Defusing Two Lethal Threats: How MDT Navigates High-Risk Ureteral Cancer with Multiple Arterial Aneurysms — Rejected by 5 Hospitals, Saved by Arion

Case Introduction

High-risk ureteral cancer is notoriously aggressive and fast-progressing. Multiple arterial aneurysms are like "ticking time bombs" inside the body, liable to rupture fatally at the slightest provocation. When these two lethal conditions converge in a single 65-year-old patient, treatment enters a seemingly impossible deadlock: treating the cancer risks triggering aneurysm rupture; treating the aneurysm first risks delaying cancer cure beyond the window of opportunity. This patient had already been turned away by five different hospitals before arriving at Beijing Arion Cancer Hospital, where a specialized MDT team broke through disciplinary barriers, precisely weighed competing risks, and successfully resolved this double lethal crisis — providing invaluable clinical reference for similarly complex comorbid cases.

I. Case Overview: Baseline and Core Challenges

Baseline Status

A 65-year-old woman presented with sudden painless gross hematuria at a local hospital in Hebei Province. Imaging revealed a 1.3 × 2.0 cm space-occupying lesion at the second narrowing of the right ureter within the pelvic segment, accompanied by severe hydronephrosis. Urinary cytology confirmed high-grade urothelial carcinoma, establishing the diagnosis of high-risk ureteral cancer (cT2N0M0).

This type of lesion is highly malignant and rapidly progressive. Without intervention, the median time to progression is 4–9 months, with most patients developing frank lymphatic metastasis and distant dissemination within 6 months. However, this patient's situation was extraordinarily complex due to multiple concurrent conditions: severe thoracic aortic aneurysm (ulcerative transmural type at the arch), abdominal aortic aneurysm, iliac artery aneurysm, coronary artery disease, pulmonary embolism, multiple cerebral infarctions, arrhythmia, and bradycardia — with extremely high risk of both arterial and venous thrombosis. By the time she arrived at Arion, she had been referred sequentially through five hospitals, all of which declined to operate.

The Therapeutic Deadlock

Urologic oncology concern: The presence of thoracic, abdominal, and pelvic large-vessel aneurysms meant that any intraoperative blood pressure fluctuation could trigger catastrophic aneurysm rupture. The aortic arch aneurysm, bearing the greatest hemodynamic stress and appearing nearly transmural, carried the highest risk. Furthermore, the ureteral tumor lay adjacent to the right iliac aneurysm, making surgical dissection extraordinarily treacherous; and the right renal artery showed full-length calcification, raising the risk of rupture during arterial clamping.

Cardiovascular surgery concern: Aortic arch aneurysm repair is inherently highly traumatic with significant perioperative mortality. The patient's poor overall condition — pulmonary embolism, compromised lung function, multi-vessel coronary disease, and limited cardiac reserve — made her unsuitable for major vascular surgery in principle. Moreover, the concurrent ureteral malignancy further complicated candidacy for such a procedure.

Family concern: Even if the aortic arch surgery were successful, the typical 3–6 month recovery period would likely push the highly aggressive ureteral cancer past any chance of radical cure.

II. Decision-Making: MDT Core Analysis and Strategy Deliberation

MDT Team Composition

Upon the patient's arrival at Arion, a specialized MDT was immediately convened, drawing from the Urologic Oncology Center, Anesthesiology Center, Cardiology, Aortic Surgery Center, Intensive Care Center, and Nutrition Department.

Treatment Pathway Deliberation

The team conducted a comprehensive evaluation of the patient's cardiac, pulmonary, cerebral, and macrovascular history alongside the tumor status, ultimately confirming that oncologic surgery and major vascular surgery were in direct conflict — the case had reached a genuine therapeutic impasse. Given the highly aggressive nature of ureteral cancer and its classification as a time-sensitive surgical indication, the team determined that addressing the ureteral cancer first, under maximal cardiovascular risk mitigation, was the most reasonable strategy to break the deadlock.

Final Decision: Three Core Objectives

1. Adequate blood preparation with strict hemorrhage control — maintain absolute hemodynamic stability to create foundational conditions for surgery.
2. Electrolyte correction and preoperative nutritional optimization — rigorously prevent malignant arrhythmias.
3. Standardized perioperative bridging of antithrombotic medications — minimize both arterial and venous thrombotic risk while preventing fatal postoperative complications.

With these objectives in mind, the team repeatedly rehearsed and refined the surgical workflow, developing a full-cycle risk contingency plan covering preoperative preparation, intraoperative emergency response, and postoperative recovery.

III. The Breakthrough: Treatment Journey and Technical Highlights

Treatment Blueprint

Preoperative antithrombotic adjustment + nutritional support → Laparoscopic radical ureteral cancer resection → Postoperative continuation of antithrombotic therapy + clinical observation → Discharge at postoperative day 7.

Critical Intraoperative Moment

On hospital day 5, laparoscopic radical right ureteral cancer resection was formally initiated. Immediately after anesthesia induction, the patient's heart rate suddenly dropped to 45 bpm and blood pressure fell to 97/63 mmHg — a perilous moment in a patient with multiple aneurysms. The anesthesia team precisely titrated medications, rapidly restoring vital signs to the safety range. Throughout the remainder of the procedure, the surgical and anesthesia teams coordinated seamlessly, maintaining life signs within the optimal range. The surgery was completed with only 20 mL of blood loss.

Postoperative Precision Management

After one day of observation in the Intensive Care Center, the patient was transferred uneventfully to the general ward. Aspirin was resumed at 24 hours postoperatively, with low-molecular-weight heparin bridging intravenous antithrombotic therapy. By postoperative day 3, clopidogrel and rivaroxaban were gradually reintroduced, ensuring that all three core antithrombotic agents were restored within 72 hours — fundamentally reducing the risk of aneurysm rupture, myocardial infarction, cerebral infarction, and pulmonary infarction. On postoperative day 7, all indicators met discharge criteria, and the patient was discharged in good condition.

IV. Outcome Assessment and Follow-Up Strategy

Postoperative Pathology and Prognosis

Pathology confirmed: no lymph node metastasis in the paracaval nodes; high-grade papillary invasive urothelial carcinoma of the ureter, tumor size 2.0 × 1.5 × 0.7 cm, with surrounding urothelial carcinoma in situ. The tumor invaded the full thickness of the ureteral wall with evidence of lymphovascular invasion. Final staging: pT3N0M0.

For T3 upper tract urothelial carcinoma (UTUC), the median time to recurrence/progression is typically 12–18 months; with lymphovascular invasion, this can shorten to 8–12 months. The 3-year progression-free survival rate is approximately 50%, and the 5-year PFS around 40%. Adjuvant therapy has been shown to significantly improve survival outcomes.

Adjuvant Treatment and Surveillance

The patient initiated adjuvant therapy at one month postoperatively: a planned course of 6 cycles of disitamab vedotin + toripalimab, followed by toripalimab maintenance for 1 year (note: this regimen has not yet entered clinical guidelines). To date, 5 cycles of the combination have been completed with good tolerance. During the postoperative treatment and surveillance phase, one cystoscopy and urinary cytology examination have been performed, with no evidence of disease progression.

V. Case Insights

Reflecting on this extraordinary case of concurrent ureteral cancer and major arterial aneurysm, the key to success lay in three critical treatment details anchored by a mature cardiovascular-oncology MDT team:

1. Preoperative fine-grained assessment of underlying cardiac disease and aneurysm risk, identifying the viable pathway through the deadlock.
2. Intraoperative precision coordination between the anesthesia and surgical teams, averting a cascade of fatal risks associated with hemodynamic instability.
3. Postoperative scientific sequencing of antithrombotic medications, constructing a multi-organ protective barrier against thrombosis.

This case vividly illustrates the core value of MDT in managing complex oncologic disease with cardiovascular comorbidities. From meticulous preoperative assessment, through intraoperative risk navigation, to scientific postoperative management, each disciplinary team broke down professional silos to collaborate with exceptional efficiency — successfully achieving radical tumor resection while minimizing the potentially fatal risks of the patient's multiple underlying conditions.

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Expert Commentary

Prof. Qiao Zhiyu

Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University

From the perspective of aortic surgery, performing oncologic surgery in the presence of an unaddressed aortic arch aneurysm and ulcer carries the risk of aortic pathology progression or even rupture, driven by stress changes in the aortic wall during anesthesia induction, pneumoperitoneum establishment, and intraoperative hemodynamic fluctuations — particularly increases in heart rate and blood pressure.

The key to the success of this case lies in the MDT's deep collaborative decision on the "tumor first, arch later" treatment sequencing: the urologic oncology team precisely completed radical ureteral cancer resection adjacent to the aneurysm, with clear anatomical planes, no collateral injury in the peritumoral dissection zone, and only 20 mL of blood loss. They achieved oncologic radicality without triggering an aortic catastrophe, successfully avoiding the massive trauma and prolonged recovery associated with upfront arch replacement. This case fully demonstrates the exceptional intraoperative risk management capability of the urologic oncology and anesthesia teams under the extreme constraint of high-risk cardiovascular comorbidity, and exemplifies the systemic treatment value of multi-disciplinary sequential decision-making with aortic safety as the absolute bottom line.

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