Ureteral carcinoma is a tumor that may be located in any part of the ureter. This malignancy is commonly referred to as urothelial tumor of the renal pelvis and ureter; the greatest majority of the neoplasms are of urothelial nature and isolated ureteral cancer is a rare medical occurrence with few pertaining literary documentations [1].

The predominant manifesting symptom of a primary ureteral carcinoma is gross hematuria, often with no other accompanying symptoms, either specific to a urinary tract pathology or constitutional [2]. The second most frequently reported complaint is a flank pain, observed in 1 in 5 patients diagnosed with a ureteral carcinoma [3]. Flank pain can be initially misdiagnosed as originating from an episode of renal colic due to ureterolithiasis, and in a case of ureteral carcinoma, the painful feeling is attributed to blood clots forming in the area. An equal percentage of patients also present with a palpable lumbar mass and less than 10% report dysuric symptoms, such as pain or burning upon urination and an increased frequency to urinate. Generalized manifestations such as weight loss and skeletal pain are rarely documented and are a sign of progressed malignant disease.

A ureteral carcinoma can also occur as a metastatic tumor, in which case most patients report no symptomatology and are diagnosed incidentally [4] [5]. The minority of patients who experience cancer-related symptomatology present with dysuric symptoms consistent with a renal colic due to obstruction (flank pain) or a urinary tract infection. Hematuria is also a symptom of a metastatic ureteral carcinoma and, in the uncommon case where the ureters are bilaterally affected, patients may present with anuria [6] [7].

• Recurrent Urinary Tract Infection

  Eighty days after transplantation complete obstruction of the proximal ureter was observed, complicated by recurrent urinary tract infections. [ncbi.nlm.nih.gov]

  She had previously been treated five times by her local general practitioner for recurrent urinary tract infections. The only relevant finding on clinical examination was that of an ill-defined left flank mass with pain on palpation. [liebertpub.com]

  The other clinical features included recurrent urinary tract infections, microscopic or gross haematuria as in our reported case 7. Imagings are usually sufficient to make diagnosis of retrocaval ureter. [latunisiemedicale.com]

  urinary tract infection ; urethral discharge and swelling". [4] Risk factors [ edit ] Tobacco smoking is associated with an increased risk of ureteral cancer. [5] Diagnosis [ edit ] Example of ureteral cancer Diagnosis may include a fluorescence in situ [en.wikipedia.org]

  Regarding risk factors, tobacco smoking was referred by 66% of the patients and 33% had recurrent urinary tract infections or calculi. In one patient there was an hereditary nonpolyposis colorectal cancer syndrome associated (3%). [scielo.br]

• Dry Cough

  Case Presentation An 80-year-old Japanese female presented with a 1-month history of progressive dyspnea and dry cough. [karger.com]

• Tachypnea

  On admission, she had tachycardia (102 beats per minute), tachypnea (32 respirations per minute), and normotensive blood pressure (123/75 mm Hg). Initial oxygen saturation was 83% with the patient breathing room air. [karger.com]

• Abdominal Pain

  Two of the three patients had abdominal pain, while the other patient had no upper urinary tract symptoms. All patients had excretory urograms that showed delayed or no excretion of contrast medium on the side of obstruction. [jamanetwork.com]

  A 79-year-old woman visited her home doctor with the chief complaint of right lower abdominal pain. Abdominal computed tomographic scan (CT) disclosed a tumor measuring about 5 cm in diameter at the right lower quadrant of the abdomen. [ncbi.nlm.nih.gov]

  If papillary urothelial carcinoma spreads, it can cause other signs and symptoms, including: loss of appetite swelling in feet pelvic pain abdominal pain tiredness jaundice fever weight loss Bladder cancer overview Bladder cancer can affect any part of [medicalnewstoday.com]

  At about 12 months after surgery, the patient had symptoms of frequent urination, urgency, dysuria, and abdominal pain. [dovepress.com]

• Left Flank Pain

  This is the case report of a 69‑year‑old male patient who presented with left flank pain and gross hematuria. Following diagnosis of ureteral carcinoma, nephroureterectomy was performed. [spandidos-publications.com]

  Case Presentation A 39-year-old, HIV-negative woman presented with a 1-year history of worsening left flank pain, intermittent visible hematuria, and a fullness in the left flank. [liebertpub.com]

  The clinical symptom was just left flank pain. Imageology examination showed the hydronephrosis and occupied lesions. Compared with other cases, this one is maybe in an early stage of the tumour. [ncbi.nlm.nih.gov]

• Tachycardia

  On admission, she had tachycardia (102 beats per minute), tachypnea (32 respirations per minute), and normotensive blood pressure (123/75 mm Hg). Initial oxygen saturation was 83% with the patient breathing room air. [karger.com]

• Myalgia

  The patient tolerated adjuvant chemotherapy and radiation therapy well, with no significant side effects or adverse reactions, except for intermittent nausea, vomiting and generalized myalgia. [wjso.biomedcentral.com]

  Side effects and complications of intravesical BCG The following side effects and complications can be seen after intravesical instillation of BCG: Flu-like symptoms: fever, malaise, fatigue, myalgias, arthralgias. [cancertherapyadvisor.com]

• Hematuria

  Hematuria is also a symptom of a metastatic ureteral carcinoma and, in the uncommon case where the ureters are bilaterally affected, patients may present with anuria. [symptoma.com]

  Gross hematuria was present in all the patients. Three cases had multicentric tumor sites. Three tumors were located in the distal ureter. Four cases showed a non functioning kidney at IVP. [ncbi.nlm.nih.gov]

• Flank Pain

  The second most frequently reported complaint is a flank pain, observed in 1 in 5 patients diagnosed with a ureteral carcinoma. [symptoma.com]

  He presented with bilateral flank pain accompanied by nausea, vomiting and oliguria. Bilateral hydronephrosis with upper ureteral filling defects was found on antegrade pyelogram. [ncbi.nlm.nih.gov]

  We report a 70-year-old woman who presented with left-sided flank pain. The clinical impression and diagnosis following renal ultrasound was of a calculus in the distal left ureter. [bjuinternational.com]

  The patient is a 70 year-old man who presented with bilateral flank pain. Laboratory investigations showed high serum creatinine. There was left hydronephrosis on ultrasonography. [omicsonline.org]

• Macroscopic Hematuria

  However, on urinalysis, there was macroscopic hematuria and 40–50 white blood cells per high-power field. [spandidos-publications.com]

  The vast majority of patients with bladder cancer present with microscopic or macroscopic hematuria (85%). Intermittent painless gross hematuria is the most common presentation. [cancertherapyadvisor.com]

  Rhéaume-Lanoie J, Lepanto L, Fradet V et al: Diagnostic performance of ultrasound for macroscopic hematuria in the era of multidetector computed tomography urography. Can Assoc Radiol J 2014; 65: 253. [auanet.org]

• Pelvic Pain

  If papillary urothelial carcinoma spreads, it can cause other signs and symptoms, including: loss of appetite swelling in feet pelvic pain abdominal pain tiredness jaundice fever weight loss Bladder cancer overview Bladder cancer can affect any part of [medicalnewstoday.com]

  Patients present with abnormal vaginal bleeding and can have pelvic pain from local spread of disease or inflammation (, 3 ). [pubs.rsna.org]

  Diabetes mellitus Apex 3.3 Partial cystectomy TCC, G2, with squamous and glandular differentiation osteochondrosarcoma pT2 min N/A 38 (51) F/75 Hematuria, pelvic pain von Recklinghausen disease Left trigone 11 Cystectomy High grade TCC with glandular [onlinelibrary.wiley.com]

• Bilateral Flank Pain

  He presented with bilateral flank pain accompanied by nausea, vomiting and oliguria. Bilateral hydronephrosis with upper ureteral filling defects was found on antegrade pyelogram. [ncbi.nlm.nih.gov]

  The patient is a 70 year-old man who presented with bilateral flank pain. Laboratory investigations showed high serum creatinine. There was left hydronephrosis on ultrasonography. [omicsonline.org]

The complete workup involved in diagnosing a ureteral carcinoma consists of blood laboratory testing, imaging modalities and histopathologic assessment of the lesion.

Laboratory testing aims at the evaluation of the general patient status as well as kidney function. A complete blood count and biochemical profile are performed, alongside prothrombin time, international normalized ratio and activated partial thromboplastin time tests, in order to eliminate potential abnormalities in the coagulation process. Urinalysis is a basic initial test since it allows for the confirmation of hematuria and helps to rule out a simple urinary tract infection that could account for the same symptoms elicited by a ureteral carcinoma. As far as imaging is concerned, excretory urography has been presently replaced to a large extent by computerized tomography (CT). A CT urogram that focuses extensively on the excretory stage of urination can illustrate tumors of the ureters, primarily those that are larger than 5 mm in size. CT scans also aid in determining the extent to which a malignancy has spread peripelvically or periureterally, although it contributes very little to the staging process of a transitional cell carcinoma.

Cytology evinces a satisfactory accuracy rate in diagnosing high-grade ureteral carcinomas and more aggressive disease, whereas, in the case of low-grade malignant lesions, the analysis renders cancer-negative results in most of the samples [8]. Low-grade neoplastic lesions are better detected with the use of fluorescence in situ hybridization (FISH) [9] [10]. Ureteroscopy is usually also employed in order to directly visualize a ureteral carcinoma [11].

• Left Shift of WBC

  Because of clinical findings of fever, a left shift of WBCs, and elevation of C-reactive protein level, the condition of one of our patients ( Fig. 6 ) was diagnosed as a urinary tract infection. [ajronline.org]

1. Ito Y, Kikuchi E, Tanaka N, et al. Preoperative hydronephrosis grade independently predicts worse pathological outcomes in patients undergoing nephroureterectomy for upper tract urothelial carcinoma. J Urol. 2011;185:1621–1626.
2. 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: 181.
3. Xiong X, Jia L, Wang J. Primary adenocarcinoma of the renal pelvis, ureter and the urinary bladder: A case report and review of the literature. Oncol Lett. 2016 Mar; 11(3): 1811–1814.
4. Cohen WM, Freed SZ, Hasson J. Metastatic cancer to the ureter: a review of the literature and case presentations. J Urol. 1974;112:188–189.
5. Winalski CS, Lipman JC, Tumeh SS. Ureteral neoplasms. Radiographics. 1990;10:271–283.
6. Richie JP, Withers G, Ehrlich RM. Ureteral obstruction secondary to metastatic tumors. Surg Gynecol Obstet. 1979;148:355–357.
7. Puech JL, Song MY, Joffre F, et al. Ureteral metastases- computed tomographic findings. Eur J Radiol. 1987;7:103–106.
8. Brien JC, Shariat SF, Herman MP, Ng CK, Scherr DS, Scoll B. Preoperative hydronephrosis, ureteroscopic biopsy grade and urinary cytology can improve prediction of advanced upper tract urothelial carcinoma. J Urol. 2010 Jul. 184(1):69-73.
9. Luo B, Li W, Deng CH, Zheng FF, Sun XZ, Wang DH. Utility of fluorescence in situ hybridization in the diagnosis of upper urinary tract urothelial carcinoma. Cancer Genet Cytogenet. 2009 Mar. 189(2):93-7.
10. Mian C, Mazzoleni G, Vikoler S, Martini T, Knuchel-Clark R, Zaak D. Fluorescence in situ hybridisation in the diagnosis of upper urinary tract tumours. Eur Urol. 2010 Aug. 58(2):288-92.
11. Sarosdy MF, Kahn PR, Ziffer MD, Love WR, Barkin J, Abara EO. Use of a multitarget fluorescence in situ hybridization assay to diagnose bladder cancer in patients with hematuria. J Urol. 2006 Jul. 176(1):44-7.