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stinkysulfaeggs
Great explanation - just one addition. The retroperitoneal fibrosis could also be a direct consequence of the external beam radiation. It's linked to both causes. Either way, it's a better fit than urothelial carcinoma (in retrospect).
+17
spow
Why would the onset be 15 years later though?
+3
drzed
I was thinking the same thing @spow. I had put urothelial carcinoma, thinking that a field defect would result in bilateral tumor.
+3
yesa
My understanding is the cancer risk with radiation is late-onset, a decade or more after the fact
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fatboyslim
Why does she have increased daytime and nighttime urination? I couldn't figure that part out.
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charcot_bouchard
Chance of bilateral ureteral ca is very rare. Also preincipal r/f for transitional cell ca is Smoking not radiation
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peridot
Hi temmy, yes it sounds like it would. There is a similar question from NBME 21 for those who have already taken that one (https://nbmeanswers.com/exam/nbme21/744). In that one, it's cancer in the uterus instead of bladder, but it's the same concept - the cancer can spread from the uterus into the bladder, or compress on the bladder, leading to bilateral hydroureter and hydronephrosis. So basically the takeaway point from that question and this question is that we learned a few things that can lead to bilateral hydronephrosis and hydroureter: 1. bladder cancer 2. uterine cancer 3. surgical and radiation treatment of cancer in that region, leading to bilateral fibrosis of the ureters.
+2
peridot
Whoop just realized that urothelial carcinoma is a possible answer choice here. Well, I'm lost.... :x
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abcdefbhiximab
Urothelial carcinoma presents as painless hematuria with risk factors (i.e. smoking, aniline dyes)
+2
mutteringly
In addition, the wording says "distal ureteral narrowing" which wouldn't happen with bladder cancer
+1
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submitted by โsajaqua1(607)
The patient has a prior history of hysterectomy with bilateral salpingo-oophorectomy, and received external beam radiation to the pelvis. The patient now displays hydronephrosis and hydroureter, with distal ureteral narrowing bilaterally. The likeliest option is that we are seeing adhesions from previous surgery constrict the ureters, causing this.
E) Urothelial carcinoma (also called transitional cell carcinoma) is also a possibility. What makes this unlikely is the location: bilateral. The prior hysterectomy and bilateral salpingo-oophorectomy would leave scar tissue on both sides of the body, but the odds of urothelial carcinoma arising bilaterally are very slim.
A) The patient had a hysterectomy, so the odds of recurrent cervical carcinoma are also incredibly low. C) and D) Urethral condyloma and urethral transitional cell papilloma are in the wrong location to account for bilateral urethral narrowing with hydroureter.