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Cystic renal cell and squamous cell carcinoma of single kidney with concurrent transitional cell carcinoma of ipsilateral ureter and urinary bladder
CYSTIC RENAL CELL AND SQUAMOUS CELL CARCINOMA OF SINGLE KIDNEY WITH CONCURRENT TRANSITIONAL CELL CARCINOMA OF IPSILATERAL URETER AND URINARY BLADDER R. S. CHARLES, M.D. A. J. WEIN, M.D. S. WILCZYNSKI, M.D.
J. E. TOMASZEWSKI, P. M .HANNO, M.D.
M.D.
From the Division of Urology, Departments of Surgery and Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
We report on a case of the simultaneous occurrence of cystic renal cell and squamous cell carcinoma in a single kidney in a patient with concurrent transitional cell carcinoma of the ipsilateral ureter and urinary bladder, A review qf the literature reveals this to be the first such occurrence. ABSTRACT-
The association of two primary tumors within the same kidney is a rare event, however several cases have been reported.‘m6 The finding of two different histologic tumors within the same kidney and a third histologic type in the ipsilateral ureter and bladder appears to be a unique event and to our knowledge does not appear in the literature to date.
A seventy-year-old white male retired engineer who was completely asymptomatic was found on routine physical examination to have a large abdominal mass on his right side. An intravenous urogram performed elsewhere revealed a large hydronephrotic right kidney. The level of obstruction could not be defined clearly. Cystoscopy showed a 12 g bladder tumor involving the right ureteral orifice. The tumor was resected entirely. Pathologic examination revealed a grade II noninvasive transitional cell carcinoma. The patient was referred to our institution for further evaluation and treatment. On physical examination, the patient was noted to have a massive nontender mass on the
right side extending from the lower border of his ribs to his right iliac crest. The prostate was small and nodular. Routine laboratory studies revealed a blood urea nitrogen (BUN) of 22 mgi dL and a creatinine of 2.0 mg/dL. Urinalysis showed 34-36 white blood cells/HPF with 6-8 red blood cells/HPF Urine culture grew greater than 100,000 Escherichia coli. Antibiotic treatment was initiated. Metastatic workup consisting of chest tomograms, bone scan, liver function tests, liver-spleen scan, barium contrast studies of the gastrointestinal tract, and computed tomography (CT) of the abdomen showed no evidence of locally invasive or distant disease. An attempt was made to catheterize the right ureter; however, the orifice was not visible in the previously resected area. Random biopsy specimens from the bladder and margins of the resected area showed no evidence of tumor. A percutaneous right antegrade pyelogram was performed in an attempt to visualize the right ureter and delineate the point of obstruction. Approximately 100 cc of “chocolate” fluid was aspirated from the renal pelvis. Contrast
470
UROLOGY
Case Report
/
MAY 1992
/ VOLUME
XXXIX.
NUMBER
5
the midportion of the kidney, a nodular lesion measuring 2.5 cm in diameter was found protruding into a dilated calix. The cortex \+‘as diffusely thinned, and multiple cysts filled with clear to brownish fluid were identified. Several of the cysts did not comnlunicate with either the pelvis or each other. One 2.5 cm cyst at the superior pole \vas noted to ha\.e a fibrotic, partially calcified wall. Microscopic examination of this cyst showed a fibrotic wall infiltrated by focal clear cell carcinoma (Fig. 2A). No tumor was seen within the cyst lumen. The papillar!, ureteric lesion was a grade III papillary transitional cell carcinoma extending deeply into the muscle with focal involvement of the adventitia (Fig. 2B). Localized squamous change was noted. On histologic examination, the nodular caliceal lesion w’as a keratinized moderately differentiated squamous cell carcinoma (Fig. 2C). Focal papillar!, transitional cell carcinoma was noted Lvithin this tumor. Comment
FIGIIHE 1. Antegrade pyelogram of right kidney with marked h!ydronephrosis and complete ohstruc lion at the rtrctcropclcic jum-tion.
material outlined a markedly dilated right renal collecting system to the level of the llreteropel\,ic jllnction where complete obstruction was found (Fig. 1). Cystoscopic finding on the aspirated fluid was class 1, and cultures were negative. the patient was explored Sllbsecpmtly, through a right flank eleventh-rib incision. A large h:y.dronephrotic kidney was encountered. A mass was palpated in the upper third of the ureter jvhich was dilated proximally. Frozen section of the ureteral wall revealed an invasive transitional cell carcinoma. A right nephroureterectom!. was performed. Patholog! Cross examination of the nephroureterectom!. specimen showed a cystic hydronephrotic kidney obstructed by a papillary ureteric tumor. The tumor filled the majorit!, of the ureteral lumen but spared the most proximal 3 cm adjacent to the kidne!,. The kidney \\‘as massivel\. dilatctd measuring 17 x IO x 7 cm. At
Carcinoma of the urinar!, tract accounts for approximately 4 percent of all new cancers and constitutes :3 percent of all cancer-related deaths.7 The multipotential nature of urothelium is well known and malignanc:ies of the urinary tract may exhibit a wide \,ari8et!. of histologic patterns. Adenocarcinoma of the kidne) is by far the most common renal malignancy, accounting for 85 to 90 percent of tumors in adults. The simultaneous occurrence of renal cell carcinoma and a histologically different neoplasm Lvithin a single kidne!. has been well described. 1,undell ct al. ’ reviewed 16 previously reported cases and estimated the frequency of this combination in a single patient to be about 1 to 2 per 1,000 cases of renal cell carcinoma. If simultaneous tumors \\‘ere limittld to a single kidney, an even smaller frequenq. ~vas estimated. Gillis, Finnerty. and Maxted” described a case of hypernephroma and transitional cell carcinoma in the contralateral kidney. discovered four years later. Orlin:’ reported a case of Wilms tumor with carcinoma in situ. papillary carcinoma of the renal pelvis and transitional cell carcinonla of the ipsilateral ureter. The present case reinforces the concept of field effect in urothelial malignancies. Hladder carcinoma is not infrequentI\ associated \vith coexistent tumors of the ureter and renal pelvis.h Squamous change \f,ithin a rlrothelial
FIGURE2. (A) Portion of cyst wall with rim of sclerosti bordering clear cell carcinoma. (B) Papillary transitional cell carcinoma, grade Ill. (C) Squamous cell carcinoma with focal keratin pearl formation. (Hematoxylin and eosin, original magnifications x 200 x 250, and x 400, respectively.)
malignancy in an obstructed, chronically inflamed organ is not unexpected. The coexistence, however, of cystic renal cell carcinoma with two distinct expressions of urothelial malignancy appears to be unique. Department of Urolog) Temple University School of Medicine Philadelphia, Pennsylvania 19104 (DR. HANNO) Keferences 1. renal 127: 2.
472
Lundell C, Kadir S, Engel R. and Nybcrg LXI: Concurrent cell and transitional cell carcinoma in a single kidney J Ural 761 (1982). Gillis DJ. Finnert). P. and hlaxted LVC: Simultaneous occur-
rence of hypernephroma and transitional cell carcinoma with development of transitional cell carcinoma in the opposite kidney, J Ural 106: 646 (1971). 3. Orlin I: Association of t\vo contiguous urological tumors with adult Wilms’ tumor, J Urol 109: 362 (1973). 3. Fallon B, and Schellhammer PF: Transitional cell carcinoma and renal cell adenocarcinoma in a single kidney Urolo~q 6: 774 (1975). 5. Kohut ND, and Goldman RI,: An unusual composite carcinoma of the renal pelvis, J Urol 109: 56i (1973). 6. De La Pen A, Navarro M, Melicow MM, and Uson AC: Concomitant unrelated neoplasms of the renal pelvis, J Urol 99: 21 (1968). 7. American Cancer Society: Cancer statistics. CA 36: 3 (1986). 8. Koss LC: Involvement of the ureters, urethra and renal pelvis in urothelial bladder cancer, in: Tumors of the Urinar), Bladder, 2nd ed, Washington D.C., Armed Forces Institute of PathologzT. 1975, p 73.
UROLOGY
/
MAY 1992
/
VOLUME
XXXIX, NUMBER
5
J. E. TOMASZEWSKI, P. M .HANNO, M.D.
M.D.
From the Division of Urology, Departments of Surgery and Pathology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
We report on a case of the simultaneous occurrence of cystic renal cell and squamous cell carcinoma in a single kidney in a patient with concurrent transitional cell carcinoma of the ipsilateral ureter and urinary bladder, A review qf the literature reveals this to be the first such occurrence. ABSTRACT-
The association of two primary tumors within the same kidney is a rare event, however several cases have been reported.‘m6 The finding of two different histologic tumors within the same kidney and a third histologic type in the ipsilateral ureter and bladder appears to be a unique event and to our knowledge does not appear in the literature to date.
A seventy-year-old white male retired engineer who was completely asymptomatic was found on routine physical examination to have a large abdominal mass on his right side. An intravenous urogram performed elsewhere revealed a large hydronephrotic right kidney. The level of obstruction could not be defined clearly. Cystoscopy showed a 12 g bladder tumor involving the right ureteral orifice. The tumor was resected entirely. Pathologic examination revealed a grade II noninvasive transitional cell carcinoma. The patient was referred to our institution for further evaluation and treatment. On physical examination, the patient was noted to have a massive nontender mass on the
right side extending from the lower border of his ribs to his right iliac crest. The prostate was small and nodular. Routine laboratory studies revealed a blood urea nitrogen (BUN) of 22 mgi dL and a creatinine of 2.0 mg/dL. Urinalysis showed 34-36 white blood cells/HPF with 6-8 red blood cells/HPF Urine culture grew greater than 100,000 Escherichia coli. Antibiotic treatment was initiated. Metastatic workup consisting of chest tomograms, bone scan, liver function tests, liver-spleen scan, barium contrast studies of the gastrointestinal tract, and computed tomography (CT) of the abdomen showed no evidence of locally invasive or distant disease. An attempt was made to catheterize the right ureter; however, the orifice was not visible in the previously resected area. Random biopsy specimens from the bladder and margins of the resected area showed no evidence of tumor. A percutaneous right antegrade pyelogram was performed in an attempt to visualize the right ureter and delineate the point of obstruction. Approximately 100 cc of “chocolate” fluid was aspirated from the renal pelvis. Contrast
470
UROLOGY
Case Report
/
MAY 1992
/ VOLUME
XXXIX.
NUMBER
5
the midportion of the kidney, a nodular lesion measuring 2.5 cm in diameter was found protruding into a dilated calix. The cortex \+‘as diffusely thinned, and multiple cysts filled with clear to brownish fluid were identified. Several of the cysts did not comnlunicate with either the pelvis or each other. One 2.5 cm cyst at the superior pole \vas noted to ha\.e a fibrotic, partially calcified wall. Microscopic examination of this cyst showed a fibrotic wall infiltrated by focal clear cell carcinoma (Fig. 2A). No tumor was seen within the cyst lumen. The papillar!, ureteric lesion was a grade III papillary transitional cell carcinoma extending deeply into the muscle with focal involvement of the adventitia (Fig. 2B). Localized squamous change was noted. On histologic examination, the nodular caliceal lesion w’as a keratinized moderately differentiated squamous cell carcinoma (Fig. 2C). Focal papillar!, transitional cell carcinoma was noted Lvithin this tumor. Comment
FIGIIHE 1. Antegrade pyelogram of right kidney with marked h!ydronephrosis and complete ohstruc lion at the rtrctcropclcic jum-tion.
material outlined a markedly dilated right renal collecting system to the level of the llreteropel\,ic jllnction where complete obstruction was found (Fig. 1). Cystoscopic finding on the aspirated fluid was class 1, and cultures were negative. the patient was explored Sllbsecpmtly, through a right flank eleventh-rib incision. A large h:y.dronephrotic kidney was encountered. A mass was palpated in the upper third of the ureter jvhich was dilated proximally. Frozen section of the ureteral wall revealed an invasive transitional cell carcinoma. A right nephroureterectom!. was performed. Patholog! Cross examination of the nephroureterectom!. specimen showed a cystic hydronephrotic kidney obstructed by a papillary ureteric tumor. The tumor filled the majorit!, of the ureteral lumen but spared the most proximal 3 cm adjacent to the kidne!,. The kidney \\‘as massivel\. dilatctd measuring 17 x IO x 7 cm. At
Carcinoma of the urinar!, tract accounts for approximately 4 percent of all new cancers and constitutes :3 percent of all cancer-related deaths.7 The multipotential nature of urothelium is well known and malignanc:ies of the urinary tract may exhibit a wide \,ari8et!. of histologic patterns. Adenocarcinoma of the kidne) is by far the most common renal malignancy, accounting for 85 to 90 percent of tumors in adults. The simultaneous occurrence of renal cell carcinoma and a histologically different neoplasm Lvithin a single kidne!. has been well described. 1,undell ct al. ’ reviewed 16 previously reported cases and estimated the frequency of this combination in a single patient to be about 1 to 2 per 1,000 cases of renal cell carcinoma. If simultaneous tumors \\‘ere limittld to a single kidney, an even smaller frequenq. ~vas estimated. Gillis, Finnerty. and Maxted” described a case of hypernephroma and transitional cell carcinoma in the contralateral kidney. discovered four years later. Orlin:’ reported a case of Wilms tumor with carcinoma in situ. papillary carcinoma of the renal pelvis and transitional cell carcinonla of the ipsilateral ureter. The present case reinforces the concept of field effect in urothelial malignancies. Hladder carcinoma is not infrequentI\ associated \vith coexistent tumors of the ureter and renal pelvis.h Squamous change \f,ithin a rlrothelial
FIGURE2. (A) Portion of cyst wall with rim of sclerosti bordering clear cell carcinoma. (B) Papillary transitional cell carcinoma, grade Ill. (C) Squamous cell carcinoma with focal keratin pearl formation. (Hematoxylin and eosin, original magnifications x 200 x 250, and x 400, respectively.)
malignancy in an obstructed, chronically inflamed organ is not unexpected. The coexistence, however, of cystic renal cell carcinoma with two distinct expressions of urothelial malignancy appears to be unique. Department of Urolog) Temple University School of Medicine Philadelphia, Pennsylvania 19104 (DR. HANNO) Keferences 1. renal 127: 2.
472
Lundell C, Kadir S, Engel R. and Nybcrg LXI: Concurrent cell and transitional cell carcinoma in a single kidney J Ural 761 (1982). Gillis DJ. Finnert). P. and hlaxted LVC: Simultaneous occur-
rence of hypernephroma and transitional cell carcinoma with development of transitional cell carcinoma in the opposite kidney, J Ural 106: 646 (1971). 3. Orlin I: Association of t\vo contiguous urological tumors with adult Wilms’ tumor, J Urol 109: 362 (1973). 3. Fallon B, and Schellhammer PF: Transitional cell carcinoma and renal cell adenocarcinoma in a single kidney Urolo~q 6: 774 (1975). 5. Kohut ND, and Goldman RI,: An unusual composite carcinoma of the renal pelvis, J Urol 109: 56i (1973). 6. De La Pen A, Navarro M, Melicow MM, and Uson AC: Concomitant unrelated neoplasms of the renal pelvis, J Urol 99: 21 (1968). 7. American Cancer Society: Cancer statistics. CA 36: 3 (1986). 8. Koss LC: Involvement of the ureters, urethra and renal pelvis in urothelial bladder cancer, in: Tumors of the Urinar), Bladder, 2nd ed, Washington D.C., Armed Forces Institute of PathologzT. 1975, p 73.
UROLOGY
/
MAY 1992
/
VOLUME
XXXIX, NUMBER
5