Synchronous renal cell carcinoma and urothelial carcinoma in a female: A rare case

Srilata Chitti; Arvind Ahuja; Sumit Gahlawat; Ravi Hari Phulware

doi:10.4103/JME.JME_197_20

CASE REPORT

Year : 2022 | Volume : 3 | Issue : 2 | Page : 155-157

Synchronous renal cell carcinoma and urothelial carcinoma in a female: A rare case

Srilata Chitti¹, Arvind Ahuja¹, Sumit Gahlawat², Ravi Hari Phulware³
¹ Department of Pathology, ABVIMS, PGIMER, RML Hospital, New Delhi, India
² Department of Urology and Renal Transplant, ABVIMS, PGIMER, RML Hospital, New Delhi, India
³ Department of Pathology and Laboratory Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission	11-Dec-2020
Date of Decision	19-May-2021
Date of Acceptance	20-May-2021
Date of Web Publication	29-Aug-2022

Correspondence Address:
Dr. Ravi Hari Phulware
Department of Pathology and Laboratory Medicine, Room No. C-2, Level-3, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_197_20

How to cite this article:
Chitti S, Ahuja A, Gahlawat S, Phulware RH. Synchronous renal cell carcinoma and urothelial carcinoma in a female: A rare case. J Med Evid 2022;3:155-7

How to cite this URL:
Chitti S, Ahuja A, Gahlawat S, Phulware RH. Synchronous renal cell carcinoma and urothelial carcinoma in a female: A rare case. J Med Evid [serial online] 2022 [cited 2023 Jun 3];3:155-7. Available from: http://www.journaljme.org/text.asp?2022/3/2/155/354982

Introduction

Multiple primary tumours (MPMTs) are entities with different histologically that appear at different sites. These tumours are known as synchronous tumours (STs) and metachronous tumours (MTs).^[1] As per the Surveillance, Epidemiology and End Results (SEER) project, STs appear either at the same time or after 2 months apart from each other. MTs appear at an interval of 6 months.^[1] The pathophysiology of MPMT is unknown, and several factors are considered, such as inherited predisposition to cancers, cancer-promoting aspects of lifestyle, hormonal factors, environmental factors and history of the treatment of previous primary cancer.^[1],[2]

The incidence of MPMT in the cancer population varies between 2.4% and 8% up to 17%.^[1] Renal cell carcinoma (RCC) is mainly a disease of the elderly and typically present in the sixth and seventh decade of life and accounts for 3% of all adult cancers and 85% of all kidney tumours. RCC is most likely to occur in men than in the female and is most likely to be associated with breast, prostate, colorectal, bladder and non-Hodgkin's lymphoma, but the synchronous association with bladder cancer is rare.^[2],[3] Synchronous double primary RCC and urothelial carcinoma (UC) of the renal pelvis and bladder are extremely uncommon. Proper management is a medical dilemma, and no standard treatment modality has been suggested upon for this rare situation.^[1],[2],[3] Indian data regarding MPMTs are limited to a few cases or case series. Herein, we present a case of synchronous RCC and UC in a 58-year-old woman.

Case Report

A 58-year-old female presented with complaints of painless gross haematuria and with a history of pyuria. There was no history of fever, weight loss, neither abdominal pain. The complete blood count, renal function test and biochemical tests were normal on the routine blood investigation. The patient was on antihypertensive medications and had previously undergone cholecystectomy. The abdomen's ultrasonography revealed a heterogeneous echotexture mass of 60 mm × 40 mm in the mid cortex of the left kidney. The abdominal computed tomography (CT) showed a large heterogeneously enhancing mass lesion measuring 82 mm × 54 mm × 49 mm arising from the left kidney and extending anteriorly up to the tail of the pancreas. The left kidney was enlarged due to infiltration by the mass, and large non-enhancing areas of necrosis were noted within the tumour. The urinary bladder was partially distended and showed a lesion of 2.5 cm × 2 cm on the left posterior wall [Figure 1].

Figure 1: Computed tomography scan coronal section image showing a large heterogeneously enhancing mass lesion in the left kidney (red arrow). The urinary bladder was partially distended and showing a lesion on the left posterior wall (green arrow)

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Following these findings, initially, the transurethral resection of bladder tumour (TURBT) showed low-grade UC features with invasion into the lamina propria with no muscle invasion [Figure 2]a, [Figure 2]c, [Figure 2]c, [Figure 2]d.

Figure 2: Photomicrographs of the bladder tumour. (a) Shows low grade papillary urothelial carcinoma (H and E, ×100); (b) shows well-formed papillae with minimal papillary fusion (H and E, ×200); (c and d) shows mild loss of cellular polarity with a cell having mild nuclear pleomorphism, nuclear enlargement, fine chromatin and indistinct nucleoli (H and E, ×400). (e) Gross finding of the surgical specimen – nephrectomy – Note the infiltrating tumour arising from the kidney's mid pole (scale bar = 3 cm). (f) Tumour cells arranged in nests and having clear cell morphology (H and E, ×200); (g and h) shows branching vascular septa along with tumour cells having nucleoli which are easily identifiable (WHO/ISUP Grade 2) (H and E, ×400)

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The patient underwent a left renal nephrectomy along with restaging TURBT. Grossly nephrectomy specimen measured 12 cm × 6 cm × 6 cm. The cutting surface showed an infiltrating tumour of 5 cm × 2 cm × 5 cm at the mid pole of the kidney. The tumour was grey-white to grey yellow and showed few pinpoint haemorrhagic areas with a few cystic changes.

The microscopy examination showed clear cell RCC features, WHO/ISUP Grade 2, with a pathological staging of pT1b N0MX [Figure 2 e-h]. Sections from restaging TURBT showed no features of malignancy. The post-operative period of the patient was uneventful. The patient is currently undergoing hyperthermic intravesical chemotherapy of Mitomycin C (MMC) and bacillus Calmette–Guérin. Now, after the operation, she attends regular medical visits and is still disease-free.

Discussion

In 1991, Billroth first described MPMTs.^[4] The first case of simultaneous dual urological malignancy was reported by Graves and Templeton in the year 1921.^[5] Warren and Gates^[6] described the criteria for diagnosing MPMT: (i) each tumour must possess a definitive sign of malignancy, (ii) each tumour should have a histological pattern and (iii) the possibility of the tumour being metastasis of each other should be ruled out.

We were able to diagnose two histologically different tumours in the same patient. These tumours had their own histological features and were not metastatic to each other, thus fulfilling the criteria of MPMT. We also found both the tumours within 2 months, thus by SEER definition, its synchronous MPMTs. For the development of MPMT, several theories are being considered, such as cancer predisposition syndrome, genetics, hormonal factors and prior treatment exposures, lifestyle factors such as alcohol, tobacco use and exposure to dyes or occupational hazards.^[6] Several possible aetiological factors have been implicated for primary renal pelvic neoplasms. Although the aetiology of coexistence of different renal neoplasms is still unclear, chronic irritation, hydronephrosis and urinary calculi have been the most commonly discussed aetiologic factors.^{[3],[4],[5],[6]} Our patient had no history of smoking or tobacco chewing; the patient is a housewife. There was no family history of genetic predisposition to multiple tumours or hereditary syndromes.

Rabbani et al.^[3] in the year 1998 studied MPMT in RCC. This study followed records of 551 patients, including 354 men and 197 women with a median age of 63 years, who were initially diagnosed and operated on for RCC. The study had found that RCC was most commonly associated with breast, prostate, colorectal, bladder cancer and non-Hodgkin's lymphoma. This study also found that the incidence of bladder cancer followed by RCC increased significantly in men. Very few synchronous RCC cases associated with bladder carcinoma are seen in women, making our case one of these rare cases.

Qi et al.^[7] studied patients with RCC and UC. This study had 27 patients diagnosed with RCC and UC, out of which 22 patients were male and only 5 patients were female. This study also evaluated the prognosis and different treatment procedures used in these patients. The author concluded that the prognosis of patients is associated with the tumour's aggressive nature and that the treatment should be individualised.

Data regarding MPMT are usually found in case reports or case series [Table 1]. However, Indian data regarding MPMT is limited. On review of literature, it was found that the most common combination of MPMT were gastrointestinal tract, genitourinary tracts, head-and-neck tumours, gynaecological cancers and breast cancers.^{[5],[6],[7],[8]} A combination of MPMTs in the genitourinary tract is most commonly seen in males. The most common combination of tumours seen in females is breast carcinoma and gynaecological tumours. Very few incidences of female patients suffering from synchronous RCC and urinary bladder carcinoma were seen.^[8],[9],[10]

Table 1: Comparison of present case study with other long term studies having multiple primary tumours in female patient

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The treatment of patients with multiple synchronous primaries is challenging and is often considered a therapeutic dilemma. If the disease is localised, then the treatment options may be surgery or chemotherapy or radiotherapy, but if it is an advanced disease, then a selection of antitumour therapy is challenging.^[1] Germline mutation and somatic mutations play an important role in carcinogenesis and should also be considered targets of treatment.^[3]

The incidence of STs has increased simultaneously with the increase in the number of cases of genitourinary tumours. Considering the past studies and case reports, very few synchronous RCC and UC cases in female patients have been noted. Hence, it is necessary to pay attention to the possible occurrence of synchronous urothelial cancer in clinical practice through proper follow-up of the case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the consent form, the patient has given her consent for her images and other clinical information 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.

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