Vol. 114, October

Copyright© 1975 by The Williams & Wilkins Co.

Printed in U.S.A.




From th e Departments of Urologv and Pathologv. The Second Tokyo National Hospital. T okvo, Japan


A 74-year-old Japanese woman with a dissemin ated metastatic mela noma in the right ureter is described . CASE REPORT

A 74-year-old Japanese woman was referred to our outpatient clinic because of macroscopic hematuria with cystitis symptoms. Urinary tract antiseptics were given for 1 week without improvement in the hematuria. Cystoscopic examina tion revealed right ureteral bleeding and the patient was hospitalized on November 28, 1973 for malignant tumor in the upper urinary tract. The patient had been in good health until 2 years ago when palate and cutaneous nevoid nodules were repeatedly excised. Initial pathological examination of the specimens disclosed no definite evidence of malignancy and was compatible wit h the so-called blue nevus. However, final diagnosis was malignant melanoma primar:,- to the oral palate. Physical examination was essentially negative except for a black pigmented nevus, 2 cm. in diameter, in the right lower abdomina l wall. The bilateral a xillary areas were negative for noda l involvement on pa lpation . Although blood urea nitrogen was 22 mg. per cent and creat inine was 1.40 mg. per cent, phenolsulfonphthalein test was 49 per cent in the 2-hour total and creatinine clearance was 50 ml. per minute. There was no pathological change in bleeding and clotting tim e. Hemoglobin was 12.7 mg. per di. and hematocrit was 40 per cent. White blood cell count (WBC) was 6,700 with a normal differential but reticulocyte count was 7%o and platelet count was 17.7 times 10'. There was no evidence of anemia and red blood cell count (RBC) was 4.43 times 10'. Urinalysis showed numerous RBCs and slight proteinuria but almost no WBCs or casts could be observed. An excretory urogra m (IVP) revealed a normal collecting system with acceptable drainage on the left side but no visualization on the right side. The scintigram showed almost the same find ings as those on IVP. The aortogram disclosed the right main renal artery with a poor blood distribution in the right kidney. Chest x-ray showed metastatic shadows in the entire field. To make a definite diagnosis and at the famil y's request right nephroureterectomy and partial cystectom y were performed through a right lumba r Accepted for publication April 18. 197S .

skin mc1s10n. On the renal surface several pigmented freckles were observed and the ureter was black in color in the entire length but no pathological changes were found in the urinary vesical wa ll. A cross section of the affected ureter showed that most of the ureteral wall was completely replaced with neoplastic tissue (part A of figure) . Histological examination disclosed metastatic melanoma of the ureter and kidney. The proliferated melanoma cells were mostly ellipsoid and frequently the cyst plasma was heavily pigmented (part B of figure). The ureteral serosa was not involved. The kidne.v present ed a moderate degree of hydronephrotic contract ion weighing 80 gm. The remaining renal parenchyma showed· moderate atrophic changes . The glomeruli were mostly ruined and hyaline degeneration was frequently observed. The tubuli were moderately dilated and colloidal casts were present. Occasionally deposited melan in-pigments were noticed in the tubula r epithelium. following melanin-laden casts in the tubular cavities . The postoperat ive course was uneventful and the patient was discharged from the hospit al on January 11, 1974. She returned to the hospital on May 19 because of a moderate degree of dyspnea and macroscopic hematu ria . No treatment was effective and the patient died on Mav 2:3. :\lecropsy revea led multifocal generali zation of malignant melanoma in the liver. lungs. skeletal bones a nd so forth. No evidence of metastasis in the urinary system except in the left kidney was obtained. DlSCl!SSIOI\

The reasons we perform ed the operat ion despite the evidence of metastatic tumors in the chest x-ray were: I) to control the gross he maturia. which was considered an essential life-savi ng procedure. and :2) we could not make a definit e diagnosis because the excised sk in tissue showed uncommon histologica l features of mali gnant mela noma . The so-called blue nevus does not ori ginate from mela nocytes but rat her from pigmented cel ls of mesodermal origin which a re blue-black in color a nd this must be diffe rentia ted from the pigment ed mole. which is brown in color. However. malignant tumor origi -







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iw.a~~"':. '; A, cross section of affected ureter shows ureteral wall completely replaced with neoplastic tissue. B, microscopic findings of affected ureter reveal proliferated melanoma cells mostly ellipsoid and frequent, heavily pigmented cytoplasm.

nates from melanocytes in the epidermis whether in normal skin, in lentigo or in the epidermal component of a benign pigmented nevus. According to Becker, however. the clinical diagnosis of malignant melanoma was correct in only about half of the cases studied. 1 Melanin deposition in the kidney is not so common. The lumina of the loops of Henle, especially the excretory ducts, are frequent sites where melanin-laden casts can be found. We did not perform preoperative studies on melauria or melanocyte and both studies were negative postoperativelv. Of the 9 cases of malignant melanoma involving the ureter previously reported 6 originated in the

skin' and I each originated in the adrenal gland,3 the choroid layer of the eye• and the female urethra. 5 REFERENCES 1. Becker. S. W.: Pitfalls in diagnosis and treatment of melanoma. Arch. Dermat. Syph., 69: 11, 19.54.

2. Edson, :VI. and Hutchins. K. H.: Metastatic melanoma of ureter. \LY. State ,J. Med., 73: 459, 197:3. :3. Kniseley. R. M. and Baggenstoss, A. H.: Primary melanoma of adrenal gland. Arch. Path .. 42: :345. 1946.

4. ,Judd, R. L.: Melanoma of the ureter: a case report. ,J. lJrol., 87: 805 , 1962. 5. Shaw, E. C.: Primary tumor of the female urethra with metastasis to each ureter. ,J. lJrol., 34: 244, 19:35_


Disseminated metastatic ureteral melanoma: a case report.

THE JOURNAL OF UROLOGY Vol. 114, October Copyright© 1975 by The Williams & Wilkins Co. Printed in U.S.A. DISSEMINATED METASTATIC URETERAL MELANOMA...
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