Original ArticleFrequency and etiology of unexplained bilateral hydronephrosis in patients with breast cancer: results of a longitudinal CT study
Introduction
Breast cancer is the most common fatal cancer in women and accounts for 41,000 deaths annually in the United States [1]. The two major histological subtypes are invasive ductal and invasive lobular carcinoma, which account for approximately 85% and 15% of cases, respectively [1], [2]. Mortality is primarily due to the development of metastases, which occur in about 15% of patients [3]. Imaging, particularly CT, plays a key role in the detection of metastases, with common sites of spread being bone, lung, and liver [4]. Variations in the pattern of metastatic spread are recognized. For example, invasive lobular carcinoma has a predilection for spread to the gastrointestinal tract, genitourinary system, hollow organs, and retroperitoneum [2], [5], [6], [7]. On occasion, metastases may involve unusual sites such as the ureters [8], [9], [10], [11], [12], [13]. Descriptions of ureteral involvement are composed mainly of autopsy studies or case reports of patients presenting in acute renal failure, although a recent case report suggests ureteral involvement may present as hydronephrosis without obvious obstructing pathology [14]. However, the frequency with which breast cancer metastasizes to the ureters has not been established and most of the available literature is dated and lacks modern CT correlates. Therefore, we undertook this study to investigate the frequency and etiology of unexplained bilateral hydronephrosis in patients with breast cancer undergoing serial CT.
Section snippets
Subjects
The committee on human research approved this HIPAA-compliant study and waived written informed consent (CHR# 10-04269). For this study, we utilized a previously reported single-institution database composed of 153 patients with a histopathological diagnosis of breast cancer and two or more contrast-enhanced abdominal CT scans performed over a 10-year period [15]. Patients with additional known primary cancers were excluded from the database. Histologic findings, follow-up, and the
Results
Six patients developed hydronephrosis on serial CT surveillance (mean follow-up 46 months, range 35–90) months, and in two patients the hydronephrosis was unexplained and lacked an obvious etiology when first detected. In the other four patients, hydronephrosis was due to radiographic evidence of obvious obstructive bulky retroperitoneal adenopathy (three cases) or pelvic outlet obstruction secondary to lymphoceles (one case). Both patients developing unexplained hydronephrosis were among the
Discussion
Our results suggest that the development of unexplained hydronephrosis during serial CT follow-up in patients with breast cancer likely reflects malignant involvement of the ureters by metastatic lobular carcinoma. The surgical and histopathologic findings, as well as the lack of a visible obstructing mass on CT in the two patients who developed this finding, suggests the metastatic involvement is infiltrative rather than mass-like, and likely primarily in the wall of the ureters. This pattern
References (24)
- et al.
Distribution of metastases in breast carcinoma: CT evaluation of the abdomen
Clin Imaging
(1991) - et al.
Primary and metastatic lobular carcinoma of the breast
Clin Radiol
(2001) - et al.
Hydronephrosis secondary to ureteral obstruction by metastatic breast cancer
J Urol
(1969) - et al.
Cancer of the breast
- et al.
Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast
Surgery
(1993) - et al.
Infiltrating lobular carcinoma of the breast. Clinicopathologic analysis of 975 cases with reference to data on conservative therapy and metastatic patterns
Cancer
(1996) Breast carcinoma: pattern of metastasis at autopsy
J Surg Oncol
(1983)- et al.
Metastatic lobular carcinoma of the breast: patterns of spread in the chest, abdomen, and pelvis on CT
AJR Am J Roentgenol
(2000) - et al.
Radiographic diagnosis of ureteral involvement by metastatic breast cancer
Radiology
(1969) - et al.
Ureteral obstruction from metastatic breast carcinoma
Arch Pathol
(1975)
Acute renal failure due to bilateral ureteral obstruction by metastases from breast cancer
Nephron
Ureteral obstruction in patients with breast cancer
Cancer
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