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Transitional cell carcinoma (renal pelvis)

Case contributed by Ammar Ashraf
Diagnosis certain

Presentation

Painless gross hematuria. No fever, dysuria, anorexia or weight loss.

Patient Data

Age: 85 years
Gender: Female

Average size right kidney with mild to moderate hydronephrosis. An ill-defined avascular isoechoic lesion is seen within the renal pelvis. 

Relatively enlarged and poorly enhancing right kidney with moderate hydronephrosis. A non-enhancing hyper density is seen in the right renal pelvis and proximal right ureter. Given the clinical history of hematuria, this most likely represents blood clots; however possibility of underlying mass lesion cannot be entirely ruled out. No contrast excretion is seen from the right kidney. Small simple cyst at the upper pole of left kidney and a small cortical scar at the lower pole of left kidney. Colonic diverticulosis involving the transverse and descending colon.

Retro ureteroscopy-pyelography

Fluoroscopy

Irregular filling defect / mass lesion within the right renal pelvis associated with moderate hydronephrosis. Opacification of the renal vein is noted which is suspicious of fistula formation between the renal vein and the renal collecting system.

3 weeks after surgery

ct

Status post right nephrectomy. Post-surgical changes seen in the right renal bed and in the subcutaneous soft tissues of the anterior abdominal wall. Small fluid collection measuring 21 x 12 mm seen between the stomach and left lobe of the liver. Small air density in the urinary bladder; is there any history of recent catheterization? Suspicious irregular soft tissue mass lesion in the gastric fundus adjacent to the gastroesophageal junction; for further evaluation with endoscopy.

10 months later

ct

Interval development of heterogeneous retro-peritoneal mass lesion measuring about 5.6 x 4.1 cm encasing the inferior vena cava and surgical sutures of right nephrectomy. There is also interval development of a small nodule measuring 1.1 x 2.1 cm within the right renal fossa and a small enhancing lesion measuring 1.2 x 1.4 cm at the base of the urinary bladder in the region of right vesicoureteric junction. A few enlarged aortocaval lymph nodes seen adjacent to the aforementioned retroperitoneal mass. 
Impression: Scan features are suggestive of recurrent disease in the renal fossa as well as at the right vesicoureteric junction. Stable suspicious irregular mass lesion in the gastric fundus adjacent to the gastroesophageal junction. 

Procedure: Laparoscopic right nephroureterectomy.

Gross description: The specimen comprises a kidney and perinephric fat along with a 15 cm long ureter. The kidney weighs 198 grams and measures 10 x 6 x 3 cm. When the perinephric fat is removed, the kidney surface shows hemorrhagic patches. The capsule is thin but adherent to the surface and difficult to remove. On opening, the kidney shows dilated calyces and a small cortical cyst measuring 7 mm. The pelvicalyceal system contains blood clots and necrotic debris. A well-circumscribed, small white nodule measuring 8 mm is seen in the peripelvic fat. The attached renal vessels are identified and appear grossly unremarkable. The ureter is present separately within the specimen pot, showing one end that is relatively dilated as compared to the other end. The proximal end contains blood clots similar to that seen with the dilated calyces.

Diagnosis: High-grade urothelial carcinoma of renal pelvis (ISUP/WHO 2004).

Tumor size: Cannot be determined both grossly and microscopically. Vascular and ureteric margins: Free of tumor. Lymphovascular space invasion: Present (tumor embolus seen in the venule). Tumor invades beyond the muscularis propria into the peripelvic fat but not renal parenchymal tissue. Renal parenchymal tissue shows the changes of chronic interstitial nephritis. The cortical cyst is simple and benign.

Pathological staging:  pT3, pNx, pMx.

Case Discussion

  • ureteroscopy showed multiple blood clots in the ureter and renal pelvis; however, no obvious mass lesion was seen. Analysis of the blood collected from the right ureter and renal pelvis showed atypical malignant cells, suspicious of low grade malignancy. Later on, the patient underwent surgery which showed high grade urothelial malignancy. 
  • recommended ideal treatment of the TCC of the renal pelvis is surgical, consisting of a nephroureterectomy, taking not only the kidney but also the ureter and a cuff of the urinary bladder at the vesicoureteric junction, which was however, not followed in this case. 5-6 cm of the distal ureter was clearly visible on the 1st postoperative scan. Unfortunately, the patient developed mass/tumor (highly suggestive of recurrence) both at the right vesicoureteric junction as well as in the right nephrectomy bed 10 months later; however this recurrence was not biopsy proven due to the patient’s poor clinical condition. Suspicious gastric lesion was also not further evaluated. The patient died from the progressive disease a few months later.

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