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Concurrent Dissimilar Malignancies of the Urinary Tract
THE .JOURNAL OF UROLOGY
Vol. 73, No. 6, June 1955 Printed in U.S.A.
CONCURRENT DISSIMILAR MALIGNANCIES OF THE URINARY TRACT DAVID W. KLINE, MATTHEW MARSHALL, JR., S. HARRIS JOHNSON, III GLENN REED
AND
The finding of concurrent, dissimilar malignancies of the urinary tract is thought to be rare enough to warrant reporting. A search of the literature shows a rather large selection of multiple papillary tumors that are found from the renal papillas to the urethral meatus. Fewer articles deal with unrelated malignancies in the same individual at different times. There are only a few reports of different histologic tumors of the urinary tract occurring simultaneously. We are presenting 2 cases of dissimilar malignancies of the urinary tract occurring simultaneously. CASE REPORTS
Case 1. E. L. C., Sharon General Hospital No. 177061, aged 54, was admitted February 18, 1952 with hematuria of 2 days' duration. Transient hematuria occurred in 1949. The lower pole of the right kidney was palpable. A urinalysis confirmed the history of hematuria, but other laboratory examinations were not abnormal. Excretory urography visualized a normal left kidney, but the right kidney contained a mass 9.0 cm. in diameter in the lower pole which distorted the adjacent calyces. A chest film showed no metastasis. Cystoscopy visualized a pedunculated papilloma, 4.0 cm. in diameter, adjacent to the left ureteral orifice. This was resected transurethrally and the patient made an uneventful recovery. Nine weeks later right nephrectomy and subtotal ureterectomy were performed. The perirenal fat and fascia and the lymph nodes at the renal pedicle were removed with the specimen and grossly the tumor did not appear to extend beyond the specimen. Convalescence was uncomplicated. Grossly the bladder fragments were gray-red. Microscopically, there were many papillary processes covered by stratified transitional epithelium. The cells showed variation in nuclear size, some prominent nucleoli and occasional mitotic figures. Fragments of smooth muscle were present and showed no invasion by tumor. The diagnosis was low grade papillary carcinoma. Cross section of the kidney exposed a well circumscribed tumor. It was red-gray, soft, and measured 7.5 cm. in diameter. It did not invade the pelvis. Microscopic sections showed misshapen tubules lined by multiple or single cell layers. The cells were polyhedral, had eosinophilic cytoplasm and small dark nuclei. There was no penetration of the pelvis and little invasion of the surrounding parenchyma. The diagnosis was granular cell adenocarcinoma of the kidney. See figure 1. Case 2. W. F. D., Western Pennsylvania Hospital, No. 3612, aged 47, entered the hospital with a 4-month-history of hematuria, dysuria and frequency. Physical examination revealed no urologic abnormalities. A urinalysis revealed albuminuria, hematuria and pyuria. Urine culture demonstrated Pseudomonas aeruginosa. The patient was anemic but other laboratory determinations were Accepted for publication December 8, 1954. 964
CO:\fCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
965
Frn. 1. Case l. A, papillary carcinoma of bladder. B, adenocarcinoma. of kidney.
within normal limits. Excretory urography visualized a normal right kidney, but the exact renal outline on the left could not be determined and the calyces, while demonstrating marked dilatation, were poorly filled. A chest film showed no metastasis. Cystoscopy visualized a papillary tumor overlying the left ureteral
966
KLINE, MARSHALL, JOHNSON AND REED
Fm. 2. Case 2. Cross section of kidney showing papillary carcinoma and adenocarcinoma.
orifice. Left hemicystectomy, neoureterocystostomy and pelvic lymphadenectomy were performed and no gross evidence of metastasis was encountered. A cystostomy tube and left ureteral catheter were left indwelling. Postoperatively a pyelogram was performed by injection of radiopaque dye into the ureteral catheter and this demonstrated a reduplicated renal pelvis and partial reduplication of the ureter. A filling defect was present in the upper renal pelvis. A left nephroureterectomy with removal of the perirenal fat and fascia and the lymph nodes at the renal pedicle was performed and the patient made an uneventful recovery. Pathological report: A pedunculated, papillary tumor, 2.0 cm. in diameter, arose from the mucosal surface of the bladder and was penetrated by the ureter. Normal bladder surrounded the tumor mass. Six lymph nodes were received and appeared normal. Microscopically, a low papillary tumor arose from the mucosal surface. The tumor cells pierced the basement membrane at some points. The nuclei were pleomorphic and occasionally giant. A transitional epithelial pattern was preserved and invaded the muscularis superfically. The diagnosis was transitional cell carcinoma. Cross section of the kidney revealed a papillary mass, 6.0 cm. in diameter,
CONCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
967
Frn. 3. Case 2. A, papillary carcinoma of bladder. B, papillary carcinoma of kidney.
arising from the kidney pelvis and invading the parenchyma. A smaller subcortical tumor in the lower pole was separated from the first tumor by a thin zone of preserved parenchyma. It appeared encapsulated and was solid, firm and yellow-red. Microscopically, the epithelial tumor in the upper renal pelvis was almost identical with the bladder tumor but was more invasive. The parenchynial tumor was imperfectly encapsulated and had a different histologic pattern. Superfically the tumor seemed solid but consisted of intricate papillary processes. These were lined by anaplastic cuboidal or low columnar epithelium and supported by slim bands of stroma. The nuclei were relatively large and the cystoplasrn. granular and eosinophilic. The diagnosis was papillary transitional cell carcinoma of the renal pelvis and papillary renal cell adenocarcinoma. See figures 2, 3, 4. COMMENT
While there are earlier reports of multiple dissimilar tumors of the urinary tract, Graves and Templeton first presented a well documented report of dissimilar tumors in the same kidney in 1921. The simultaneous occurrence of similar multiple tumors of the urothelium has been stressed, but the cases reported by us, as well as our review of the literature, would indicate that dissimilar tumors may also occur. The tendency for any cancer patient to develop another primary tumor is a factor that must be considered in the treatment of the individual patient.
968
KLINE, MARSHALL, JOHNSON AND REED
FIG. 4. Case 2. Adenocarcinoma of kidney SUMMARY
Two case reports of dissimilar malignancies of the urinary tract are presented. Case 1 demonstrated a simultaneous papillary carcinoma of the bladder and adenocarcinoma of the kidney. Case 2 demonstrated the simultaneous occurrence
CONCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
969
of a transitional cell carcinoma of the bladder in association with a similar tumor in the upper pole of a fused double kidney and an adenocarcinonrn in the lower component of the same kidney.
Peoples E. E. Bldg., Pittsburgh 6, Pa. REFERENCES BALCH, J. F.: Papillary carcinoma and hypernephroma occurring in same kidney. J. Urol., 33: 138, 1935. BHERNDE, Y. M.: Epidermoid carcinoma and leiomyosarcoma in same kidney. Ind. MecL Gaz., 87: 158, 1952. GOLDBERG, L. G. AND KHAYAT, E.: Multiple primary carcinoma of bladder and kidney. K. Y. State J. Med, 52: 1547, 1952 GRAVES, R. D. AND TEMPLETON, E. R.: Combined tumors of kidneys. J. Urol., 5: 51.7, 192L HAYWARD, W. G.: Multiple primary tumors. J. Urol., 54: 307, 1945. HURT, H. H. A.ND BRODERS, A. C.: Multiple primary malignant neoplasms. J. Lab. & Clin. Med., 18; 765-777, 1953. ITo, S.: Case of double malignant tumors; carcinoma of prostate and urinary bladder in a. single patient. Gann, 43: 45, 1952. KAMINSKY, A. F.: Mssociated kidney tumors. J. Urol.. 61: 997, 1949. KRETSCHMER, H. L.: Multiple primary tumors. J. Urol., 40: 421, 1938. l\/IELrcow, M. M.: Tumors of urinary drainage tract; urothelial tumors. J. Urol., 54: 186, 1945. MELicow, M. M.: Personal communication. MERREN, D. AND CREDLE, W. S.: Multiple malignancies of the prostate. repor1; of case of carcinoma and sarcoma. J. Urol., 64: 758, 1950. RUPEL, E. A.ND SUTTON, W. E.: Carcinoma of renal parenchyma. J. UroL, 63: 487, 1950. WARREN, S. AND GA.TES, 0.: Multiple primary malignant tumors. Survey of literature and statistical study. Am. J. Cancer, 16: 1358, 1932.
Vol. 73, No. 6, June 1955 Printed in U.S.A.
CONCURRENT DISSIMILAR MALIGNANCIES OF THE URINARY TRACT DAVID W. KLINE, MATTHEW MARSHALL, JR., S. HARRIS JOHNSON, III GLENN REED
AND
The finding of concurrent, dissimilar malignancies of the urinary tract is thought to be rare enough to warrant reporting. A search of the literature shows a rather large selection of multiple papillary tumors that are found from the renal papillas to the urethral meatus. Fewer articles deal with unrelated malignancies in the same individual at different times. There are only a few reports of different histologic tumors of the urinary tract occurring simultaneously. We are presenting 2 cases of dissimilar malignancies of the urinary tract occurring simultaneously. CASE REPORTS
Case 1. E. L. C., Sharon General Hospital No. 177061, aged 54, was admitted February 18, 1952 with hematuria of 2 days' duration. Transient hematuria occurred in 1949. The lower pole of the right kidney was palpable. A urinalysis confirmed the history of hematuria, but other laboratory examinations were not abnormal. Excretory urography visualized a normal left kidney, but the right kidney contained a mass 9.0 cm. in diameter in the lower pole which distorted the adjacent calyces. A chest film showed no metastasis. Cystoscopy visualized a pedunculated papilloma, 4.0 cm. in diameter, adjacent to the left ureteral orifice. This was resected transurethrally and the patient made an uneventful recovery. Nine weeks later right nephrectomy and subtotal ureterectomy were performed. The perirenal fat and fascia and the lymph nodes at the renal pedicle were removed with the specimen and grossly the tumor did not appear to extend beyond the specimen. Convalescence was uncomplicated. Grossly the bladder fragments were gray-red. Microscopically, there were many papillary processes covered by stratified transitional epithelium. The cells showed variation in nuclear size, some prominent nucleoli and occasional mitotic figures. Fragments of smooth muscle were present and showed no invasion by tumor. The diagnosis was low grade papillary carcinoma. Cross section of the kidney exposed a well circumscribed tumor. It was red-gray, soft, and measured 7.5 cm. in diameter. It did not invade the pelvis. Microscopic sections showed misshapen tubules lined by multiple or single cell layers. The cells were polyhedral, had eosinophilic cytoplasm and small dark nuclei. There was no penetration of the pelvis and little invasion of the surrounding parenchyma. The diagnosis was granular cell adenocarcinoma of the kidney. See figure 1. Case 2. W. F. D., Western Pennsylvania Hospital, No. 3612, aged 47, entered the hospital with a 4-month-history of hematuria, dysuria and frequency. Physical examination revealed no urologic abnormalities. A urinalysis revealed albuminuria, hematuria and pyuria. Urine culture demonstrated Pseudomonas aeruginosa. The patient was anemic but other laboratory determinations were Accepted for publication December 8, 1954. 964
CO:\fCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
965
Frn. 1. Case l. A, papillary carcinoma of bladder. B, adenocarcinoma. of kidney.
within normal limits. Excretory urography visualized a normal right kidney, but the exact renal outline on the left could not be determined and the calyces, while demonstrating marked dilatation, were poorly filled. A chest film showed no metastasis. Cystoscopy visualized a papillary tumor overlying the left ureteral
966
KLINE, MARSHALL, JOHNSON AND REED
Fm. 2. Case 2. Cross section of kidney showing papillary carcinoma and adenocarcinoma.
orifice. Left hemicystectomy, neoureterocystostomy and pelvic lymphadenectomy were performed and no gross evidence of metastasis was encountered. A cystostomy tube and left ureteral catheter were left indwelling. Postoperatively a pyelogram was performed by injection of radiopaque dye into the ureteral catheter and this demonstrated a reduplicated renal pelvis and partial reduplication of the ureter. A filling defect was present in the upper renal pelvis. A left nephroureterectomy with removal of the perirenal fat and fascia and the lymph nodes at the renal pedicle was performed and the patient made an uneventful recovery. Pathological report: A pedunculated, papillary tumor, 2.0 cm. in diameter, arose from the mucosal surface of the bladder and was penetrated by the ureter. Normal bladder surrounded the tumor mass. Six lymph nodes were received and appeared normal. Microscopically, a low papillary tumor arose from the mucosal surface. The tumor cells pierced the basement membrane at some points. The nuclei were pleomorphic and occasionally giant. A transitional epithelial pattern was preserved and invaded the muscularis superfically. The diagnosis was transitional cell carcinoma. Cross section of the kidney revealed a papillary mass, 6.0 cm. in diameter,
CONCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
967
Frn. 3. Case 2. A, papillary carcinoma of bladder. B, papillary carcinoma of kidney.
arising from the kidney pelvis and invading the parenchyma. A smaller subcortical tumor in the lower pole was separated from the first tumor by a thin zone of preserved parenchyma. It appeared encapsulated and was solid, firm and yellow-red. Microscopically, the epithelial tumor in the upper renal pelvis was almost identical with the bladder tumor but was more invasive. The parenchynial tumor was imperfectly encapsulated and had a different histologic pattern. Superfically the tumor seemed solid but consisted of intricate papillary processes. These were lined by anaplastic cuboidal or low columnar epithelium and supported by slim bands of stroma. The nuclei were relatively large and the cystoplasrn. granular and eosinophilic. The diagnosis was papillary transitional cell carcinoma of the renal pelvis and papillary renal cell adenocarcinoma. See figures 2, 3, 4. COMMENT
While there are earlier reports of multiple dissimilar tumors of the urinary tract, Graves and Templeton first presented a well documented report of dissimilar tumors in the same kidney in 1921. The simultaneous occurrence of similar multiple tumors of the urothelium has been stressed, but the cases reported by us, as well as our review of the literature, would indicate that dissimilar tumors may also occur. The tendency for any cancer patient to develop another primary tumor is a factor that must be considered in the treatment of the individual patient.
968
KLINE, MARSHALL, JOHNSON AND REED
FIG. 4. Case 2. Adenocarcinoma of kidney SUMMARY
Two case reports of dissimilar malignancies of the urinary tract are presented. Case 1 demonstrated a simultaneous papillary carcinoma of the bladder and adenocarcinoma of the kidney. Case 2 demonstrated the simultaneous occurrence
CONCURRENT DISSIMILAR MALIGNANCIES OF URINARY TRACT
969
of a transitional cell carcinoma of the bladder in association with a similar tumor in the upper pole of a fused double kidney and an adenocarcinonrn in the lower component of the same kidney.
Peoples E. E. Bldg., Pittsburgh 6, Pa. REFERENCES BALCH, J. F.: Papillary carcinoma and hypernephroma occurring in same kidney. J. Urol., 33: 138, 1935. BHERNDE, Y. M.: Epidermoid carcinoma and leiomyosarcoma in same kidney. Ind. MecL Gaz., 87: 158, 1952. GOLDBERG, L. G. AND KHAYAT, E.: Multiple primary carcinoma of bladder and kidney. K. Y. State J. Med, 52: 1547, 1952 GRAVES, R. D. AND TEMPLETON, E. R.: Combined tumors of kidneys. J. Urol., 5: 51.7, 192L HAYWARD, W. G.: Multiple primary tumors. J. Urol., 54: 307, 1945. HURT, H. H. A.ND BRODERS, A. C.: Multiple primary malignant neoplasms. J. Lab. & Clin. Med., 18; 765-777, 1953. ITo, S.: Case of double malignant tumors; carcinoma of prostate and urinary bladder in a. single patient. Gann, 43: 45, 1952. KAMINSKY, A. F.: Mssociated kidney tumors. J. Urol.. 61: 997, 1949. KRETSCHMER, H. L.: Multiple primary tumors. J. Urol., 40: 421, 1938. l\/IELrcow, M. M.: Tumors of urinary drainage tract; urothelial tumors. J. Urol., 54: 186, 1945. MELicow, M. M.: Personal communication. MERREN, D. AND CREDLE, W. S.: Multiple malignancies of the prostate. repor1; of case of carcinoma and sarcoma. J. Urol., 64: 758, 1950. RUPEL, E. A.ND SUTTON, W. E.: Carcinoma of renal parenchyma. J. UroL, 63: 487, 1950. WARREN, S. AND GA.TES, 0.: Multiple primary malignant tumors. Survey of literature and statistical study. Am. J. Cancer, 16: 1358, 1932.