INTRODUCTION: CASE REPORT:

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1 Balekuduru Chaitanya et SYNCHRONOUS OCCURRENCE OF PAPILLARY RENAL CELL CARCINOMA AND TRANSITIONAL UROTHELIAL CELL CARCINOMA OF URINARY BLADDER a case report S. Rajasekhar Reddy 1, Balekuduru Chaitanya* 2, P. Swarna Latha 1 1. Nizam s Institute of Medical Sciences Hyderabad, Andhra Pradesh, India. 2.Dr. NTR University of Health sciences, Vijayawada, Andhra Pradesh, India. * [email protected] Abstract: The occurrence of both urothelial carcinoma and renal cell carcinoma is normally high in the elderly population. However simultaneous occurrence i.e synchronicity, of transitional cell carcinoma of urinary bladder and renal cell carcinoma of kidney is uncommon especially combination of papillary renal cell carcinoma & transitional cell carcinoma is very rare. We report a case of an elderly man with synchronous presentation of papillary renal cell carcinoma and transitional cell carcinoma of the urinary bladder. Keywords: Papillary Renal Cell Carcinoma, Transitional Cell Carcinoma, Synchronous Malignancy INTRODUCTION: RCC, the most lethal among urologic malignancies accounts for 2 3 % of all adult malignant neoplasms. [1][2] In men, urothelial carcinoma of the bladder is the fourth most common cancer after prostate, lung, and colorectal cancers, accounting for 6.6% of all cancer cases. [3] Both the malignancies tend to occur in elderly men in the sixth to seventh decades. [4] However simultaneous occurrence is very rare. CASE REPORT: A 69 year old male presented with complaints of 3 episodes of painless haematuria of 3 months duration and a swelling in the left loin of 2 months duration associated with pain. He is a chronic smoker with no significant past history or family history. Per abdomen revealed a palpable mass in the left hypochondrium and lumbar regions. Complete urine examination showed 6-8 RBC/ HPF. Other renal parameters were within normal limits. Ultrasonography showed a well defined heterogenous mass of 8 cm in diameter arising from lower pole of left kidney and an irregular hyperechoeic lesion of 2 cm along left lateral wall of bladder. Contrast enhanced computerised tomography (CECT) abdomen showed a large heterogenous enhancing lesion arising from lower pole of left kidney suggestive of a renal tumor and a small mildly enhancing papillary growth from left lateral wall of bladder ( Figure 1). Transurethral resection of bladder tumor (TURBT) and left radical nephrectomy was done in the same sitting. TUR accompanied by fulgaration of the papillary growth on left lateral wall and three small growths over right lateral wall of urinary bladder was performed along with left radical nephrectomy by transperitoneal approach. Histopathological examination revealed papillary variant of renal cell carcinoma of left kidney (stage T2N0M0) and a low grade transitional cell carcinoma of the bladder without deep muscle invasion. Gross specimen of left nephrectomy and histopathological images of papillary RCC and transitional cell carcinoma of bladder are herewith enclosed as figures 2-6. Patient had an uneventful inpatient course and was advised regular follow-up after discharge. 498

NTR University of Health sciences, Vijayawada, Andhra Pradesh, India. *E-mail: bharadwaj.chaitanya@yahoo.

2 Balekuduru Chaitanya et Fig:1 CECT showing growth in left kidney and in urinary bladder Fig: 2. Gross photograph of left nephrectomy y specimen showing variegated appearance of tumour inn the upper pole. 499

3 Balekuduruu Chaitanya et Fig: 3. Papillary RCC with macrophages in the core of papillae, H&E, 100x Fig: 4. Cellular anaplasia of lining cells of papillae alongg with macrophage, H& &E,400x 500

4 Balekuduru Chaitanya et Fig:5. Transitional cell carcinoma, low power view, H& &E,100x Fig: 6. Nuclear atypia & stratification in TCC,Bladder, H&E,400x 501

5 Balekuduru Chaitanya et DISCUSSION: Though many case reports simultaneous occurrence of clear cell renal cell carcinoma and transitional cell carcinoma of bladder are on record, coexistent papillary renal cell carcinoma with transitional carcinoma of bladder are very rare. [5][6] The most prominent risk factor of both renal cell carcinoma and transitional cell carcinoma is tobacco and this patient was found to be a chronic smoker. In addition germline and somatic mutations of c-met proto-oncogene on human chromosome 7q31-34 are specifically associated with papillary renal carcinoma and also expression of c-met in the papillary urothelial carcinoma of the urinary bladder was positively associated with histologic grade, stage, tumor size and growth pattern and c-met protooncogene has been reported to play a more important role in the progression of bladder cancers. [7][8][9][10] The role of similar risk factors and germline mutations involving the oncogenes and tumor suppressor genes can be of interest for research and provide insights into the pathogenetic mechanisms behind the occurrence of these dual malignancies. The management of such dual malignancies still remains a therapeutic challenge. Prognosis in instances of synchronous malignancies remains poor with the outcome being more influenced by the aggressive primary among the two. REFERENCES: [1]. Renal Tumours, in Campbell s Urology, Steven C. Campbell, Andrew C.Novack,Ronald M.Bukowski, Saunders, Philadelphia, PA, USA, 9th edition,2007. [2]. Pantuck et al., 2001b. Pantuck AJ, Zisman A, Belldegrun AS: The changing natural history of renal cell carcinoma. J Urol 2001; 166: [3]. Jemal et al., Jemal A, Murray T, Ward E, et al: Cancer statistics, CA Cancer J Clin 2005; 55: [4]. Lynch and Cohen, Lynch CF, Cohen MB: Urinary system. Cancer 1995; 75(Suppl):316. [5]. Mazeman I. Tumors of the upper urinary tract, calyces, renal pelvis and ureter. Eur Urol. 1976;2:120. [PubMed] [6]. Huben RP, Mounzer AM, Murphy GP. Tumor grade and stage as prognostic variables in upper tract urothelial tumors. Cancer. 1988;62:2016. [PubMed] [7]. Schmidt L, Duh F-M, Chen F, Kishida T, Glenn G, Choyke P, Scherer S, Zhuang Z, Lubensky I, Dean M, Allikmets R, Chidambaram A, Bergerheim UR, Feltis JT, Casade- vall C, Zamarron A, Bernues M, Richard S, Lips CJM, WaltherMM, Tsui L-C, Geil L, OrcuttML, Stackhouse T, Lipan J, Slife L, Brauch H, Decker J, NiehansG,Hughson MD, Moch H, Storkel S, Lerman MI, Linehan WM and Zbar B. (1997). Nature Genet., 16, 68 ± 73. [8]. Joseph A, Weiss GH, Jin L, et al: Expression of scatter factor in human bladder carcinoma. J Natl Cancer Inst 87: , [9]. Li B, Kanamaru H, Noriki S, et al: Differential expression of hepatocyte growth factor in papillary and nodular tumors of the bladder. Int J Urol 5: , [10]. Chow NH, Trink B, Eisenberger C, et al: Tyrosine kinase profile of bladder cancer. J Urol 159:1096, 1998 (abstr) 502

[5][6] The most prominent risk factor of both renal cell carcinoma and transitional cell carcinoma is tobacco and this patient was found to be a chronic smoker.

SEMESTER VI 3 RD YEAR PATHOLOGY KIDNEY TUMORS

SEMESTER VI 3 RD YEAR PATHOLOGY KIDNEY TUMORS LEARNING OBJECTIVES At the end of the lecture, students should be able to: Know the pathology of renal tumors. RENAL TUMORS RENAL PAPILLARY ADENOMA Common