. A recent study documented that Notch1 and its target Hes1 show significantly diminished immunohistochemical positivity in the neuroendocrine phase of biliary mixed adenoneuroendocrine carcinomas when compared to both the adenocarcinoma component and the normal biliary epithelium. Moreover, Notch1 mRNA knockdown in a cholangiocarcinoma cell line induced an increase in the concentration of chromogranin A and Ascl1 (a neuroendocrine inducer normally inhibited by Notch1 target Hes1) mRNA. (14) This suggests that, at least in some epithelia, neuroendocrine differentiation might be actively suppressed. Consequently, the loss of normal suppression mechanisms during urothelial carcinogenesis might allow transdifferentiation to a NET. While it is uncertain whether this mechanism operates in vivo, or if it can be extrapolated from biliary to urinary NET pathogenesis, it could potentially explain why many reported ureteral NETs show a mixed histologic profile. (6,15,16)

CLINICAL PRESENTATION AND DIFFERENTIAL DIAGNOSIS

Clinical presentation is widely variable, from asymptomatic microscopic hematuria to complete ureteral obstruction and hydronephrosis. The most common initial manifestations are flank pain and hematuria. (10) Locally advanced disease at presentation, as well as lymph node metastasis, are not uncommon. (6,17) Contrary to large masses in the urinary bladder, which can cause bilateral ureteral obstruction, upper UT NETs are usually unilateral and do not cause oligoanuria in binephric patients.

Besides, since unilateral obstruction in ureteral NETs ensues slowly, serum creatinine concentration would not be expected to increase dramatically if renal function was previously normal. Tumor markers are usually not helpful. In contrast, urine sediment frequently reveals different degrees of hematuria and leukocyturia. (6,7,17-19) If obstruction is complete, urine cultures may show growth of bacteria that are not the usual uropathogens. (7) Cytology specimens can demonstrate malignant neuroendocrine cells, especially if obtained during an endoscopic study. (6,7)

Ultrasonography is usually the first imaging study performed and, although it is effective at detecting ureteropelvic distention, it is insensitive for the demonstration of ureteral tumors. Intravenous and retrograde urography can indirectly detect the presence of a luminal mass, by showing a filling defect of the ureteral lumen. However, most upper UT masses are initially identified with helical computed tomography or magnetic resonance imaging. (6,10,17,19) Finally, histologic diagnosis is usually made on tissue biopsy specimens obtained through endoscopic ureteroscopy.

Ureteral NETs should be distinguished from other causes of upper UT obstruction and hematuria. Differentiation between ureteral NETs and urolithiasis is quite straightforward thanks to helical CT. Moreover, lithiasis usually causes sudden obstruction and acute pain, while tumoral obstruction tends to ensue slowly, producing subacute or chronic pain. More problematic is the differentiation of NETs from other, much more common ureteral malignancies. Although the morphology of NETs is very characteristic on hematoxylin-eosin-stained sections, immunohistochemical studies are an essential tool for differential diagnosis. It is particularly important to rule out the presence of a NET when urothelial and/or squamous carcinoma are diagnosed, since ureteral NETs can have a mixed histologic profile, and the prognosis seems to be determined by the neuroendo crine component. (6,15-17) Although a NET metastatic to the ureter would be exceptionally rare, it has been reported at least once in the literature. (20) Therefore, before making a diagnosis of primary ureteral NET, it is necessary to rule out metastatic disease from primary sites where NETs are more commonly found, such as the digestive system and the respiratory tract. (21)

MACROSCOPY, HISTOLOGY, AND IMMUNOHISTOCHEMISTRY

Macroscopically, ureteral NETs are solid sessile tumors with a firm consistency, gray to white smooth cut surface, and peritumoral mural thickening. (6,7) Their microscopic appearance is similar to that of neuroendocrine tumors from other locations, and they are invariably malignant (Figure 1, A through C). Cells are usually small- to medium-sized with speckled chromatin, scant to moderate amounts of cytoplasm, and high nuclear to cytoplasmic ratio (Figure 1, D). Most of these neoplasms show typical small cell neuroendocrine carcinoma histology, with only 1 large cell neuroendocrine carcinoma reported to date, to the best of our knowledge. (7) The architecture shows patterns that are similar to NETs from other primary locations: rosettes, diffuse sheets, and solid tumor nests. A desmoplastic stromal reaction is commonly observed, and additional nonneuroendocrine tumoral elements can be identified in more than 50% of the cases (Table). (6,7) Necrosis, lymphovascular invasion, and direct invasion of adjacent structures have been reported. (6,7,10,19) Furthermore, mixed ureteral neoplasms containing urothelial carcinoma and/or squamous carcinoma in addition to a NET have been well documented. (6,15-17) Ureteral NETs are almost invariably aggressive neoplasms, with an elevated number of mitotic figures per high-power field.

Immunohistochemical stains for synaptophysin (Figure 2, A), chromogranin A (Figure 2, B), neuron-specific enolase, and/or CD56 (Figure 2, C) show positivity in ureteral NETs. At least 1 ureteral NET has demonstrated positivity for cytokeratin 20, cytokeratin 7, pan-keratin, and epithelial membrane antigen, but uroplakin III invariably shows negativity. (7) Therefore, uroplakin III seems to be an additional tool for differentiating ureteral NETs from urothelial carcinoma, with the caveat that this marker shows positivity in 57% to 81% of urothelial neoplasms. (22,23) Nuclear Ki-67 labeling index is frequently greater than 50% to 60% (Figure 2, D), which is consistent with the high mitotic rate normally found in these tumors. (7,10)

Electron microscopy studies often reveal the presence of membrane-bound electron-dense cytoplasmic granules measuring 100 to 200 nm in diameter, which are characteristic of neuroendocrine cells. (7)

TREATMENT AND PROGNOSIS

The treatment of ureteral NETs is far from well established. Oncologists seem to favor a multimodal therapeutic approach, including surgery and adjuvant chemotherapy with or without radiation. (24) A review of 39 patients with upper UT NETs (ureter-renal pelvis) showed that patients treated with surgery alone had a median survival of 12 months, while patients receiving adjuvant chemotherapy survived for a median of 24 months. However, statistical significance was not reached. Platinum-based regimens seem to confer an important survival advantage, compared with schemes lacking platinumderived drugs. (25,26) Among the 25 cases of ureteral NETs found in the literature, only 9 patients received chemotherapy, and 4 were treated with platinum-based regimens. On the basis of results from 1 case, another group (10) has suggested that an adjuvant regimen combining irinotecan and platinum would add to the therapeutic benefit without increasing toxicity. Furthermore, neoadjuvant administration of alternating ifosfamide/doxorubicin and etoposide/ cisplatin to 30 patients with urinary tract NETs yielded promising results, especially for those patients with resectable disease at initial presentation. (27)

Although sufficient data are lacking to accurately estimate the prognosis of ureteral NETs, reports thus far indicate that patients have fared poorly. Most present with locally advanced disease (T3), and up to one-fifth show lymph node involvement (Table). Clinical course and overall prognosis seem to be similar for pure and mixed ureteral NETs, hence the same treatment strategies have been used for both types of neoplasms. (25) Review series of renal and upper UT NETs show a median survival of 8 to 15 months, a high rate of metastatic dissemination (32%-53.8%, synchronous or metachronous), and frequent relapses. (25,26) For practical purposes, the most important prognostic factor seems to be the pathologic stage at diagnosis. (25)

References

(1.) Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001 [erratum in: CA Cancer J Clin. 2001; 51(2):144].CA Cancer J Clin. 2001; 51(1):15-36.

(2.) Genega EM, Porter CR. Urothelial neoplasms of the kidney and ureter: an epidemiologic, pathologic, and clinical review. Am J Clin Pathol. 2002; 117(suppl):S36-S48.

(3.) Sehgal SS, Wein AJ, Bing Z, Malkowicz SB, Guzzo TJ. Neuroendocrine tumor of the bladder. Rev Urol. 2010; 12(4):e197-e201.

(4.) Chang CY, Reddy K, Chorneyko K, Kapoor A. Primary small cell carcinoma of the ureter. Can J Urol. 2005; 12(2):2603-2606.

(5.) Ordonez NG, Khorsand J, Ayala AG, Sneige N. Oat cell carcinoma of the urinary tract: an immunohistochemical and electron microscopic study. Cancer. 1986; 58(11):2519-2530.

(6.) Banerji JS, Korula A, PanickerJB. Multicentric small cell neuroendocrine neoplasm of the renal pelvis and ureter with concomitant focal high-grade urothelial carcinoma of the ureter: a case report. Indian J Urol. 2008; 24(4):571-574.

(7.) Oshiro H, Odagaki Y, lobe H, et al. Primary large cell neuroendocrine carcinoma of the ureter. Int J Clin Exp Pathol. 2013; 6(4):729-736.

(8.) Jaggon JR, Brown T-A, Mayhew R. Metastatic primary neuroendocrine carcinoma of the genitourinary tract: a case report of an uncommon entity. Am J Case Rep. 2013; 14:147-149. doi:10.12659/AJCR.883908.

(9.) Ahsaini M, Riyach O, Tazi MF, et al. Small cell neuroendocrine carcinoma of the urinary tract successfully managed with neoadjuvant chemotherapy. Case Rep Urol. 2013; 2013:598325. doi:10.1155/2013/598325.

(10.) Ping JH, Chen ZX, Jiong Q, Han YQ, Nong X. Small cell neuroendocrine carcinoma of the ureter: a case report and literature review. Oncol Lett. 2014; 7(3):728-730.

(11.) Czaja K, Sienkiewicz W, Vittoria A, Costagliola A, Cecio A. Neuroendocrine cells in the female urogenital tract of the pig, and their immunohistochemical characterization. Acta Anat (Basel). 1996; 157(1):11-19.

(12.) Paniz Mondolfi AE, Slova D, Fan W, et al. Mixed adenoneuroendocrine carcinoma (MANEC) of the gallbladder: a possible stem cell tumor? Pathol Int. 2011; 61(10):608-614.

(13.) Fetissof F, Dubois MP, Lanson Y, Jobard P. Endocrine cells in renal pelvis and ureter, an immunohistochemical analysis. J Urol. 1986; 135(2):420-421.

(14.) Harada K, Sato Y, Ikeda H, Hsu M, Igarashi S, Nakanuma Y. Notch1-Hes1 signalling axis in the tumourigenesis of biliary neuroendocrine tumours. J Clin Pathol. 2013; 66(5):386-391.

(15.) Kim TS, Seong DH, Ro JY. Small cell carcinoma of the ureter with squamous cell and transitional cell carcinomatous components associated with ureteral stone. J Korean Med Sci. 2001; 16(6):796-800.

(16.) Tsutsumi M, Kamiya M, Sakamoto M, Tobisu K, Kakizoe T. A ureteral small cell carcinoma mixed with malignant mesodermal and ectodermal elements: a clinicopathological, morphological and immunohistochemical study. Jpn J Clin Oncol. 1993; 23(5):325-329.

(17.) Sakuma T, Ujike T, Yoshida T, Ohashi H, Kawano K. Urothelial carcinoma of ureter with neuroendocrine differentiation: a case report. Hinyokika Kiyo. 2008; 54(2):123-126.

(18.) Jang H, Yuk SM, Kim JO, Han DS. A rare case of primary malignant small cell carcinoma combined with urothelial cell carcinoma in the ureter. World J Surg Oncol. 2013; 11(1):181.

(19.) Yang J, Zhao Z, Ni J, Dong W, Wang N, Wang B. Urography and CT features of primary small cell carcinoma of the ureter: a case report. Iran J Radiol. 2013; 10(3):160-163.

(20.) DiPietro M, Zeman RK, Keohane M, Rosenfield AT. Oat cell carcinoma metastatic to ureter. Urology. 1983; 22(4):419-420.

(21.) Brennan SM, Gregory DL, Stillie A, Herschtal A, Mac Manus M, Ball DL. Should extrapulmonary small cell cancer be managed like small cell lung cancer? Cancer. 2010; 116(4):888-895.

(22.) Parker DC, Folpe AL, Bell J, et al. Potential utility of uroplakin III, thrombomodulin, high molecular weight cytokeratin, and cytokeratin 20 in noninvasive, invasive, and metastatic urothelial (transitional cell) carcinomas. Am J Surg Pathol. 2003; 27(1):1-10.

(23.) Klopfer K, Delahunt B, Adamson M, Samaratunga H. Value of uroplakin Ill in distinguishing variants of primary bladder urothelial carcinoma from malignancy metastatic to the urinary bladder. Anticancer Res. 2014; 34(11): 6779-6784.

(24.) Essenfeld H, Manivel JC, Benedetto P, Albores-Saavedra J. Small cell carcinoma of the renal pelvis: a clinicopathological, morphological and immunohistochemical study of 2 cases. J Urol. 1990; 144(2, pt 1):344-347.

(25.) Ouzzane A, Ghoneim TP, Udo K, et al. Small cell carcinoma of the upper urinary tract (UUT-SCC): report of a rare entity and systematic review of the literature. Cancer Treat Rev. 2011; 37(5):366-372.

(26.) Majhail NS, Elson P, Bukowski RM. Therapy and outcome of small cell carcinoma of the kidney: report of two cases and a systematic review of the literature. Cancer. 2003; 97(6):1436-1441.

(27.) Siefker-RadtkeAO, Kamat AM, Grossman HB, et al. Phase II clinical trial of neoadjuvant alternating doublet chemotherapy with ifosfamide/doxorubicin and etoposide/cisplatin in small-cell urothelial cancer. J Clin Oncol. 2009; 27(16): 2592-2597.

Accepted for publication July 2, 2015.

From Anatomic/Clinical Pathology (Dr Acosta) and Transdisciplinary Pathology (Dr Kajdacsy-Balla), University of Illinois at Chicago Hospital and Health Sciences System, Chicago.

The authors have no relevant financial interest in the products or companies described in this article.

Reprints: Andres M. Acosta, MD, University of Illinois at Chicago Hospital and Health Sciences System, 840 S Wood St, Suite 130 CSN, Chicago, IL 60612 (email: amacosta@uic.edu).

Please Note: Illustration(s) are not available due to copyright restrictions.

Caption: Figure 1. A, Small cell neuroendocrine carcinoma of the ureter causing subtotal obstruction of the lumen. B and C, This neoplasm shows sheets and islands of cells with peripheral palisading, fibrous septa, and focal tumor necrosis. D, At high magnification, tumor cells show the characteristic speckled chromatin and brisk mitotic activity (hematoxylin-eosin, original magnifications X10 [A], X50 [B], X100 [C], and X400 [D]).

Caption: Figure 2. A through C, Small cell neuroendocrine carcinoma of the ureter showing immunohistochemical positivity for synaptophysin (A), chromogranin A (B), and CD56 (C). D, Ki-67 nuclear labeling index is greater than 50% (iVIEW Diaminobenzidine Detection Kit [Ventana Medical Systems, Oro Valley, Arizona]; original magnification X200 [A through D]).
Summarized Data From Primary Ureteral
Neuroendocrine Tumors Reported in the Literature (a)

                             N (%)     Mean (Range)

Total published cases      28
Age, y                                 68.25 (48-86)
Sex                        27
  Male                     19 (70.4)
  Female                    8 (29.6)
Ethnicity                  28
  White                     7 (25)
  Asian                    21 (75)
Local tumor stage          26
  pT1                       1 (3.8)
  pT2                       8 (30.8)
  pT3                      13 (50)
  pT4                       4 (15.4)
Lymph node stage (pN)      26
  pN0                      21 (80.8)
  pN1                       4 (15.4)
  pN2                       1 (3.8)
Histology                  28
  Pure NET                 12 (42.9)
  Mixed histology          16 (57.1)
  NET/UC                   12 (42.8)
  NET/UC/other (b)          3 (10.7)
  NET/other (b)             1 (3.6)
Treatment                  27
  Surgery alone            17 (63)
  Surgery + chemotherapy   10 (37)

Abbreviations: N, number of cases; NET, neuroendocrine tumor; UC,
urothelial carcinoma.

(a) Only cases of proven primary ureteral NETs (without synchronous
neuroendocrine neoplasms elsewhere in urinary tree or in different
organs) are included. The numbers in bold font indicate the total
number of cases for which a particular set of data is available.
(b) A second nonurothelial tumor component present with a NET as part
of a biphasic neoplasm, or a third tumor component in a neoplasm
already displaying a mixed UC/NET histology. The most frequent
nonurothelial component in mixed NETs is squamous cell carcinoma,
but adenocarcinoma and sarcomas have been also reported.
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Title Annotation:Resident Short Reviews
Author:Acosta, Andres M.; Kajdacsy-Balla, Andre
Publication:Archives of Pathology & Laboratory Medicine
Date:Jul 1, 2016
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