Page 1 of 3

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Al-Hawary AK, Shalaby A, Shebl AM, Khater S, Wadie BS, Abu Beih EA, et al. Synchronous ipsilateral transitional cell and papillary renal cell carcinomas. OA Case Reports 2013 Mar 01;2(3):24.

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Synchronous ipsilateral transitional cell and papillary renal cell carcinomas

AK Al-Hawary1,2*, A Shalaby1,2, AM Shebl1,2, S Khater2,BS Wadie3, EA Abu Beih4, MA El-Baz1,2

AbstractIntroductionThe coexistence of renal cell carci-noma and urothelial carcinoma of renal pelvis or ureter has rarely been described in literature. This paper discusses synchronous ipsilateral transitional cell and papillary renal cell carcinomas.Case reportWe present a case of a 69-year-old male who was admitted in Mansoura Urology and Nephrology Centre with a history of loin pain and occasional haematuria confirmed to be transi-tional cell carcinoma combined with papillary renal cell carcinoma.ConclusionIn more than 31 years, this was the first reported case of synchronous renal tumour in Mansoura Urology and Nephrology Centre, Mansoura University, Egypt.

IntroductionRenal cell carcinoma (RCC) is the most common adult renal epithe-lial cancer, accounting for more than 90% of all renal malignancies1. Pri-mary transitional cell carcinoma (TCC) of the renal pelvis or ureter is a relatively rare disease. It accounts for

<1% of genitourinary neoplasms and 5%–7% of all urinary tract tumours2. The coexistence of RCC and TCC of renal pelvis or ureter is uncommon3. According to Choi et al4., 26 cases of synchronous renal carcinoma and TCC are reported in the literature. This paper discussed the first case of synchronous papillary RCC and pel-vic TCC managed in Mansoura Urol-ogy and Nephrology Center.

Case reportA 69-year-old man presented with left loin pain and occasional total haematuria for 6 months prior to admission in the Urology and Neph-rology Center. A palpable left renal mass was the main finding on his physical examination. Laboratory tests were unremarkable, except for the high serum creatinine (1.7 mg/dl). Serum total prostatic specific an-tigen was also elevated (8.7 ng/ml). Transrectal ultrasound and biopsy confirmed benign prostate enlarge-ment. An abdominal computerized tomography scan (CT) revealed a large renal mass, about 15 cm in di-ameter. This mass occupied most of the lower and middle zones of the left kidney and was compressing the descending colon and sigmoid colon. No enlarged hilar or regional lymph-nodes were detected. The other kid-ney showed no abnormalities.

On cystoscopy, there was no asso-ciated bladder tumour, and bone scan showed no evidence of metastasis. The patient had left radical nephrec-tomy via supracostal (above the elev-enth rib) approach. On exploration, no visibly enlarged lymph nodes were detected. Liver surface was normal with no metastasis. There

was a large renal mass attached to the transverse mesocolon and the descending colon was stretched and attached to the anterior surface of the kidney. Dissection of the kidney with its covering perirenal fascia was performed. Ligation of a single hilar renal artery was performed followed by the vein. The wound was closed in layers with suitable drain, and the post-operative period was unevent-ful. He was discharged in good con-dition 5 days after the surgery. No post-operative chemotherapy was administered. This patient will be followed up with abdominal CT, com-plete blood count, cystoscopy, urine cytology and prostate specific anti-gen assay every 3 months.

Macroscopically, the kidney was en-larged with irregular surface but with an intact capsule. The cross section revealed two morphologically distinct masses (Figure 1). The first mass was a well-demarcated large mass, which measured 8×8×6 cm and occupied the middle and lower poles. The mass was firm in consistency and light brown in colour. The second mass was a grey-ish-white papillary tumour measuring 2×1×1 cm and occupied the middle calyx. The adjacent renal tissue, renal vein, renal capsule and the ureter ap-peared normal. Microscopically, the brownish tumour showed type I pap-illary RCC, Fuhrman grade 1, with no vascular/renal capsular/perinephric fat invasion (pT2, Nx, Mx) (Figure 2). The papillary tumour in the calyx showed grade II papillary TCC, infil-trating the subepithelial layer of the re-nal pelvis (pT1, Nx, Mx) (Figure 3). The ureter showed no evidence of malig-nancy. There was no area of transition between these dissimilar tumours.

* Corresponding author Email: amira960@hotmail.com1 Pathology Department, Faculty of Medicine,

Mansoura University, Mansoura, Egypt2 Pathology Department, Urology and

Nephrology Centre, Mansoura University, Mansoura, Egypt

3 Urology Department, Urology and Nephrology Centre, Mansoura University, Mansoura, Egypt

4 Radiology Department, Urology and Nephrology Centre, Mansoura University, Mansoura, Egypt

Page 2 of 3

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Al-Hawary AK, Shalaby A, Shebl AM, Khater S, Wadie BS, Abu Beih EA, et al. Synchronous ipsilateral transitional cell and papillary renal cell carcinomas. OA Case Reports 2013 Mar 01;2(3):24.

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Figure 1: (a) Radical nephr ectomy specimen demonstrating synchronous pelvic urothelial carci noma (white arrow) and RCC (green arrow). (b) The TCC involving middle calyx (white arrow).

Figure 2: (a) Type I papillary RCC, with area of necrosis (H&E, 100×); (b and c) Type I papillary RCC, Fuhrman grade 1 with foamy macrophages within the core of the papillary structure (H&E, 400×).

DiscussionRare cases of synchronous ipsilateral TCC of the renal pelvisand RCC have been reported in literature. The first report was by Graves and Temple-ton in 19215 and the most recent, to our knowledge, was by Choi et al. in 20094. Those patients were predomi-nantly male (at a 2:1 ratio) with an average age of 65 years, and had hae-maturia at initial presentation (90%) with a left-side trend (at a 3:1 ratio)6. Out of 1806 radical nephrectomies performed so far in our Urology and Nephrology Center since inception in 1981, this was the first case of syn-chronous TCC and RCC in the same kidney.

von Eschenbach et al.7 reviewed more than 700 cases of RCC over a 30-year period at M.D. Anderson Centre, Houston, Texas, identifying only a single case of synchronous development of TCC and RCC in the same kidney (0.14%). These com-bined tumours had no tendency to-wards a specific histologic pattern of RCC compared with cases with a single type of tumour3. The histo-logical type of papillary RCC in this

case is similar to cases reported by Yokohama et al8. and Guarin et al9. Contrarily, other combinations have also been reported. Ke et al6. and Saavedra-Briones et al10. reported synchronous clear RCC and TCC, while synchronous chromophobe RCC and TCC was reported by Choi et al4. The renal pelvic tumour in this report was a low-grade TCC, which is

Figure 3: (a) Grade II papillary urothelial carcinoma infiltrating the subepithelial layer of the renal pelvis (H&E, 200×); (b and c) Grade II papillary urothelial carcinoma (H&E satin, 400×).

similar to the observation by Gómez-García et al11. who reported that the majority of patients with synchro-nous TCC and RCC present low-grade transitional tumours though cases of high-grade tumours have also been described.

The prognosis for a patient with dual malignancies is likely most in-fluenced by the more aggressive of the two tumours. In this case, the RCC was in stage II, which translates

Page 3 of 3

Case report

Licensee OA Publishing London 2013. Creative Commons Attribution License (CC-BY)

For citation purposes: Al-Hawary AK, Shalaby A, Shebl AM, Khater S, Wadie BS, Abu Beih EA, et al. Synchronous ipsilateral transitional cell and papillary renal cell carcinomas. OA Case Reports 2013 Mar 01;2(3):24.

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kidney diagnosed by preoperative angiog-raphy. Cancer. 1981 Dec;48(12):2762–6.9. Guarin U, Gabriel JB, Patel R, Chauhan PM. Bilateral renal cell carcinoma and synchronous occurrence of transitional cell carcinoma of renal pelvis. Urology. 1986 May;27(5):456–9.10. Saavedra-Briones DV, Hernández-Castellanos VA, Merayo-Chalico CE, Sánchez-Turati JG, Leos-Acosta CA, Cama-rena-Reynoso HR, et al. Synchronous transitional and clear cell renal carcino-ma. Rev Mex Urol. 2009;69:116–8.11. Gómez-García R, Rodríguez-Patrón S, Conde-Someso E, Sanz Mayayo E, Garcia Navas R, Palmeiro A. Tumor sincrónico renal: asociación de adenocarcinoma renal y tumor transicional de pelvis re-nal, en el mismo riñón, un hallazgo ex-cepcional. Actas Urol Esp. 2005 Jul–Aug; 29(7):711–4.12. Lam JS, Shvarts O, Leppert JT, Figlin RA, Belldegrun AS. Renal cell carcinoma 2005: new frontiers in staging, prognos-tication and targeted molecular therapy. J Urol. 2005 Jun;173(6):1853–62.13. Semra O, Madhu M, Guido D, Vic-tor ER. Urothelial carcinoma of the re-nal pelvis: a clinicopathologic study of 130 cases. Am J Surg Pathol. 2004 Dec; 28(12):1545–52.

organs. Lyon, France: IARC Press; 2004.p9–78.2. Kirkali Z, Tuzel E. Transitional cell car-cinoma of the ureter and renal pelvis. Crit Rev Oncol Hematol. 2003 Aug;47(2): 155–69.3. Hart AP, Brown R, Lechago I, Truong LD. Collision of transitional cell carcino-ma and renal cell carcinoma. An immu-nohistochemical study and review of the literature. Cancer. 1994 Jan;73(1):154–9.4. Choi IJ, Jung SH, Seo WI, Kang PM, Jung SJ, Chung JI. Simultaneous occurrence of chromophobe renal cell carcinoma and urothelial carcinoma in the same kidney. Kor J Urol. 2009;50:508–11.5. Graves RC, Templeton ER. Com-bined tumors of the kidney. Urology. 1921;5:517–37.6. Ke QH, Kuo HC. Synchronous ipsilateral renal cell and transitional cell carcino-mas: a case report. JTUA. 2006;17:67–70.7. von Eschenbach DE, Johnson DE, Ayala AG. Simultaneous occurrence of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis. Urology. 1977;116:105–6.8. Yokoyama I, Berman E, Rickert RR, Bastidas J. Simultaneous occurrence of renal cell adenocarcinoma and urothelial carcinoma of the renal pelvis in the same

into a 5-year survival rate in more than 75%12. The renal pelvis TCC was grade II tumour and pT1N0M0 (Stage 1), therefore the 5 year survival rate is 60%–90%13. The prognosis in this case is expected to be good after radi-cal nephro-ureterectomy.

ConclusionThis report showed that syncronus renal tumour is rare. This is the first report of its kind in over three dec-ades at Mansoura Urology and Neph-rology Center, Mansoura University, Egypt.

ConsentWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

References1. Eble JN, Togashi K, Pisani P. In: Eble JN, Sauter G, Epstein JI, Sesterhenn IA, edi-tors. Pathology and genetics of tumors of the urinary system and male genital