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Year : 2020  |  Volume : 63  |  Issue : 3  |  Page : 497-498
Urothelial carcinoma of the renal pelvis with synchronous ipsilateral papillary renal cell carcinoma


1 Department of Pathology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Urosurgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
3 Department of Medicine, Dr SNMC, Jodhpur, Rajasthan, India

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Date of Submission24-Sep-2018
Date of Decision17-Jan-2019
Date of Acceptance19-Jan-2019
Date of Web Publication7-Aug-2020
 

How to cite this article:
Bagga N, Khera S, Choudhary GR, Tuteja RK. Urothelial carcinoma of the renal pelvis with synchronous ipsilateral papillary renal cell carcinoma. Indian J Pathol Microbiol 2020;63:497-8

How to cite this URL:
Bagga N, Khera S, Choudhary GR, Tuteja RK. Urothelial carcinoma of the renal pelvis with synchronous ipsilateral papillary renal cell carcinoma. Indian J Pathol Microbiol [serial online] 2020 [cited 2020 Oct 30];63:497-8. Available from: https://www.ijpmonline.org/text.asp?2020/63/3/497/291679




Upper tract Urothelial carcinomas (UTUC) are uncommon entities and account for less than 1% of genitourinary neoplasm's.[1] Synchronous appearance of UTUC with Renal Cell Carcinoma in the same kidney is even more rare event. Till date only 50 cases of synchronous renal and Urothelial tumours have been reported.[2],[3],[4],[5]

A 47 year old male presented to the OPD with chief complaints of on and off left flank pain and generalised weakness since 1.5 years. He had no episodes of hematuria/dysuria decreased urination or weight loss. On physical examination no palpable abdominal mass was detected. Patient was chronic smoker for 7–8 years and had been receiving treatment for Rheumatoid arthritis since 3 years. No other co-morbid condition was present. Family history was negative for urologic malignancy. A CT KUB was performed outside and showed a moderately enhancing mass lesion of size 6.2 × 5.1 cm arising from pelvis of left kidney and diffusely infiltrating in pelvis. Necrotic areas were also noted. Mass was seen infiltrating cortex of kidney. Inferior vena cavae, renal veins and aorta were normal. Multiple calculi were seen embedded in the mass with severe hydro-nephrosis in remaining left kidney. CT findings were suggestive of left renal pelvic mass/malignancy. Exfoliative cytology of urine was negative for malignant cells. Results from routine examinations were within normal limits. The patient underwent left radical nephro-ureterectomy, which was performed uneventfully. The specimen was received subsequently in Pathology Department of AIIMS Jodhpur.

Grossly the specimen measured 14 × 10 × 5 cm. Left ureter measured 6 cm in length. On serial section two distinct masses were noted, one grey white papillary to solid area projecting in to the large multi-loculated cyst and the second grey white solid growth around renal pelvis with impacted large stones [Figure 1]. Cyst measured 10 × 3.5 × 3 cm and was filled with hemorrhagic to greenish serous fluid. Solid areas measured 7 × 4 × 3.5 cm. Two gray brown stones were seen impacted in the Pelvi-ureteric junction. Representative sections from both the masses were taken for subsequent histological examination. On microscopic examination, sections from solid growth around pelvis showed a tumor arranged in papillae, nests and sheets. The papillae were lined by multilayered transitional layered epithelium with focal loss of polarity. Brisk mitotic figures and squamous differentiation were also seen [[Figure 2] Right]. Adjacent areas of extensive necrosis were noted. Lympho-vascular invasion was identified. The tumor was seen invading into the adjacent connective tissue. No peri-neural invasion was noted. Sections from solid areas projecting into the cyst showed a tumor composed of cells arranged predominantly in papillary pattern showing focal pseudo-stratification [Figure left]. The cells have well-defined borders with abundant eosinophilic granular cytoplasm, vesicular nuclei, and prominent nucleoli visible at 400× magnification, but not prominent at 100× magnification (G2). The ureteric margin, peri-nephric fat, and Gerotas fascia were free of tumor. Tumor was abutting the renal capsule, but did not invade it. Hence, a diagnosis of high-grade invasive Papillary Urothelial carcinoma with squamoid differentiation (origin renal pelvis) was made with pathological staging: PT2 PN1 (AJCC staging for Urothelial carcinoma arising from renal pelvis) and Papillary Renal Cell Carcinoma type 2 stage PT2aNx was made. The patient did well postoperatively and was discharged with proper schedule of post operative chemotherapy. Two months later, the patient visited OPD with complains of heaviness in abdomen. A CT scan of abdomen revealed presence of multiple enlarged necrotic lymph nodes in retro-peritoneum at left para-ortic location suggestive of metastasis. The patient was referred to tertiary care center at Bikaner for radiotherapy cycles. However, the patient succumbed to the disease and died within 2 months.
Figure 1: Gross image of the nephrectomy specimen. Red arrow indicates papillary projections in to the cyst. Blue arrow indicates solid areas around renal pelvis. Grossly two distinct morphologies of tumor identified

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Figure 2: Papillary renal cell carcinoma (type 2) Papillae are lined by pseudo stratified layers of cells with abundant eosinophilic cytoplasm (left, L). High grade papillary Urothelial Carcinoma showing a tumor composed of transitional cells arranged in a papillary pattern (right R). Hematoxylin and eosin stain (original magnification 100×)

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   Discussion Top


Multiple primary malignant neoplasm (MPMN) was first described by Bilroth in 1889. Since then many studies have addressed this subject. In a review of 1,104,269 cancer patients the prevalence of MPMN has been reported between 0.734% and 11.7%.[4] In 1977 Von Eschenbach encountered a single case of synchronism with the transitional cell cancer out of a total 700 nephrectomies for renal cell carcinoma with a proportion of mere 0.14% of the total cases.[2],[3],[4] So far, no specific risk factors for the simultaneous presence of tumors is identified; however, the prognosis of such patients is likely governed by the more aggressive tumor.

In the present case, patient had only left flank pain with no complaints of hematuria/left flank lump. We were able to successfully diagnose two separate primary malignancies involving the same kidney on the basis of thorough histo-pathological examination and adequate sectioning.

To conclude, with increasing incidence of genito urinary tumors, the possibility of encountering synchronous tumors also increases. Overlapping signs and symptoms can lead to missing of these cases. Hence, a combined effort by the surgeon and extensive histo-pathological examination by the pathologist becomes the key which can lead to correct diagnosis and treatment of such cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Messing EM. Urothelial tumors of the urinary tract. In: Campbell M, Retik AB, Vaughan ED, editors. Campbell's Urology. 8th ed. Philadelphia: Saunders; 2002. p. 2732-84.  Back to cited text no. 1
    
2.
Atilgan D, Uluocak N, Parlaktas BS. Renal cell carcinoma of the kidney with synchronous ipsilateral transitional cell carcinoma of the renal pelvis. Case Rep Urol 2013;2013:194127.  Back to cited text no. 2
    
3.
Dutta G, Silver D, Oliff A, Harrison A. Synchronous renal malignancy presenting as recurrent urinary tract infections. Case Rep Urol 2011;2011:832673.  Back to cited text no. 3
    
4.
Leveridge M, Isotalo PA, Boag AH, Kawakami J. Synchronous ipsilateral renal cell carcinoma and urothelial carcinoma of the renal pelvis. Can Urol Assoc J 2009;3:64-6.  Back to cited text no. 4
    
5.
Fernández Arjona M, Santos Arrontes D, De Castro Barbosa F. Synchronous renal clear-cell carcinoma and ipsilateral transitional-cell carcinoma: Case report and bibliographic review. Arch Esp Urol 2005;58:460-3.  Back to cited text no. 5
    

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Correspondence Address:
Sudeep Khera
Assitant Professor, Department of Pathology, All India Institute of Medical Sciences, Basni Phase 2, Jodhpur - 342 005, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJPM.IJPM_617_18

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