Case 13-2002

Abstract

A 43-year-old man was admitted to the hospital because of hemoptysis and dyspnea.The patient had been well until 28 months earlier, when pain in the right flank and hematuria developed. Cytologic examination of the urine showed malignant tumor cells. An intravenous urographic study revealed a tumor in the right ureter and renal pelvis. A computed tomographic (CT) scan of the abdomen disclosed no evidence of metastatic disease. A right nephroureterectomy was performed, with a finding of grade 3 (poorly differentiated), papillary transitional-cell carcinoma that involved the ureter and renal pelvis; the tumor was classified as stage T3, N0. A CT scan of the chest, obtained postoperatively, showed a small right-sided pleural effusion but no other abnormalities. Twenty-five months before the current admission, adjuvant chemotherapy consisting of four cycles of cisplatin, methotrexate, and vinblastine was begun; it was completed four months later. A thoracic CT scan obtained 17 months before admission revealed no abnormalities. An abdominal and pelvic CT scan showed surgical clips and evidence of the right nephrectomy. The detection of several small lymph nodes in the aortocaval space suggested the presence of metastasis. No other abnormalities were observed.Fourteen months before the current admission, an abdominal and pelvic CT scan revealed abnormal numbers of lymph nodes, all less than 1 cm in diameter; no other abnormality was detected. A repeated CT scan obtained four months later disclosed a softtissue density that surrounded the celiac axis and the origin of the superior mesenteric artery. The multi-ple paraaortic lymph nodes were larger and more numerous than on the previous scan, and there was nonhomogeneous enhancement of the liver, a finding consistent with the presence of fatty infiltration but not metastatic disease. No other abnormalities were detected. Chest radiographs showed no abnormalities.Nine months before admission, examination of a specimen of the largest lymph node (obtained by CT-guided needle biopsy) disclosed metastatic transitional-cell carcinoma. A thoracic CT scan revealed a new parenchymal opacity, 1.5 by 2.0 cm, in the lingula at the left diaphragm. An abdominal and pelvic CT scan revealed lymph nodes as large as 2.4 by 1.6 by 3.5 cm; they extended along the aorta to the level of the superior mesenteric artery and celiac axis. Tumor surrounded the mesenteric vessels and extended to the hepatic portal, and there were changes that suggested the presence of intrahepatic thrombosis in several branches of the right portal vein.Eight months before admission, an indwelling central venous catheter was inserted, and investigational chemotherapy was begun; the regimen consisted of paclitaxel, gemcitabine, and dexamethasone given in 12 doses over about a 24-week period. Four months before admission, a thoracic CT scan revealed a platelike opacity, 1.9 by 0.7 cm, in the left lower lobe; it was suspected to represent subsegmental atelectasis or scarring. No mediastinal or hilar lymphadenopathy or m...