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Transitional Cell Carcinoma of the Ureter in a Patient With Buttock Pain: A Case Report

      Abstract

      Murphy DR, Morris NJ. Transitional cell carcinoma of the ureter in a patient with buttock pain: a case report.
      This case reports on a patient with an unusual presentation of a rare tumor: urethral transitional cell carcinoma (TCC). Urethral TCC occurs in approximately 0.7% to 4.0% of patients who have had primary bladder cancer. The initial symptoms usually involve hematuria, with approximately a third of patients reporting flank area pain. Buttock pain and the absence of hematuria are uncommon with this disorder. The patient was initially suspected to have piriformis syndrome, but when he did not respond as expected to treatment, and because of his history of primary bladder cancer, further evaluation was undertaken and the diagnosis was made. The patient responded well to radiation and chemotherapy. Musculoskeletal physicians should be particularly suspicious of the presence of urethral TCC in a patient with a history of primary bladder cancer who reports low back or buttock pain, particularly if the patient does not respond quickly to treatment.

      Key Words

      PATIENTS WITH MUSCULOSKELETAL complaints only uncommonly have potentially serious pathology as the primary cause. However, some patients exhibit characteristics that should alert physicians to the possibility of a non-musculoskeletal process requiring further investigation. Urethral transitional cell carcinoma (TCC) is a rare tumor that occurs in 0.7% to 4.0% of people who have had primary bladder cancer.
      • Kirkali Z.
      • Tuzel E.
      Transitional cell carcinoma of the ureter and renal pelvis.
      It most commonly occurs in the sixth and seventh decades, rarely occurring in people under the age of 50.
      • Kirkali Z.
      • Tuzel E.
      Transitional cell carcinoma of the ureter and renal pelvis.
      Gross and microscopic hematuria is the most common symptom in patients with renal pelvic or ureteral tumors and is present in more than 75% of the patients. About a third of these patients report flank pain. Urinary frequency and weight loss are less common. However, in 10% to 15% of the patients, the lesion may be completely asymptomatic.
      • Stenzl A.
      • Bartsch G.
      • Rogatsch H.
      The remnant urothelium after reconstructive bladder surgery.
      We report on a patient who was complaining of right buttock pain, which was suspected to be primarily of muscular origin, but for whom the ultimate diagnosis was urethral TCC.

      Case Description

      The patient was a 69-year-old man who complained of right buttock pain that extended into the posterior thigh, remaining above the knee. It developed insidiously, but became severe after a 3-hour airplane trip. Pain was constant, although it increased with walking. He denied the presence of neurologic symptoms in the lower extremities as well as bowel or bladder difficulty, including hematuria, but he was being treated for primary bladder cancer. He also had a history of prostate cancer that had been treated 11 years previously with prostatectomy.
      His vital signs were normal and his neurologic examination was unremarkable. Right-sided straight-leg raise test with and without ankle dorsiflexion was nonpainful. Palpable tightness and exquisite tenderness were noted to palpation of the right piriformis muscle, which reproduced the patient’s buttock pain. Decreased joint play, that is, involuntary movement of the joint induced by manual forces induced by the practitioner,
      • Mennel J.M.
      Back pain.
      • Hungerford B.
      • Gilleard W.
      • Lee D.
      Altered patterns of pelvic bone motion determined in subjects with posterior pelvic pain using skin markers.
      was noted in the right hip.
      He was diagnosed with right piriformis trigger points and hip joint dysfunction and was treated with manipulation to the hip joint and postisometric relaxation
      • Lewit K.
      Postisometric relaxation in combination with other methods of muscular facilitation and inhibition.
      to the piriformis muscle. He was treated 3 times, after which he reported that he felt some relief after each treatment, but the pain would return. No new symptoms had developed.
      At that point, the patient was referred for magnetic resonance imaging (MRI) of the pelvis. The MRI revealed a mass in the right lower pelvic wall that was reported as involving the right obturator internis muscle, a muscle located near the piriformis muscle (Fig 1, Fig 2).
      • Papadopoulos E.L.
      • Khan S.N.
      Piriformis syndrome and low back pain: a new classification and review of the literature.
      The mass was suspected to be metastasis from the primary bladder cancer. The patient’s oncologist was alerted to the finding and the patient saw his oncologist. He was found to have transitional cell urethral TCC. He was treated with radiation and chemotherapy using gemcitabine and cisplatin. Stent placement was also done to prevent hydronephrosis. Follow-up positron emission tomography (PET) scan 1 year later was essentially normal, suggesting clinical remission. However, 6 months later the patient had recurrence of the urethral TCC and had another bout of radiation and chemotherapy. He did well with this second line of treatment and 20 months after initial diagnosis, he continued to be disease-free.
      Figure thumbnail gr1
      Fig 1A T2-weighted MRI image of the pelvis showing a 48.25mm lesion in the right lower pelvic wall.
      Figure thumbnail gr2
      Fig 2A contrast-enhanced MRI of the pelvis showing high-signal intensity of the lesion (arrow).

      Discussion

      Urethral TCC is relatively rare, but should be suspected in the patient who has a history of primary bladder carcinoma, particularly if hematuria is reported. If pain is reported, it is most typically described as being located in the flank area. The case we report was interesting in that the patient was specifically asked about hematuria, but he denied this. Also, his pain was located in the buttock, rather than the flank. His physical examination suggested muscle pain involving the piriformis muscle; however, treatment for this diagnosis, which is believed to be effective in most cases,
      • Papadopoulos E.L.
      • Khan S.N.
      Piriformis syndrome and low back pain: a new classification and review of the literature.
      did not bring about resolution to the problem. It was felt that, despite his history of bladder cancer, it was prudent to undergo a trial of treatment for the suspected piriformis syndrome, particularly given the absence of hematuria. After 3 treatments, however, there was no lasting change in his symptoms; hence, MRI of the pelvis was ordered. The MRI raised the suspicion of neoplasm, which was confirmed by computed tomography and PET scans. These imaging studies revealed a mass in the vicinity of the right obturator internis muscle. The obturator internis is among a group of muscles in the pelvis, which, along with the piriformis, superior gemellus, inferior gemellus, and quadratus femoris, are located deep to the gluteus maximus and function as external rotators of the hip.
      • Papadopoulos E.L.
      • Khan S.N.
      Piriformis syndrome and low back pain: a new classification and review of the literature.
      It may be that the involvement of the obturator internis muscle is the reason that the clinical presentation was similar to that of the typical piriformis syndrome.
      It is important for physicians who see patients with spine or pelvic pain to be aware of visceral or carcinomatous processes that may mimic common musculoskeletal disorders. Many of these processes are serious and potentially life threatening, so early diagnosis is essential. Often there are signs or symptoms that are specific indicators of the disease, but the presence of these signs or symptoms cannot be counted on in all cases, as we found in the case presented here. One of the most important red flags for a non-musculoskeletal cause of symptoms is lack of response to treatment of the suspected musculoskeletal entity.
      • Joines J.D.
      • McNutt R.A.
      • Carey T.S.
      • Deyo R.A.
      • Rouhani R.
      Finding cancer in primary care outpatients with low back pain A comparison of diagnostic strategies.
      Most spinal or pelvic disorders, when correctly diagnosed, can be expected to respond fairly quickly to specific treatment,
      • Childs J.D.
      • Fritz J.M.
      • Flynn T.W.
      • et al.
      A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study.
      so one should begin the investigation for possible alternate diagnoses as soon as it becomes clear that the patient is not responding as expected.
      In patients presenting with buttock pain, the physician should be alert to the possibility of pathologic processes such as rectal carcinoma.
      • Akasu T.
      • Yamaguchi T.
      • Fujimoto Y.
      • et al.
      Abdominal sacral resection for posterior pelvic recurrence of rectal carcinoma: analyses of prognostic factors and recurrence patterns.
      In addition, particularly if the patient is a young woman, one must be suspicious of perineal tumor
      • Mourra N.
      • Hoeffel C.
      • Gaujoux S.
      • Coindre J.M.
      • Flejou J.F.
      Myxoid perineal tumour in a 25-year-old woman.
      • Fetsch J.F.
      • Laskin W.B.
      • Lefkowitz M.
      • Kindblom L.G.
      • Meis-Kindblom J.M.
      Aggressive angiomyxoma: a clinicopathologic study of 29 female patients.
      or endometriosis.
      • Troyer M.R.
      Differential diagnosis of endometriosis in a young adult woman with nonspecific low back pain.
      Other local tumors such as those involving the sciatic nerve
      • Consales A.
      • Poppi M.
      • Stumpo M.
      Sciatic schwannoma spanning the sciatic notch: removal by an anterior, transabdominal approach.
      should also be considered. Sacral stress fractures should be suspected in patients who are athletic, particularly those who are runners or volleyball players.
      • Shah M.K.
      • Stewart G.W.
      Sacral stress fractures: an unusual cause of low back pain in an athlete.
      Other rare disorders that can cause buttock pain include gluteal artery pseudoaneurysm
      • Yurtseven T.
      • Zileli M.
      • Goker E.N.
      • Tavmergen E.
      • Hoscoskun C.
      • Parildar M.
      Gluteal artery pseudoaneurysm, a rare cause of sciatic pain: case report and literature review.
      • Nunoo-Mensah J.W.
      • Ritter M.P.
      • Wasserberg N.
      • Ortega A.
      • Harrell D.
      Pseudoaneurysm of the inferior gluteal artery: an unusual complication after abdominoperineal resection for rectal cancer Report of a case.
      and tumors of the sacrum and pelvis.
      • Althausen P.L.
      • Schneider P.D.
      • Bold R.J.
      • Gupta M.C.
      • Goodnight J.E.
      • Khatri V.P.
      Multimodality management of a giant cell tumor arising in the proximal sacrum case report.
      • Wurtz L.D.
      • Peabody T.D.
      • Simon M.A.
      Delay in the diagnosis and treatment of primary bone sarcoma of the pelvis.

      Conclusions

      We presented the case of a patient with buttock pain, which was initially suspected to be of muscular origin, but was ultimately diagnosed as urethral TCC. Because urethral TCC is a potentially life-threatening illness, it is important to make the diagnosis early so that treatment can be instituted. Musculoskeletal physicians should be particularly suspicious of the presence of urethral TCC in a patient with a history of primary bladder cancer who reports low back or buttock pain, particularly if the patient does not respond quickly to treatment. All patients with back or buttock pain with a history of bladder cancer should be questioned about hematuria.

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