Bilateral Primary Malignant Renal Tumors of Dissimilar Histogenesis: Report of 2 Cases and Review of the Literature

Vol. 08, Oct.

THE JOURNAL OF UROLOGY

Copyright

© 1967 by The Williams & Wilkins Co.

Printed in [J.S.A.

BILATERAL PRI1\IARY MALIGNANT RENAL TUMORS OF DISSil\iIILAR HISTOGENESIS: REPORT OF 2 CASES AND REVIEW OF THE LITERATURE ANTONIO C. VILLEGAS* From the Department of Pathology, Ottawa General Hospital and University of Ottawa Facul/y of ivleclicine, Ottawa, Canada

While bilateral primary malignant renal tumors of similar histogenesis are relatively uncommon, those of dissimilar histogenesis are extremely rare. Only 2 case reports of the latter have been found in the literature. In 1912 Wagner reported the first such case in a 76-year-old man who was found at autopsy to have a hypernephroma of the right kidney with metastasis in the retroperitoneal lymph nodes, the right adrenal and both lungs. 1 The left kidney had a spindle cell sarcoma apparently originating from the renal capsule. In 1940 Camerer reported the second case in a 70year-olcl woman who died of carbon monoxide intoxication. 2 The incidental autopsy findings included papillary carcinoma of the left renal pelvis with metastasis to the regional lymph nodes and a typical hypernephroma of the right kidney without metastasis. The controversial issue has been whether one is dealing with primary bilateral renal neoplasms or whether the renal tumor iR a metastasis from the opposite kidney or from another organ. This issue has been debated for many years and various criteria have been mentioned in determining when a tumor is primary or secondary. In the 2 cases herein presented, I believe that the neoplasms are bilateral primary malignant renal tumors of dissimilar histogenesis. CASE REPORTS

Case 1. T.P., a 74-year-old man, was admitted to the hospital on November 15, 1959 with the Accepted for publication September 27, 1966. Presented at twenty-first Semi-Annual Conference, Workers in Pathology and Allied Sciences, Eastern Ontario, Ontario Hospital School, Smiths Falls, Ontario, April 27, 1966. * Current address: Department of Pathology Veterans Administration Hospital, Albany, New York. 1 Wagner, P. : Zur Kasuistik primarer doppelsei tiger maligner Nierentumoren. Folia Urolog., 6: 619-632, 1912. 2 Camerer, J.: Simultaneous occurrence of medullary carcinoma of pelvis of one kidney and hypernephroma of other kidney. Ztschr. f. Path., 54: 313-318, 1940.

chief complaint of gross hematuria, 4 weeks in duration. Physical examination was unremarkable except for a blood pressure of 160/112 and an enlarged prostate. Pyelographic studies indicated a tumor in the left renal pelvis; the right kidney was normal. A left nephro-ureterectomy was clone. Convalescence was uneventful. The kidney weighed 130 gm. The upper portion of the renal pelvis was occupied by a yellowishgrey, soft, cauliflower-like mass, 2.5 cm. in diameter, arising by a broad base from the pelvic mucosal surface. Niicroscopic examination revealed papillary transitional cell carcinoma. Numerous papillary fronds with delicate fibrous cores were covered by neoplastic epithelium of transitional type. Tumor cells had invaded the collecting tubules of involved renal papillae but the wall of the renal pelvis was not invaded. The pathological diagnosis was grade 2 papillary transitional cell carcinoma of the left renal pelvis (fig. 1). In October 1961 the patient was readmitted to the hospital for chronic prostatitis, benign prostatic hypertrophy and possible carcinoma. of the prostate. In the same year he had undergone fissurectomy and excision of fibro-epithelial papilloma of the anus. In July 1963 the patient was readmitted to the hospital because of pain in the right lumbar region, 4 months in duration. His blood pressure was 160/90. Pyelographic studies revealed a mass in the upper pole of the right kidney. An aortogram demonstrated stenosis of the right renal artery and an aberrant artery to the lower pole of the right kidney. Other findings included an enlarged hard prostate and cardiomegaly with electrocarcliographic evidence of complete right bundle branch block and a healed posterior myocardial infarct. The patient, who had signs and symptoms of congestive cardiac failure, died 3 weeks after admission to the hospital. On autopsy the right kidney weighed 420 gm. and measured 16 by 8 by 5 cm. A large mass,

450

BILATERAL RENAL TUMORS OF DISSIMILAR HISTOGENE8IS

13 G.,5 cm.. occupied the medial portion of the kidney and bulged 1nedially into peripelvic fatty tissue. The cut surfaces wrre lobulated and yelwith areas of hemorrhage and necrosis, Direct exten~ion of the tumor into fatty tissue had occurred in the hilar region and metastatic tumor deposits were fJI"esent in the lungs, J\Iicroscoriic examination revealed that the tumor was renal cell carcinmna, com-posed of :3 distinct features: l) large clear cell type, 2) alveolar pattern and 3) cells with a granular acidophilic cytoplasm. arranged in sheets and cmds, :Nuclei 1vere often pleorn.orphic and mitotic were not infrequent (fig. 2). Small veins and lymphatics were invaded by tumor cells. The metastatic nodules in the lungs were histologically similar to the renal tumor. Other findings at autopsy included a.naplastic adenocarcinoma of the prostate without evidence of metastatic spread, a small cortical aclenoma of the right adrenal, 3 small adenomatous polyps of the colon, an adenornatous goiter, marked atherosclcrotic stenosis of the ostium of the right renal artery, an aberrant artery to the lower pole of the kidne~· and severe coronary arteriosclerosis with a large healed nnc,j·r.,•,r,.- myocardial infarct, to which wa~ attributed the death. Case 2. F an white woman, was admitted to the hospital in December 1962 complaining of left lower abdorn.inal pain, anorexia and lo~s of weight., several months in duration. Physical examination revealed a pulsatabdorninal mass and the x-ray showed an anem~·sm of the lower abdominal aorta, 6 cm. in diameter. hematuria, pyuria and bacteriuria. (coliform organisms) were noted. vn,•D''""" urograµhy showed enlargement of the renal pelvis with poor visualization of the

F1G

1

4:31

FIG. 2

Fm. 3

calyces. There was al~o poor visualization of the calyceal system on the left side. pyelography was not done and the patient lefi the hospital 5 days after admission. She was readmitted to the hos]lital in .July 19(lc3. The patient was in shock and had severe left lumbar pain. She died 2 hours after admission, On autop~y the left kidney weighed 2.50 gm. and measured 12 by 7.5 and 7 cm, Its distorted and on sectioning, the renal was noted to be replaced by yellowish, soft., friable tumor tissue. The pelvis and ralyces were filled with dirty-looking creamy material mixed with calcareous debris (fig. 3). J\Iicrnscopic examination showed highly keratinizing squamous cell carcinoma, apJJarentl_v arising from the renal pelvis and deeply infiltrating the renal parenchyma. Acute and chronic pyelonephritis and necrotizing papillitis were also present (fig. 4, The right kidney weighed 220 gm. and measured 14 by 7 by 3.5 cm, A tumor, 4 cm. in diame-

452

VILLEGAS

FIG. 4

ter, occupied the uppor portion of the kidney. The tumor was circumscribed, lobulated, firm and yellowish-orange. It compressed adjacent renal calyces (fig. 3). Microscopic examination revealed renal cell carcinoma (adenocarcinoma) composed of polygonal cells with acidophilic granular cytoplasm arranged in nests or clusters in a delicate connective tissue stroma. Occasional tubular formations were apparent. Multinucleated tumor cells, hyperchromatic nuclei and mitotic figures were not infrequent. Blood vessel and lymphatic invasions were evident (fig. 4, B). There was an arteriosclerotic aneurysm of the lower abdominal aorta which had ruptured retroperitoneally, with massive hemorrhage. Other findings included generalized arteriosclerosis, moderate atherosclerosis of coronary arteries and pulmonary emphysema. DISCUSSION

After a reasonably thorough but not exhaustive review of the literature, I found 39 acceptable cases of bilateral primary renal cell carcinoma of similar histogenesis, 11 cases of transitional cell carcinoma of the renal pelvis, 1 case of squamous cell carcinoma of the renal pelvis, 33 cases of bilateral renal sarcoma and 116 cases of Wilms tumor, of which 52 cases were acceptable primary in both kidneys.

Undoubtedly there have been other cases of bilateral primary renal tumors which were not reported. On the other hand, there ,Yere 50 cases reported which were not assessable due to lack of clarity of the authors' reports. 1 • 3- 7 In 1965 Carroll reported a case concerning a 46-year-old man who had an infiltrating epithelioma of the left renal pelvis and a well differentiated papillary transitional cell carcinoma of the right renal pelvis. 8 Doth of these tumors have similar histogenesis although their nomenclature was different. Table 1 is a review of reported cases of bilateral 3 Senger, F, L., Bottone, J. J. and Murray, G. E.: Bilateral hypernephroma: Case report. J. Urol., 57: 106-115, 1947. 4 Hunt, V. C. and Hager, B. H.: Review of 271 cases of malignant renal neoplasms. S. Clin. N. America, 9: 149-159, 1929. 5 Sanford, H. L.: Carcinoma of both kidneys. Report of a case with review of the literature on multiple primary malignant tumors. Surg., Gynec. & Obst., 53: 360-364, 1931. • Kretschmer, H. L.: Bilateral primary sarcoma of the kidney; report of a case and review of literature. Quart, Bull Northwest. Med. Sch., 20: 77-91, 1946. 7 Lucke, B. and Schlumberger, H. G.: Tumors of the kidney, renal pelvis and ureter. In: Atlas of Tumor Pathology. Washington: Armed Forces Institute of Pathology, sec. 8, fasc. 30, 1957. 8 Carroll, G.: Bilateral transitional cell carcinoma of the renal pelvis. J. Urol., 93: 132-135, 1965.

BIL),TERAL RENAL TUMORS OF DISSIMILAR HISTOGENESIS

TABLE

1. Bilateral prirnary renal carcinomas of

similar histogenesis References (39 Cases)

Sex

Nenbert, C. J., 1868* Weigert, C., 1876* Chute, A. L., 1910*

l'vI

Kinney, W. 11., 1927* Hunt, V. C.: Surg. Clin. No. America, 7: 1457, 1927 Hanlon, F. R.: Amer. J. Cane., 15: 2001, 1931 Sprenger, A. and Bohrod, M. G.: J. Urol., 33: 427, 1935

M

Diagnosis

Renal ca. Adeno-ca. Hyperneph-

JVI

roma

M

65

Hypernephroma Hypernephroma Adeno-ca.

M

71

Renal ca.

M

47

Rena.I ca. Adeno-ca..

M

I\1

Jeck, H. S.: J. Urol., 35: 206, 1936 Hmtolomeiandassociates, 1937* McCagne, 1938*

M

37

Rena.I ca.

l\I

50

Elward and Spire,

M

36

M

50

Hypernephroid type Hypernephroma Hypernephroma

l\!1

62

M

59

M

39

M M M

50 52 73

Clear cell ca. Clear cell ca. Hypernephroma Hypernephroma

F

37

M

59

Hyperneph·· roma Hypernephroma

M

46

M

39

F

54

1940*

Beilin, L. M. and Neiman, B. H.: J. Urol., 48: 575, Hl42 Forsythe, W. E.: J. UroL, 47: 784, 1942 Mallory, J. Urol., 47: 784, 1942 Melicow, lVl. M.: J. 51: 333, 1944 Luber, M., 1944* Hanley, H. G.: Brit. J. Surg., 32: 399, 1945 Abeshonse, B. S. and Weinberg, T.: Arch. Surg., 50: 46, 1945 Senger, F. L. and a.ssocia.tes 3 Bailey, M. K. and Youngblood, V. H.: J. Urol., 63:593, 1950 Almor, 1952* Lewis and associates, 19-52* Rummelha.rdt, S. F., 1953*

-~~--

?

Hypernephroma Hypemephroma Cl ear cell ca.

Hypernephroma. Clear cell ca. Hypernephroma

i~·-·~-~----

References ( 39 Cases)

Hermann, H. B. and M Lieberman, JVI. L.: New York Med. J., 55: 1915, 1955 Bastable, J. R., 1960 1° F Brocks, IT. and asso- M cia.tcs: Urol. Int., 18;

56

Renal

64 51

Renal en Renal

43, 19G4

Riches, E. and associates: Brit. J. Urol., I 23: 297, 195lt i Moertel, C. G. and associatcs: Cancer, 14: , 221, 1961t I Harvard, B. M. and I Evans, J. S.: J. Urol., 91: 14, 19G4§ J

* Original pa.per not seen, referred l:o in ruticle by Ba.sta.ble 10 or by Kretschmer
primary renal carcinoma of similar There were 23 men and 3 women, with a ratio of 7.7 male to 1 female. The sex is not g,iven in 13 cases. The highest age incidence is from 50 to 5!} years which compri~es 10 cases; .5 are from 60 to 6.5 years old. The greater i1,c1dence men than in worn.en is indeed significant and suggests hormonal influence does exist in thc,e ncn-· plasms, which may be of gonadal origin.'' Table 2 is a review of reported case~ of bilatenil primary trarnitional cell carcinoma of the renal pelvis. There were 7 men and 2 1Yomen, with ratio of 3 ..5 male to l female. Sex is noi m cases. The highest age incidence is from 51 to 60 9 Riches, E.: Tumours of the kidney aud ureter. In: Textbook of Neoplastic Disease at V a.rious Sites. Baltimore: The Williams & Wilkins Co. vol. 5, cha.pts. 13, 14, 18-22, 25, 196.Jc. 10 Bastable, J. R.: Bilateral carcinc;rna of tlie kidneys. Brit. J. Urol., 32: G0-68, 1\JGO

454

VILLEGAS

TABLE 2. Bilateral primary transitional cell carcinoma of renal pelvis (papillary carcinoma of renal pelvis) References (11 Cases)

Sex

Age

M F

56 57

M M

86 66

F

75

M

51

ciates' series of 69 cases of squamous cell carcinoma, 29 per cent were associated with stones in the kidney and 0.9 per cent of the parenchymal kidney tumors. SUMMARY

Sanford, H. L. 5 Colston, J. A. C. and Arcadi, J. A.: J. Urol., 73: 460, 1955 Gibson, T. E., 1955* Potampa, P. B. and Schneider, I. J.: J. Urol., 86: 522, 1961 Harvard, B. M. and Evans, J. S.: J. Urol., 91: 14, 1964 ·Carroll, G. 8 Shapiro, I. J. 8 Draper, J. 8 Nagamatsu, G. R. 8 Goodwin, W. E. 8 .Jensen, P. B.8

M M M

? ?

63 ? ?

* Original paper not seen. years, 3 cases; 2 patients are from 61 to 70 years old and 2 patients are 75 and 86 years old. In 4 cases, age is not given. In approximately 88 to 90 per cent of cases of transitional cell carcinoma of the renal pelvis, painless hematuria, sometimes associated with pain, constitutes the presenting symptom. About 5 per cent of patients present with pain alone and an equal number are asymptomatic. Papillary neoplasms of the renal pelvis are commonly associated with similar tumors in the ureter and bladder which may be bilateral. The association of pelvic, ureteral and bladder lesions is uncommon in the case of non-papillary carcinoma of the renal pelvis and in renal parenchymal tumors. In the first case report the adenocarcinoma of the prostate represents the third primary malignant tumor. Although benign, it is worthwhile mentioning the cortical adenoma of the right adrenal, the adenomatous polyps of the colon, the adenomatous goiter and the papilloma of the anus. In case 2 the squamous cell carcinoma of the left renal pelvis without metastatic spread did not follow the usual course of this type of tumor to metastasize early. The tumor was associated with renal calculus which is a relatively common finding in squamous cell carcinoma of the renal pelvis. Renal calculi have been reported in association with squamous cell carcinoma of the renal i;elvis in 48 to 63 per cent of cases. In Riches and asso-

Two cases of bilateral primary renal tumors of dissimilar histogenesis are reported. One patient was found to have a renal cell carcinoma of the right kidney at autopsy, about 3 years 9 months after a left nephrectomy for papillary transitional cell carcinoma of the renal pelvis. The other patient at autopsy had a renal cell carcinoma of the right kidney and a squamous cell carcinoma of the left renal pelvis, invading the renal parenchyma. A total of 4 cases of bilateral primary malignant renal tumors of dissimilar histogenesis has been reported to date. The literature is reviewed. REFERENCES AcKERMAN, L. V. AND DEL REGATO, J. A.: Cancer: Diagnosis, Treatment and Prognosis. St. Louis, Missouri: C. V. Mosby Co., 2nd edit., 1954. AcKERY!AN, L. V. AND DEL REGNro, J.: Cancer: Diagnosis, Treatment and Prognosis. St. Louis, Missouri: C. V. Mosby Co., chapt. 11, 3rd edit., 1962. ALLEN, A. C.: The Kidney: Medical and Surgical Diseases. New York: Grune & Stratton. Inc., chapt. 15, 2nd edit., 1962. · BOWEN, J. A. AND BENNETT, G. A.: Squamous cell carcinoma of the kidney pelvis. J. Urol., 24: 495-501, 1930. CAMPBELL, M. F.: Bilateral embryonal adenomyosarcoma of the kidney (Wilms tumor). J. Urol., 59: fi67-.571, 1948. CARLSON, H. E.: Squamous cell carcinoma of the renal pelvis: A five year cure. J. Urol., 83:813814, 1960. CHILKO, A. J.: Contribution to the problem of diagnosis, treatment and prognosis of Wilms tumor. J. Urol., 83: 804-812, 1960. COLSTON, J. A. C., SR.: Followup report on a case of bilateral papillary carcinoma of the renal pelvis. J. Urol., 83: 3.Si:i-3ii9, 1960. CONSTANCE, T. J.: Bilateral rhabdomyoma of kidney. J. Path. & Bact., 59: 492-495, 1947. DEAN, A. L.: Wilms' tumors. New York State J. Med., 45: 1213-1217, 1945. DEA:,r, A. L., JR. AND P,1crc, G. T.: Embryonal adenosarcoma of the kidney. J.A.M.A., 98: 10-18, 1932. DEES, J.E.: Prognosis of primary tumors of renal pelvis and ureter. J. Urol., 75: 419-423, 19.56. FET'J'ER, T. R. AND SNYDER, A. I.: Survival study in renal cell carcinoma. Surg., Gynec. & Obst., 117: 7-9, 1963. FITZGERALD, w. L. AND H,IRDIN, II. C., JR.: Bilateral Wilms tumor in Wilms tumor family: Case report. J. Urol., 73: 468-474, 19.55. FOOT, N. c., HUMPHREYS, G. A. AND WHITMORE, W. F ., JR.: The importance of accurate pa-

BILATERAL RE~AL TUMORS OF DISSIMILAR HISTOGENESIS

thological classification in the prognosis of renal tumors: Second reporC J. Urol., 61: 477, 1949. H. Q. AND REED, W. K.: Squamous cell carcinoma of the renal pelvis: Three case reports and review of the literature. J. Urol., 62: I:3\), 1949. R. E. ,\.ND NEUHAUSER, E. B. D.: Treatment of mixed tumors of the kidney in childhood. Pediatrics, 6: 843-8.'i2, 19ii0. HARPER, ,J. JVL AND ANDERSON, E. E.: Bilateral diffuse Wilms tumor: A case report. J. Urol., 91: 220-222, 1964. HOLMAN, R. L. AND LEE-TsuN, H.: Bilateral nephroblastoma1.osis in a premature infant. J. Path. & Bact., 82: 249-255, 1961. HoRNBAK, H. AND lvlOLLER, .J.: Multiple tumours: Report, of a case with five histologically different neoplasms. Danish Med. Bull., 11: 67-69, 1964. H,IMPHREYS, G. A. AND FooT, N. C.: Survival of patients (235) following nephrectomy for renal cell and transitional cell tumors of the kidney. J. Urol., 83:81:5-819, 1960. JAGASIA, K. H., THURMAN, w. G., PICKETT, E. AND GRABSTALD, H.: Bilateral Wilms' tumors in children . .J. Pediat., 65: 371-376, 1964. KRETSCHMER, H. L. ,\.ND HrnBs, W. G.: Mixed tumors of the kidney in infancy and childhood. Surg., Gynec. & Obst., 52: 1-24, 1931. LADD, W. E. AND WHITE, R.R.: Embryoma of the kidney (Wilms' tumor). J.A.M.A., 117: 18581863, 1941. :NLwALPINE, .J. B.: Papillomatous disease of renal pelvis. Brit, J. Surg., 35: 113-132, 1947. :l\iAcALPINE, J. B.: Case in which 2 dissimilar growths, adenoma (adenocarcinoma) and papillo-carcinoma, occurred in same kidney, Brit. J. Surg., 35: 134-136, 1947, MAcALPINE, J. B.: Papilloma of rellal pelvis in dye workers: Two one of which shows bilateral growths. Brit. . Surg., 35: 137-140, 1947. lvIAcALPINE, J. B.: Bilateral renal papillomata: Two cases. Brit. J. Surg., 35: 132-134, 1947. J\TACLEAN, J. T. AND Fcrn"LER, V. B. · Pathology

of tumors of the renal pelvis and meter ...L Urol., 75: 384-415, 195G. lVIAGNER, D.: Tumours of Urinary dian Tumour Registry. Study MARTI;<;, L. w. AND KLOECKER, R. ,J. nephroblastoma (Wilms tumor) 28: 101-106, 1961. McDONALD J R AND PnrnsTLEY J. T.: Carcinoma' of ~en;! pelvis: Histopa/hologic of seventy-five cases with special reference prognosis . .J. Urol., 51: 245-258, Hl44. lVIEISEL, H ..J.: Bilateral polyadenomaLOllS kid. neys; adenomatosis or the kidneys ,;imnlati polycystic disease. J. U rol., 72: 1954. MELEN, D. H.: Tumors of the renal pc!Yis . J. Urol., 51: 386-394, 1944. O'CoNoR, V. J.: The diagnosis of tumors of t.lte renal pelvis and ureter. J. U rol., 75: 41()-418, 1956. PRIESTLEY, J. T.: Snrvival following rerncnrnl ol malignant renal neoplasms. J.A.JVI.A. 113: 902-906, 1939. RICK.HAM, P. P.: Bilateral Wilrns' lrnnor. Brit. Surg., 44: 492, 1957. SAMUELSSON, S. M.: Bilateral primary renal carcinoma? Acta Med. Scand., 174: 457-·461, HJG:3. ScoTT, L. S.: Bilateral Wilms' tumor. Bri\. J. Surg., 42: ,513-516, 1955. SHAHEEN, A. L., CASSANO, C. •I.ND R, Primary tumors of the kidney. 51.: 597-600, 1944. SHEACH, J. JVI.: Bilateral Wilms' tum()ur Case report with review of literature. Brit. J. Urol., 25: 109-113, 1953. SILVER, II. K.: Wilms' tumor (embryonrn of kidney). J. Pediat., 31: 643-6GO, 1947 ScruMP, T. A. AND GARRETT, R, A.: Bilateral ·wilms's tumor in a male pseudohernrnphrodite. J. Urol., 72: 1146-1152, 1954. THOMPSON, I. JVI., SCHNEIDER, ,J. AlsD KAV,IN, L. C.: Bilateral sqnamous cell carcinoma of the kidneys ..L Urn!., 79: 807-810, 1958. Woon, D. A.: Adenomyosarcoma. of the kidn()y in the adult (Wilms's tumor): Repon of case. ,J. Urol., 51: 235-244, 1944