The common symptoms of upper urinary tract urothelial carcinoma (UTUC) include hematuria, dysuria, and flank pain, which are usually localized disease. UTUC with extension of iliac vein and initial finding of deep venous thrombus is relatively rare condition. We describe a case of metastatic ureteral urothelial carcinoma presenting with deep vein thrombosis causing painful left lower limb swelling.

A 75-year-old man with medical history of hypertension, asthma and benign prostate hyperplasia underwent transurethral resection was admitted to cardiology ward with left lower limb swelling and pain for one week. The venography of lower extremity revealed suspicious thrombus in left common, external iliac and femoral vein (Fig. 1). Due to acute kidney injury, renal ultrasound exam was performed and showed left severe hydronephrosis. Abdomen computed tomography (CT) scan reported space-occupying lesions in left distal ureteral with obstructive uropathy, para-aortic lymphadenopathy and thrombus in left common iliac, external iliac and femoral vein (Fig. 2). The patient underwent ureteroscopic biopsy with ureteral stent placement and final pathologic result was high grade invasive urothelial carcinoma. Patient refused surgery and died 6 months after systemic chemotherapy.

Hematuria is the most common sign of the UTUCs and could be either gross or microscopic. The incidence of hematuria is 56% to 98% of cases. The gradual onset of obstruction and hydronephrosis is associated with the flank pain, which is observed in 20% to 30% of cases. Thrombosis is well-established as a common complication of malignancy and represents the second most frequent cause of death in cancer patients. Cancer patients are generally hypercoagulable or prothrombotic, as they usually present with abnormalities in each component of Virchow's triad including stasis of blood flow, endothelial injury and hypercoagulability. Several literatures reported that the prognosis of urothelial carcinoma with venous thrombus was poor even if chemotherapy and radiotherapy are scheduled.

We reported a case of metastatic ureteral urothelial carcinoma presenting with painful left lower extremity swelling with absence of hematuria and flank pain. Comprehensive CT scan may be performed to exclude malignancy if patient presented with venous thrombus and hydronephrosis with acute kidney injury.