British Journal of Radiology (2006) 79, e187-e189
© 2006 British Institute of Radiology
doi: 10.1259/bjr/34773521
Synchronous ipsilateral renal cell and transitional cell carcinoma
C-H Chiu, MD
C-C Lee, MD
P-Y Chong, MD
C-M Ling, MD
H-W Huang, MD
K-H Chiang, MD
and
A S-B Chou, MD
Department of Medical Imaging, Hualien Buddhist Tzu Chi General Hospital, Taiwan
Correspondence: Andy Shau-Bin Chou, No 707, Section 3, Chung Yang Road, Hualien, Taiwan. E-mail: chiuqiu{at}ms24.hinet.net.
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Abstract
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The coexistence of multiple and synchronous primary neoplasms in the genitourinary system has only rarely been described in the literature. We present the case of a 78-year-old man with haematuria as the initial presentation, finally proven to be transitional cell carcinoma (TCC) combined with renal cell carcinoma (RCC). Intravenous urography (IVU), CT and arterial angiography studies revealed a space-occupying nodule at the right upper renal pelvicalyces showing mild enhancement with contrast medium. Another strong contrast medium enhancing exophytic tumour was found at the lower pole of kidney; there were hypodense foci and calcified components in this lesion. A right nephroureterectomy was performed. Pathological diagnosis was a papillary TCC and a clear cell type RCC. This is a rare case of combined renal malignancies diagnosed by imaging.
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Introduction
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Simultaneous occurrence of renal cell carcinoma (RCC) and transitional cell carcinoma (TCC) in the same kidney is unusual. To our knowledge there are only 47 cases of synchronous renal adenocarcinoma and TCC reported in the literature [1, 2] and this is the first case ever described in the radiology journals.
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Case report
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A 78-year-old male with a history of benign prostate hyperplasia and a status of post-open prostatectomy for 10 years was referred to our department for recurrent gross haematuria. His physical examination revealed no remarkable findings. Laboratory data showed mild anaemia, haemoglobin 12.4 g dl–1 (normal 13–18 g dl–1). Urinary cytology revealed atypical cells. Intravenous urography (IVU) showed an exophytic mass at the lower pole of the right kidney and a space-occupying lesion at the right upper kidney with distorted renal pelvicalyces (Figure 1
). Abdominal CT (Lightspeed Ultra; GE Medical Systems, Milwaukee, WI) showed a 1.7 cmx1.6 cm space-occupying nodule located in the right upper renal pelvicalyces showing mild enhancement with contrast medium (Figure 2a). Another strong contrast medium enhancement exophytic tumour was found at the lower pole of kidney. It was approximately 3.4 cmx2.7 cm in size, and there were hypodense foci and calcified component in this lesion (Figure 2b). These two lesions were in close proximity to each other in the mid-part of the kidney. Abdominal digital subtraction angiography (Advantax LCA; GE Medical Systems) was arranged and selective right renal arterial angiography revealed a hypervascular protruding mass at the lower pole of the right kidney with enlarged feeding arteries, early filling at the arterial phase and pooling of contrast (Figure 3). There was a direct drainage vein into the inferior vena cava. Besides a perfusion defect located in the upper pole of the right kidney was seen by right renal arterial angiogram, this area was directly supplied by the aortic branch and was depicted by aortogram. The right renal vein was patent without any apparent filling defect. Pyelogram showed a space-occupying lesion at the upper pole of the right kidney without definite vessel deformity in this region as well as IVU finding. The left renal arterial angiogram showed patent renal arteries and well functioning kidney with smooth contours; the left renal vein was patent. According to those image findings, synchronous ipsilateral conventional RCC and TCC were suggested by our radiologist.
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Figure 1. Intravenous urography in delayed 5 min film shows an exophytic mass from lower pole of right kidney (arrowheads) and a space-occupying lesion at right upper kidney with distorted renal pelvicalyces (arrows).
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Figure 2. (a) Dynamic contrast medium enhanced abdominal CT in excretory phase shows a 1.7 cmx1.6 cm space-occupying nodule at right upper renal pelvicalyces with mild contrast medium enhancement (arrows). (b) In the nephrographic phase, another exophytic tumour showing strong enhancement with contrast medium at lower pole of kidney about 3.4 cmx2.7 cm in size, there were hypodense foci and calcified component in this lesion (arrowheads).
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Figure 3. Selective right renal arterial angiography shows a hypervascular protruding mass at lower pole of right kidney with enlarged feeding arteries, early filling at arterial phase and pooling of contrast(arrows). Besides a perfusion defect at upper pole (arrowhead), this area was supplied directly by aortic branch and was depicted by aortogram.
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Radical right nephroureterectomy was performed 6 days after angiography. Intraoperative findings showed one papillary tumour in the renal pelvis and one solid yellow tumour at the lower pole of the kidney. No obvious regional lymphadenopathy was seen. Gross pathology showed one bulging mass in the lower pole with a well-defined, golden yellowish appearance, measuring 5.0 cmx4.0 cmx4.0 cm in size on cutting surface. In addition, one whitish papillary tumour measuring 3.5 cmx2.0 cmx2.0 cm in size occupied the upper pelvis. Microscopically, it showed two separate cancerous structures in the kidney. The papillary part in the pelvis showed grade II papillary TCC limited on the surface. No parenchymal invasion was seen. The golden yellow part showed clear cell type RCC composed of clear cells with capillary stroma and intact capsule without tumour emboli formation. The kidney parenchyma and ureter were free. No metastatic lymph node was found.
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Discussion
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Rare cases of synchronous ipsilateral TCC of the renal pelvis and RCC have been reported in the literature. The median age of diagnosis was 65 years. Haematuria was the most common presentation seen in 90% of the cases. There was a male predominance (2:1) and tumours were more commonly located on the left side (3:1) [3, 4]. Several possible aetiological factors in primary renal pelvic neoplasms have been discussed in recent reviews. Although the aetiology remains uncertain, the postulated pathogenesis of this multiple renal pelvis neoplasms is related to its frequent association with chronic irritation such as inflammation, hydronephrosis and urinary calculi [5]. Distinction of urothelial carcinomas of undifferentiated morphology from collecting duct carcinoma can be difficult since both may be associated with fibrotic or desmoplastic stroma and they may exhibit a tubular pattern of growth [6]. The differential diagnosis can be made with the immunological method. In our case, pre-operative diagnosis could be well established by the radiologist since these two lesions presented a typical imaging presentation. The TCC was presented as a filling defect in the opacified collecting system without definite hypervascular appearance. The RCC was depicted as an exophytic renal parenchymal tumour with hypervascularity and inhomogeneous enhancement. The CT scans combined with angiography are highly suggestive of an urothelial tumour and lead to an accurate pre-operative diagnosis.
Opinions vary on the management of synchronous renal tumours of different histogenesis. It is believed that management planning must be individualized and the life quality of the patient should be considered [7]. In our case, the RCC was thought to be in Robson stage I, which translates into a 5 year survival rate of more than 75% [8]. The renal pelvis TCC was grade II tumour and pTaN0M0 (Stage 0), therefore the 5 year survival rate is 60–90% [9]. The prognosis of our case should be good after radical nephroureterectomy, and no post-operative chemotherapy was given. The patient was healthy at the 3 month follow-up post-surgery.
Finally, it is noteworthy that this is a very rare case manifesting combinations of neoplasms and is the first such reported case in the radiology literature following a search of Medline.
Received for publication September 12, 2005.
Revision received January 13, 2006.
Accepted for publication January 25, 2006.
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References
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Abstract
Introduction
