The typical symptoms of advanced can-
cer of the stomach are well known in clin-
ical practice. The presented case con-
cerns a patient with symptoms of
left-sided renal colic, caused by a ma-
lignant tumour involving the ureter,
which was diagnosed with aCT scan. The
multifocal process, involving the stom-
ach, two parts of the colon, the left ovary
and the side of the pelvis, was confirmed
only during surgery.
The resection or partial resection of
the above-mentioned organs involved by
the malignant process and reconstruc-
tion of the alimentary tract as well as the
ureter were performed at time of this
operation. The patient’s recovery was
without any complications. The histo -
patho logical findings support the diag-
nosis of this malignant process as dis-
seminated stomach cancer.
In the available literature only two cas-
es of stomach cancer metastasis to
the ureter have been described. In both
cited examples resection of the ureter
with nephrectomy was performed. The
review of the literature supports the val-
ue of stomach palliative resection in pro-
longing life and improving quality of life.
Key words: Key words: advanced stomach cancer,
palliative stomach resection, renal colic.
Wspolczesna Onkol 2012; 16 (2): 191–193
Left-sided renal colic as a symptom
of advanced stomach cancer –
a case report
Janusz Godlewski1,2, Grażyna Kuciel-Lisieska1, Grażyna Licznerska1,
1Division of Oncology, Department of Oncological Surgery, Faculty of Medical Sciences,
University of Warmia and Mazury in Olsztyn, Poland
2Department of Human Histology and Embryology; Faculty of Medical Sciences,
University of Warmia and Mazury in Olsztyn, Poland
Gastric cancer is the second most frequent neoplasm of the alimentary tract
after the large intestine. 5,103 people in Poland were affected by it in 2008.
The case-to-death ratio of around 1 indicates unfavourable prognosis as to recovery
from this disease [1, 2]. This poor result is determined by the fact that it is rarely
(only in around 8%) detected in the form of early gastric cancer, in the mildly symp-
tomatic or asymptomatic phase. In most patients it is diagnosed at ahigher de-
gree than the 1st degree of disease progression and its classic symptoms are weight
loss, continuous and dull pain in the epigastrium, loss of appetite, nausea, vom-
iting and chronic bleeding [3, 4]. This paper presents rare symptoms of dissemi-
nated gastric cancer manifested as renal colic. The existence of gastric cancer metas-
tasis to the ureter has been described twice in the literature to date.
A female patient, age 67, was diagnosed at the district hospital (22.04-
30.04.2010) because of intensified symptoms of left-sided renal colic. Based on
the conducted USG and single-phase computed tomography tests of the abdominal
cavity and the pelvis, dilation of the ureter was found because of its infiltration
by apathological focus with the dimensions of 28mm × 15mm. Another lesion
was located nearby at the level of the left iliac muscle – 30mm × 27mm × 20mm,
adhering to the sigmoid colon. Tissue infiltration of the pelvis minor wall was found
descending in the direction of the left appendages. Colonoscopy was conduct-
ed and in this test the large intestine was described without pathology, while
the gynaecological USG test confirmed the presence of fluid in the pelvis. Dur-
ing her stay the patient was treated with analgesic and diastolic medication and
then referred for further treatment at the regional oncology centre.
Because of reported pain complaints, she was immediately admitted to the
department of oncological surgery on the day of her visit to the outpatient clin-
ic (04.05.2010). The urologist consulting the patient indicated the possibility of
kidney damage due to ureteral obstruction with recommendation for an ac-
celerated operation. Therefore, pre-operative diagnostics were not extended be-
yond the tests received from the district hospital. The patient underwent surgery
on 10.05.2010 and intraoperatively, besides the expected neoplastic tumour of
the left ovary with infiltration of the ureter, numerous neoplastic foci were also
found: asigmoid colon tumour, acaecum tumour, atumour of the body of the
stomach and two single tumours in the omentum. Because of the resectabil-
ity of the neoplastic foci described above, the operation plan adopted earlier was
changed and the following were performed in succession with palliative intention:
partial gastrectomy by the Rydygier method, right-sided hemicolectomy, left
ovariectomy and sigmoid resection. After restoring the continuity of the alimentary
współczesna onkologia/contemporary oncology
tract, the technically difficult resection of the neoplastic tumour
in the left ureter was started. The tumour occluded the lumen,
which is why segmental ureterectomy was performed with end-
to-end anastomosis over apigtail catheter. The operative pro-
cedure lasted atotal of 3 hrs 20 min. The patient passed the
post-operative period without complications, except atwo-day
fever. Because of the expected alimentary tract failure, par-
enteral nutrition was included on the 1st day after the procedure
and blood deficits were supplemented with 2 units of ery-
throcyte mass and 7 units of plasma. On the 9th day after the
operation, the patient was discharged home in a good gen-
eral condition with recommendations for further treatment.
The received postoperative histopathological protocol indicated
that the stomach was the origin of the neoplastic process. It
was the intestinal form (acc. to Lauren), type I (acc. to Gose-
ki), of astomach adenocarcinoma with aG2 malignancy de-
gree, with occupation of the whole thickness of the stomach
wall, with the following immunohistochemical characteristics:
CK7(+++), CK20(++), CA125(+), Mucicarmine(+). Neoplastic in-
filtrations along nerves and neoplastic embolisms of blood ves-
sels, as well as metastatic foci in the greater omentum, were
observed in the specimen. Because of the palliative partial gas-
trectomy type, only 3 lymph nodes were described in this spec-
imen and all of them contained neoplastic cells. Besides the
above, histopathological confirmations were obtained of the
metastatic character of the foci in the ovary, caecum and sig-
moid colon. The cancer occupied large and small intestine walls
without infiltration of the mucous membrane and the im-
munohistochemical characteristics were identical as for the
primary lesion. According to the above protocol, excision with-
in tissues with a healthy margin of these organs was
It is interesting biologically and constitutes the basis for
this paper that the ureteral tumour was described by the
pathologists not as a neoplastic infiltration encroaching on
the ureter, but as a metastatic focus to the ureteral wall.
After the operative treatment, the patient was qualified
for palliative chemotherapy and received it from 28.07.2010.
The first treatment course was according to the EOX regimen
(oxaliplatin and capecitabine), but because of the occurrence
of neutropenic fever the regimen was changed to PF (cisplatin
and 5-fluorouracil). She again received only one course and
the treatment was changed once more because newly formed
metastatic foci in the liver were located in imaging tests. Next,
three chemotherapy courses were administered according
to the FOLFIRI regimen (irinotecan, leucovorin and 5-fluo-
rouracil), but only until 11.11.2010 because due to progression
of changes in the liver described in examinations the
chemotherapy was discontinued and the patient was qual-
ified for symptomatic treatment. According to our knowledge,
the patient died in January 2011.
Fig. Fig. 1. 1. CT axial scan. The widening of the left ureter is visible
(marked by arrow)
Fig. Fig. 4. 4. Neoplastic invasion in the ureter wall. Microscopic section,
HE staining, magnification 100×
Fig.Fig. 2 2 an
Microscopic section, HE staining, magnification 40×
and d 3. 3. Focus of metastatic carcinoma in the ureter wall.
Left-sided renal colic as a symptom of advanced stomach cancer – a case report
Treatment of gastric cancer in the disseminated phase of
the disease aims at extension of life and achieving agood pal-
liative effect. The recommended methods, allowing the
above to be achieved, are chemotherapy or combination ra-
diochemotherapy. In an advanced stage, palliative operations
on this organ are performed for life reasons and serve to elim-
inate complications such as bleeding, perforation or obstruction
of the organ. It is indicated that the above complications forced
surgical intervention in 1/4 of the patients previously disqualified
from operative treatment because of the presence of metasta-
tic foci. According to literature data, patients operated on by
palliative resection in the disseminated phase of the disease
achieve asurvival time of between 9 and 15 months. The sur-
vival time is limited by the number of metastatic foci; when
their number is higher than two foci, no statistically signifi-
cant differences are observed in this scope. The value of these
procedures is increasing because of the reported low periop-
erative mortality and the observed significant improvement in
the further quality of life for these patients [5-13]. It seems that
the operative procedure conducted in the presented patient
allowed agood palliative effect to be achieved along with loss
of severe colic and maintenance of kidney function. The liter-
ature often presents, as characteristic of gastric cancer, blood-
borne metastasis to the ovary, termed aKrukenberg tumour.
Metastasis of asimilar type occurred in this patient. This is aterm
generally defining metastasis to the ovary, mainly gastric can-
cer and next colon cancer. Metastases from other organs, such
as the lungs, the mammary gland and the uterus, are also pos-
sible, though much rarer. Krukenberg tumours are encountered
in the course of 2-4% of disseminated neoplastic processes. This
is a negative prognostic factor, with varying median survival
time after its diagnosis: 12-13 months in the course of gastric
cancer compared to 17-29 months in the course of large intestine
cancer. This undoubtedly results from biological differences in
the course of these neoplasms [14-23].
In summary, the rare character of gastric cancer metas-
tasis to the ureter should be stressed.
The available literature sources have described this only twice
to date (in 1976 and 2000). However, nephroureterectomy was
conducted in these quoted cases [24, 25]. In the presented pa-
tient the kidney was spared and healing of the ureter after end-
to-end suture was achieved. No uroplania or renal failure were
observed in the postoperative period. It seems that such asur-
gical management strategy is worth presenting.
The dissemination of a neoplasm with extremely rarely
encountered symptomatology described above is an inter-
esting experience which we wanted to share. The beginning
of the symptomatic disease as a left-sided renal colic is, in
itself, a previously unreported case.
1. Zakład Epidemiologii i Prewencji Nowotworów, Centrum Onkologii
– Instytut, Krajowa baza danych nowotworowych (2008)
2. Wojciechowska U, Didkowska J, Zatoński W. Nowotwory złośliwe
w Polsce w 2006 roku. Biuletyn Centrum Onkologii 2006; 86.
3. Zarys chirurgii onkologicznej. Kopacz A (ed.). Akademia Medyczna
w Gdańsku 2000; 171.
4. Nowotwory przewodu pokarmowego. KrawczykM (ed.). Wydawnict-
wo Lekarskie PZWL, Warszawa 2001; 153-5.
5. Hartgrink HH, Putter H, Klein KE, Bonenkamp JJ, van de Velde CJ. Val-
ue of palliative resection in gastric cancer. Br J Surg 2002; 89: 1438-43.
6. Kunisaki C, Shimada H, Akiyama H, Nomura M, Matsuda G, Ono H.
Survival benefit of palliative gastrectomy in advanced incurable gas-
tric cancer. Anticancer Res 2003; 23: 1853-8.
7. Moriwaki Y, Kunisaki C, Kobayashi S, Harada H, Imai S, Kasaoka C.
Does the surgical stress associated with palliative resection for pa-
tients with incurable gastric cancer with distant metastasis short-
en their survival? Hepatogastroenterology 2004; 51: 872-5.
8. Zhang XF, Huang CM, Lu HS, Wu XY, Wang C, Guang GX, Zhang JZ,
Zheng CH. Surgical treatment and prognosis of gastric cancer in 2,613
patients. World J Gastroenterol 2004; 10: 3405-8.
9. Kahlke V, Bestmann B, Schmid A, Doniec JM, Kuchler T, Kremer B.
Palliation of metastatic gastric cancer: impact of preoperative symp-
toms and the type of operation on survival and quality of life. World
J Surg 2004; 28: 369-75.
10. Samarasam I, Chandran BS, Sitaram V, Perakath B, Nair A, MathewG.
Palliative gastrectomy in advanced gastric cancer: is it worthwhile?
ANZ J Surg 2006; 76: 60-3.
11. Kunisaki C, Makino H, Takagawa R, et al. Impact of palliative gas-
trectomy in patients with incurable advanced gastric cancer. Anti-
cancer Res 2008; 28: 1309-15.
12. Lin SZ, Tong HF, You T, et al. Palliative gastrectomy and chemotherapy
for stage IV gastric cancer. J Cancer Res Clin Oncol 2008; 134: 187-92.
13. Sarela AI, Yelluri S. Gastric adenocarcinoma with distant metasta-
sis: is gastrectomy necessary? Arch Surg 2007; 142: 143-9.
14. Yada-Hashimoto N, Yamamoto T, Kamiura S, Seino H, Ohira H, SawaiK,
Kimura T, Saji F. Metastatic ovarian tumors: areview of 64 cases. Gy-
necol Oncol 2003; 89: 314-7.
15. Cheong JH, Hyung WJ, Chen J, Kim J, Choi SH, Noh SH.Surgical man-
agement and outcome of metachronous Krukenberg tumors from
gastric cancer. J Surg Oncol 2004; 87: 39-45.
16. Cheong JH, Hyung WJ, Chen J, Kim J, Choi SH, Noh SH. Survival ben-
efit of metastasectomy for Krukenberg tumors from gastric cancer.
Gynecol Oncol 2004; 94: 477-82.
17. Gottwald L, Jakubik J, Goral E, Korczynski J, Kordek R, Bienkie -
wicz A.[Krukenberg tumor - common problem of gynecologists, sur-
geons oncologists and pathologists. Report of three cases and re-
view of the literature]. Ginekol Pol 2006; 77: 58-62.
18. Kiyokawa T, Young RH, Scully RE. Krukenberg tumors of the ovary:
aclinicopathologic analysis of 120 cases with emphasis on their vari-
able pathologic manifestations. Am J Surg Pathol 2006; 30: 277-99.
19. Young RH. From krukenberg to today: the ever present problems posed
by metastatic tumors in the ovary: part I.Historical perspective, gen-
eral principles, mucinous tumors including the krukenberg tumor.
Adv Anat Pathol 2006; 13: 205-27.
20. Young RH. From Krukenberg to today: the ever present problems
posed by metastatic tumors in the ovary. Part II. Adv Anat Pathol 2007;
21. Yook JH, Oh ST, Kim BS. Clinical prognostic factors for ovarian metas-
tasis in women with gastric cancer. Hepatogastroenterology 2007;
22. Jiang R, Tang J, Cheng X, Zang RY. Surgical treatment for patients with
different origins of Krukenberg tumors: outcomes and prognostic
factors. Eur J Surg Oncol 2009; 35: 92-7.
23. Kim WY, Kim TJ, Kim SE, Lee JW, Lee JH, Kim BG, Bae DS. The role of
cytoreductive surgery for non-genital tract metastatic tumors to the
ovaries. Eur J Obstet Gynecol Reprod Biol 2010; 149: 97-101.
24. Fitch WP, Robinson JR, Radwin HW. Metastatic carcinoma of the
ureter. Arch Surg 1976; 111: 874-6.
25. Shimoyama Y, Ohashi M, Hashiguchi N, et al. Gastric cancer recognized
by metastasis to the ureter. Gastric Cancer 2000; 3: 102-5.
Address for correspondence
Janusz GodlewskiJanusz Godlewski MD, PhD
10-628 Olsztyn, Poland
tel. +48 698 694 528