Synchronous ipsilateral pRCC of the kidney and TCC of the renal pelvis
Presentation
Hematuria and left flank pain. No fever, vomiting, anorexia, or weight loss.
Patient Data
average-size kidneys. Some avascular heterogeneous echogenicity material is seen filling the left pelvicalyceal system and proximal ureter. In view of the history of hematuria, it may be a blood clot; another possibility is a neoplastic lesion. The possibility of thick pus is unlikely
an avascular heterogeneous echogenicity lesion measuring about 4.6 x 4.5 x 3.0 cm is seen in the posterior dependent portion of the urinary bladder which is likely a blood clot; another possibility is a neoplastic lesion
bilateral simple renal cortical cysts, the largest seen at the mid pole of the left kidney measures 3.1 x 2.2 cm
a soft tissue density mass lesion (average density=33 HU on plain and 82 HU on post-contrast), is seen in the left renal pelvicalyceal system and proximal ureter. This is suspicious for a neoplastic process like transitional cell carcinoma (TCC)
another well-defined exophytic lesion, showing almost similar imaging features (average density=39 HU on plain and 77 HU on post-contrast) is seen at the upper pole of the left kidney. This lesion is suspicious for a neoplasm-like renal cell carcinoma (RCC). Please note that this lesion was overlooked on the ultrasound examination.
a few simple cortical cysts (Bosniak I) are seen in both kidneys. No suspicious mass lesion is seen in the right kidney and partially distended urinary bladder (the bladder lesion seen on ultrasound was likely a blood clot and had been passed)
no radiopaque renal or ureteric calculi are seen
marked atherosclerotic changes noted in the infra-renal abdominal aorta
Flexible ureteroscopy
Retrograde pyelography (during flexible cystoureteroscopy) showed a filling defect in the left renal pelvicalyceal system which was biopsied. No suspicious mass lesion was seen in the urinary bladder. A double-J stent was left in place.
Histopathology reports
initial biopsy of the left renal pelvicalyceal system lesion was positive for high-grade papillary urothelial cell carcinoma (UCC). It showed focal invasion of the lamina propria and adjacent renal pyramids on the radical nephroureterectomy specimen (pT1,pNx,pMx)
exophytic left renal lesion turned out to be a papillary renal cell carcinoma (pRCC), pT1a,pNx,pMx
Case Discussion
Synchronous renal cell carcinoma (RCC) and urothelial cell carcinoma (UCC) in the same kidney is a rare entity 1,2. Approximately 50 such cases have been reported in the literature up till now 2-4. No definitive risk factors are known for such concurrence of the RCC and UCC; however, some reports have shown smoking to be an important etiological factor 1,3. These cases are more commonly seen in men, in the 6th‑7th decade, and are more commonly affecting the left kidney 1-4. Hematuria is the most common presenting symptom, seen in 90% of the cases 2-4. Because of its rarity, there is no certain consensus about its treatment; however, radical nephroureterectomy with bladder cuff removal is usually curative, especially in low-grade tumors 2.
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