Vol. 118, July, Part 1 Printed in U.SA.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
SIMULTANEOUS OCCURRENCE OF RENAL ADENOCARCINOMA AND TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS A. C. VONESCHENBACH, D. E. JOHNSON
AND
A.G. AYALA
From the Department of Surgery, Section of Urology and Department of Pathology, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
ABSTRACT
An unusual case of synchronous development of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis in the same kidney is presented. The simultaneous occurrence of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis in the same kidney is unusual with less than a dozen cases reported in the literature. 1- 9 Herein we describe an additional case to emphasize the dilemmas that may arise when 1 tumor is not recognized clinically.
(
renal carcinoma. Additional examinations, including a complete physical examination, pertinent laboratory studies, chest x-ray, bone scan, inferior venacavography and celiac arteriograms, failed to demonstrate metastatic disease. Subsequently, the patient underwent transabdominal right radical nephrectomy in August 1976. Section of the re-
1
~.. pw11111 11111111,~rn11u1i
•'~Ec:~A~n'
Fm. 1. Transected right kidney demonstrates lower pole renal adenocarcinoma and renal pelvic tumor. CASE REPORT
A 61-year-old white man, undergoing e~cretory urography (IVP) as part of an evaluation for labile hypertension, had a mass in the lower pole of the right kidney. Arteriographic studies demonstrated a hypervascular lesion consistent with Accepted for publication February 11, 1977. 105
Fm. 2. A, clear cell adenocarcinoma of kidney. B, primary papillary transitional cell carcinoma. moved specimen revealed a 5 by 4 cm. solid tumor confined to the kidney in the lower pole and an unsuspected papillary transitional cell carcinoma arising from the superior portion of the renal pelvis (fig. 1). Histologic examinations confirmed the presence of 2 separate and distinct malignant entities: a renal carcinoma and a non-invasive transitional cell carcinoma with extensive carcinoma-in-situ changes involving the renal pelvis (fig. 2). A careful review of the arteriograms as well as the
VONESCHENBACH, JOHNSON AND AYALA
106
IVPs revealed an obvious filling defect in the renal pelvis, which had been misrepresented originally as overlying bowel gas. A distal ureterectomy was performed down to the level of the posterior vesical wall but a total nephroureterectomy with bladder cuff could not be performed because the patient had not given permission. After a satisfactory postoperative recovery the patient was later readmitted to the hospital and underwent endoscopy and a transvesical distal ureterectomy with wide excision of the adjacent vesical mucosa. No additional malignant disease was present and he is being followed at periodic intervals appropriate for both malignant diseases. DISCUSSION
Synchronous development of histogenic dissimilar carcinomas in the same kidney is uncommon. Our case represents the only instance of such a finding in more than 700 cases (0.14 per cent) of renal adenocarcinoma evaluated at this hospital during the preceding 30 years. Rarely have both tumors been diagnosed preoperatively. In the past the renal pelvic tumor has been discovered generally during urological evaluation for hematuria and the renal carcinoma was found incidentally at operation or by the pathologist on examination of the excised specimen. However, the increased reliance on arteriographic studies today for evaluation of patients with hematuria and the less frequent performance of retrograde pyelograms have caused a reversal in the type of tumor diagnosed preoperatively in these cases. The presence of a vascular renal parenchymal tumor may capture so completely the attention of a busy radiologist and urologic surgeon that the less obvious findings of a second dissimilar tumor may be overlooked entirely. In our case the obvious filling defect in the renal pelvis
was confused for overlying bowel gas and the renal pelvic tumor was diagnosed only after sectioning the kidney. Because the patient had not undergone endoscopy, as well as having not given permission for excision of a bladder cuff, a total nephroureterectomy could not be performed. This mistake necessitated a second operation to complete the required procedures. REFERENCES
1. Graves, R. C. and Templeton, E. R.: Combined tumors of the kidney. J. Urol., 5: 517, 1921. 2. Patch, F. S. and Rhea, L. J.: Papillary cyst-adenoma of the kidney associated with papillomatous growths in the pelvis, ureter, and bladder. J. Urol., 12: 671, 1924. 3. Wildbolz, H.: Discussion. Proc. 5thCongr. Int. Soc. Urol., 2: 163: 1933. 4. Balch, J. F.: Papillary carcinoma and hypernephroma occurring in the same kidney. J. Urol., 33: 138, 1935. 5. Melicow, M. M.: Tumors of the urinary drainage tract: urothelial tumors. J. Urol., 54: 186, 1945. 6. MacAlpine, J.B.: Case in which 2 dissimilar growths, adenoma (adenocarcinoma) and papillo-carcinoma, occurred in the same kidney. Brit. J. Surg., 35: 134, 1947. 7. Rupel, E. and Sutton, W. E.: Carcinoma of the renal parenchyma: one case with metastases to opposite kidney, bladder and ureteral wall; the other associated with papillary carcinoma of the same kidney and metastases to skin. J. Urol., 63: 487, 1950. 8. Gillis, D. J., Finnerty, P. and Maxted, W. C.: Simultaneous occurrence of hypernephroma and transitional cell carcinoma with development of transitional cell carcinoma in the opposite kidney: case report. J. Urol., 106: 646, 1971. 9. Fallon, B. and Schellhammer, P. F.: Transitional cell carcinoma and renal cell adenocarcinoma in single kidney. Urology, 6: 774, 1975.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
SIMULTANEOUS OCCURRENCE OF RENAL ADENOCARCINOMA AND TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS A. C. VONESCHENBACH, D. E. JOHNSON
AND
A.G. AYALA
From the Department of Surgery, Section of Urology and Department of Pathology, The University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston, Texas
ABSTRACT
An unusual case of synchronous development of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis in the same kidney is presented. The simultaneous occurrence of renal adenocarcinoma and transitional cell carcinoma of the renal pelvis in the same kidney is unusual with less than a dozen cases reported in the literature. 1- 9 Herein we describe an additional case to emphasize the dilemmas that may arise when 1 tumor is not recognized clinically.
(
renal carcinoma. Additional examinations, including a complete physical examination, pertinent laboratory studies, chest x-ray, bone scan, inferior venacavography and celiac arteriograms, failed to demonstrate metastatic disease. Subsequently, the patient underwent transabdominal right radical nephrectomy in August 1976. Section of the re-
1
~.. pw11111 11111111,~rn11u1i
•'~Ec:~A~n'
Fm. 1. Transected right kidney demonstrates lower pole renal adenocarcinoma and renal pelvic tumor. CASE REPORT
A 61-year-old white man, undergoing e~cretory urography (IVP) as part of an evaluation for labile hypertension, had a mass in the lower pole of the right kidney. Arteriographic studies demonstrated a hypervascular lesion consistent with Accepted for publication February 11, 1977. 105
Fm. 2. A, clear cell adenocarcinoma of kidney. B, primary papillary transitional cell carcinoma. moved specimen revealed a 5 by 4 cm. solid tumor confined to the kidney in the lower pole and an unsuspected papillary transitional cell carcinoma arising from the superior portion of the renal pelvis (fig. 1). Histologic examinations confirmed the presence of 2 separate and distinct malignant entities: a renal carcinoma and a non-invasive transitional cell carcinoma with extensive carcinoma-in-situ changes involving the renal pelvis (fig. 2). A careful review of the arteriograms as well as the
VONESCHENBACH, JOHNSON AND AYALA
106
IVPs revealed an obvious filling defect in the renal pelvis, which had been misrepresented originally as overlying bowel gas. A distal ureterectomy was performed down to the level of the posterior vesical wall but a total nephroureterectomy with bladder cuff could not be performed because the patient had not given permission. After a satisfactory postoperative recovery the patient was later readmitted to the hospital and underwent endoscopy and a transvesical distal ureterectomy with wide excision of the adjacent vesical mucosa. No additional malignant disease was present and he is being followed at periodic intervals appropriate for both malignant diseases. DISCUSSION
Synchronous development of histogenic dissimilar carcinomas in the same kidney is uncommon. Our case represents the only instance of such a finding in more than 700 cases (0.14 per cent) of renal adenocarcinoma evaluated at this hospital during the preceding 30 years. Rarely have both tumors been diagnosed preoperatively. In the past the renal pelvic tumor has been discovered generally during urological evaluation for hematuria and the renal carcinoma was found incidentally at operation or by the pathologist on examination of the excised specimen. However, the increased reliance on arteriographic studies today for evaluation of patients with hematuria and the less frequent performance of retrograde pyelograms have caused a reversal in the type of tumor diagnosed preoperatively in these cases. The presence of a vascular renal parenchymal tumor may capture so completely the attention of a busy radiologist and urologic surgeon that the less obvious findings of a second dissimilar tumor may be overlooked entirely. In our case the obvious filling defect in the renal pelvis
was confused for overlying bowel gas and the renal pelvic tumor was diagnosed only after sectioning the kidney. Because the patient had not undergone endoscopy, as well as having not given permission for excision of a bladder cuff, a total nephroureterectomy could not be performed. This mistake necessitated a second operation to complete the required procedures. REFERENCES
1. Graves, R. C. and Templeton, E. R.: Combined tumors of the kidney. J. Urol., 5: 517, 1921. 2. Patch, F. S. and Rhea, L. J.: Papillary cyst-adenoma of the kidney associated with papillomatous growths in the pelvis, ureter, and bladder. J. Urol., 12: 671, 1924. 3. Wildbolz, H.: Discussion. Proc. 5thCongr. Int. Soc. Urol., 2: 163: 1933. 4. Balch, J. F.: Papillary carcinoma and hypernephroma occurring in the same kidney. J. Urol., 33: 138, 1935. 5. Melicow, M. M.: Tumors of the urinary drainage tract: urothelial tumors. J. Urol., 54: 186, 1945. 6. MacAlpine, J.B.: Case in which 2 dissimilar growths, adenoma (adenocarcinoma) and papillo-carcinoma, occurred in the same kidney. Brit. J. Surg., 35: 134, 1947. 7. Rupel, E. and Sutton, W. E.: Carcinoma of the renal parenchyma: one case with metastases to opposite kidney, bladder and ureteral wall; the other associated with papillary carcinoma of the same kidney and metastases to skin. J. Urol., 63: 487, 1950. 8. Gillis, D. J., Finnerty, P. and Maxted, W. C.: Simultaneous occurrence of hypernephroma and transitional cell carcinoma with development of transitional cell carcinoma in the opposite kidney: case report. J. Urol., 106: 646, 1971. 9. Fallon, B. and Schellhammer, P. F.: Transitional cell carcinoma and renal cell adenocarcinoma in single kidney. Urology, 6: 774, 1975.
