|Year : 2017 | Volume
| Issue : 2 | Page : 110-112
Synchronous urothelial carcinoma of renal pelvis and ipsilateral renal cell carcinoma
Jayalakshmy Payippat Leelamma, Lillykutty Pothen, Nair Parvati Ramachandran
Department of Pathology, Government Medical College, Kottayam, Kerala, India
|Date of Web Publication||15-Sep-2017|
Jayalakshmy Payippat Leelamma
Department of Pathology, Government Medical College, Kottayam - 686 008, Kerala
Source of Support: None, Conflict of Interest: None
The coexistence of urothelial carcinoma (UC) of renal pelvis and ipsilateral renal cell carcinoma (RCC) is remarkably rare. We present a case of an 80-year-old male who was admitted with a history of the left flank pain, painless hematuria, and passage of blood clot in urine. Computerized tomography revealed a solid mass in the left renal pelvis extending into the calyces and renal parenchyma which gave an impression of UC of renal pelvis. Left nephroureterectomy was performed for tumor in renal pelvis, and histopathological examination showed an infiltrating high-grade papillary UC of the renal pelvis with an incidental clear cell type RCC in the renal parenchyma. This is a rare case of combined renal malignancies in the same kidney. There are only 52 cases reported in English language literature till 2017.
Keywords: Incidental, ipsilateral, pelvis, renal cell carcinoma, synchronous, urothelial carcinoma
|How to cite this article:|
Leelamma JP, Pothen L, Ramachandran NP. Synchronous urothelial carcinoma of renal pelvis and ipsilateral renal cell carcinoma. Saudi J Health Sci 2017;6:110-2
| Introduction|| |
Urothelial carcinoma (UC) of the renal pelvis and renal cell carcinoma (RCC) are not uncommon malignancies, taken individually. Their simultaneous occurrence in a patient in the same kidney is, however, rare. We report a case of synchronous UC of the renal pelvis and ipsilateral RCC in an 80-year-old male.
| Case Report|| |
An 80-year-old man who had a history of the left flank pain, painless hematuria, and passage of blood clot in urine was admitted to our hospital. He was hypertensive and a chronic smoker. Physical examination and laboratory findings were normal. The ultrasonography showed a hypoechoic lesion in the middle pole of the left kidney. Computed tomography revealed a mildly, enhancing solid lesion measuring 7 cm × 6 cm × 5.5 cm arising from the left renal pelvis, extending into the calyces and renal parenchyma, with normal right kidney [Figure 1]a. Cystoscopy revealed no pathological findings. With a radiological diagnosis of UC of renal pelvis infiltrating kidney, left nephroureterectomy with lymphadenectomy was performed. The patient was discharged from the hospital without any complications.
|Figure 1: (a) Computed tomography scan shows solid growth (blue arrow) arising from the left renal pelvis, extending into the calyces and renal parenchyma. (b) Gross picture of nephroureterectomy specimen shows a growth in renal pelvis (red arrow) and yellowish growth in the upper renal pole (green arrow)|
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On opening the kidney, there were two geographically and morphologically distinct masses in the kidney [Figure 1]b. One was a well circumscribed, yellowish, soft, solid growth measuring 4 cm × 3.5 cm × 4 cm in the upper pole of kidney, and the other was a brownish, granular, and polypoidal growth measuring 6 cm × 4.5 cm × 2.5 cm in the renal pelvis with infiltration into the renal parenchyma. The two masses were not intermingled but separated by a thin rim of normal renal parenchyma. Samples from both were formalin fixed and paraffin-embedded for subsequent histological examination with Hematoxylin and Eosin stain.
Histological examination of the first growth showed a neoplasm composed of cells arranged in nests, sheets, and tubules [Figure 2]a and [Figure 2]b. The cells were round to oval with abundant clear cytoplasm and round nucleus with evenly distributed chromatin and prominent nucleolus. The nucleolus of the neoplastic cells was visible using a 10X objective lens. Few scattered cells with bizarre nuclei were also seen. A diagnosis of clear cell RCC, Fuhrman nuclear grade 3 was rendered with no vascular or renal capsular or perinephric fat invasion (pT1, N0, and Mx). On the other hand, the second growth showed a tumor composed of neoplastic urothelium arranged in papillary pattern [Figure 3]a, which infiltrated the muscular layer of the renal pelvis and renal parenchyma. The cells in the nests and papillae were cuboidal with a moderate amount of eosinophilic cytoplasm and round, moderate to markedly pleomorphic, and hyperchromatic nucleus [Figure 3]b. Numerous mitotic figures were seen. A diagnosis of infiltrating high-grade papillary UC (pT3, N0, and Mx) was made. Surgical margins were negative for both tumors.
|Figure 2: (a) Clear cell renal cell carcinoma with cells in sheets (H and E, ×200 magnification). (b) renal cell carcinoma with cells in tubules (H and E, ×200 magnification)|
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|Figure 3: (a) Transitional cells arranged in a papillary pattern (H and E, ×200 magnification). (b) Cells show high-grade nucleus (H and E, ×200 magnification)|
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| Discussion|| |
Representing 2%–3% of adult cancers, RCC accounts for 90% of renal malignancies and is the most lethal neoplasm of the urologic system. Conversely, primary UC of the renal pelvis or ureter is a relatively rare disease, and it accounts for <1% of genitourinary neoplasms and 5%–7% of all urinary tract tumors. The documented occurrence of both these types of tumors in the same kidney is extremely rare. The first case was reported in 1921. A thorough literature review revealed that till 2017, 52 cases of synchronous UC of renal pelvis and ipsilateral RCC have been reported including the most recent cases by Mucciardi et al. and Kokenek-Unal et al. in 2015.
The epidemiology of patients with concomitant RCC and UC is similar to that of patients presenting with solitary RCC or UC of the kidney. There is a higher predilection for men (2:1), and the usual mode of presentation is with hematuria (90%), flank pain (19%), or a palpable mass (14%). In our case, the patient presented with left flank pain, painless hematuria, and passage of blood clot in urine. The mean age of presentation is 65 years and these tumors, interestingly, occur with a 3-fold higher frequency in the left kidney, as noted in our case. Qing-Fei et al. highlight the fact that there are no readily identifiable risk factors for the simultaneous occurrence of both tumors, but according to Ji-Young et al., the most prominent risk factor for both RCC and UC is tobacco.
The most common subtype of RCC is clear cell type in ipsilateral RCC and renal pelvic UC cases  similar to our case, and the second most common type is papillary RCC.,, In our case, UC was high grade and infiltrating in nature. In most of the other reported cases in literature,, UC was high grade and infiltrating, and in rest of the cases, it was low grade and noninvasive in nature., The prevalence of multiple primary malignancies (MPMs) is between 0.73% and 11.7%, and the most number of synchronous tumors are seen in genitourinary and gastrointestinal tracts. Many studies pointed out that a considerable number of cases of MPMs are related to renal neoplasms.
The treatment and overall survival of a patient with double primary malignancies are dependent on the stage of the individual malignancy. In this case, UC was pathologically high grade and a pT3 lesion with infiltration of renal parenchyma, and RCC was Fuhrman nuclear grade 3 with no renal vein invasion and a pT1b lesion. There was no evidence of metastatic disease. UC was of higher stage. Renal UC is usually managed with a nephroureterectomy as renal UC can be associated with a high risk of developing ureteral UC. As the radiological diagnosis was UC of renal pelvis infiltrating kidney, left nephroureterectomy with lymphadenectomy was done for this patient which itself is curative. Since the patient has no evidence of metastatic disease, he was not given adjuvant chemotherapy. After 6 months, the patient is in good health and disease-free under strict surveillance.
In conclusion, since the simultaneous occurrence of ipsilateral RCC and renal pelvic UC is rare, further studies need to be done to throw light on the common risk factors as well as the diagnostic and treatment strategies. The cumulative data of such reports will pave the way for better insight in this group of neoplasms.
I would like to acknowledge Dr. Deepa S, Assistant Professor for providing guidance and Dr. Sangeetha R, Senior resident for the assistance given in collecting the case details.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]