92 96
Case
Discussion:
A
Man
with
Two
Synchronous
and
Symptomatic
Malignancies
Related
to
Smoking:
The
Case
for
Surgery
Renzo
Colombo
Division
of
Oncology/Urology
Unit,
Urological
Research
Institute,
IRCCS
Ospedale
San
Raffaele, Milan,
Italy
1.
Clinical
features
This
unusual
and
challenging
clinical
case
concerns
an
elderly patient with negative clinical history who presented
at
the emergency unit due
to
a
recent
appearance of
severe
symptoms
including
abdominal
pain,
jaundice,
and
gross
haematuria.
Ultrasound
and
computed
tomography
scan
were
strongly
suggestive
of
the
presence
of
two
concomitant
major
cancers:
an
advanced
biliary
neoplasm
involving
adjacent
organs
and
organ-invasive
carcinoma
at
the
left
renal
pelvis.
To
relieve
the
acute
clinical
symptoms
and
overcome
the
increasing
jaundice,
biliary
duct
drainage
with
biliary
stent
placement
was
successfully
performed
and restored both an acceptable clinical status and a normal
blood-test
setting.
2.
Discussion
The
two
cancers
identified
in
this
patient
share
some
interesting
clinical
findings.
First,
both
neoplasms
were
diagnosed
only
at
an
advanced
clinical
stage
after
a
long
period of clinical silence.
It
is recognised
that
for biliary tract
cancer,
carcinogenesis
follows
a
progression
through
a
metaplasia–dysplasia–carcinoma
sequence
that
generally
takes
years
[1].
Vagueness
of
symptoms
is
generally
responsible
for
the
delay
of
diagnosis,
which
contributes
to
the
overall
progression
of
the
disease.
In
contrast,
haematuria
is
a
unique
and
late
sign
of
an
upper
tract
urinary urothelial cancer
in almost all cases.
In
this context,
the
impact
of
imaging
on
early
diagnosis
is
known
to
be
marginal.
Second,
cigarette
smoking
is
recognised
to
be
a
substantial
risk
factor
for
both
neoplasms.
This
patient
can
be
classified
as
a
strong
smoker
based
on
both
the
number
of
cigarettes
per
day
and
the
period
of
abuse.
For
upper
tract
urinary
urothelial
cancer,
smoking
has
been
definitively
associated with pathologic
stage pT2 or higher,
high
grade,
and
multifocality
at
first
diagnosis
[2,3].
In
addition,
local
and distant
recurrence
rates
are
expected
to
be
higher
in
persistent
smokers
after
nephroureterectomy
[4,5].
Although
the
level
of
evidence
is
lower,
cigarette
smoking
is also
a
risk
factor
(with
increased
risk up
to 45%)
for
pancreatic
and
liver
cancer.
A
recent meta-analysis
of
11
selected
case–control and
cohort
studies
[6],
including a
total
of
1178
cases,
showed
that
smokers
are
at
increased
risk
of
development
of
biliary
tract
cancer
compared with
nonsmokers,
regardless
of
alcohol
abuse
and
history
of
gallstones.
Third,
both
kinds
of
cancer
have
poor
prognoses when
diagnosed
at
an
advanced
stage.
In particular,
for
advanced
biliary
cancer
(stage
T3–T4),
the
overall
mortality
rate
closely
follows
incidence.
For
this
tumour,
overall
mean
survival
is a mere 6 mo, whereas
the 5-yr
survival
rate does
not exceed 5%
[7]. This means
that
surgery
is expected
to be
curative
only
in
the
subset
of
patients
found
with
stage
pT1–pT2
and
negative
surgical
margins
and
would
be
palliative
in
the
remaining
cases.
Fourth,
for
both
kinds
of
cancer
at
advanced
clinical
stage, major
international
guidelines
lack
grade
A
recom-
mendations
for
treatment.
Based
on
reduced
clinical
evidence,
the
administration
of
a
combined
chemotherapy
regimen with
cisplatin
and
gemcitabine
in
neoadjuvant
or
adjuvant
settings
is
suggested
for
both
cancers
[8,9] .3.
Treatment
recommendation
Left
nephroureterectomy
with
or
without
retroperitoneal
lymph
node
dissection
may
be
proposed
but
will
not
influence
patient
survival, which
is
predominantly
driven
by
biliary
cancer.
In
the
absence
of
severe
haematuria,
I
would
avoid
nephroureterectomy
at
this
time.
If,
based
on
imaging, hepatic artery and vena porta
involvement
leads
to
consideration of
the biliary
cancer
as unresectable,
I would
not
recommend
an
upfront
palliative
surgery.
Due
to
normal
renal
function
and
the
absence
of
comorbidities,
I would
propose
that
the
patient
be
given
first-line
palliative
chemotherapy
with
a
combination
of
gemcitabine
and
cisplatin
for
6–8
cycles.
This
treatment
may
prolong
disease-free
survival
from
6.5 mo
to
8.4 mo
[8] .If
the
patient
is
able
to
complete
the
scheduled
chemotherapy
regimen
with
bulky
tumour
response,
according
to
the
general
clinical
conditions,
combined
surgery
including hepatic and biliary
tract
resection and
left
nephroureterectomy
could
be
reconsidered.
In
the
case
of
completion
of
scheduled
chemotherapy
without
significant
clinical
response
but
with
proven
stabilised
disease,
I
would
consider
this
patient
to
be
a
candidate
for
observation.
Conflicts
of
interest:
The
author
has
nothing
to
disclose.
References
[1]
Hundal R, Shaffer EA. Gallbladder cancer: epidemiology and out- come. Clin Epidemiol 2014;6:99–109.
[2]
Simsir A, Sarsik B, Cureklibatir I, Sen S, Gunaydin G, Cal C. Prognostic factors for upper urinary tract urothelial carcinomas: stage, grade, and smoking status. Int Urol Nephrol 2011;43:1039–45.
[3]
Rink M, Zabor EC, Furberg H, et al. Impact of smoking and smoking cessation on outcomes in bladder cancer patients treated with radical cystectomy. Eur Urol 2013;64:456–64.[4]
Hagiwara M, Kikuchi E, Tanaka N, et al. Impact of smoking status on bladder tumor recurrence after radical nephroureterectomy for upper tract urothelial carcinoma. J Urol 2013;189:2062–8.
DOI
of
original
article:
http://dx.doi.org/10.1016/j.euf.2015.07.002.
address:
columbo.renzo@hsr.it.
E U R O P E A N U R O L O G Y F O C U S 1 ( 2 0 1 5 ) 9 0 – 9 392