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2010, Volume 26, Number 1, Page(s) 082-084
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DOI: 10.5146/tjpath.2010.01001 |
Solitary Synchronous Metastasis to the Urinary Bladder from Renal Cell Carcinoma: A Case Report |
Abidin TUNA1, Burçin TUNA2, Mustafa SEÇİL3, Aydın ŞAHİN4, Kutsal YÖRÜKOĞLU2 |
1Departments of Urology, M.H. Seyfi Demirsoy State Hospital, M.H. Seyfi Demirsoy State Hospital
2Departments of Pathology, Dokuz Eylül University, Faculty of Medicine, İZMİR, TURKEY
3Departments of Radiology, Dokuz Eylül University, Faculty of Medicine, İZMİR, TURKEY
4Departments of Pathology, M.H. Seyfi Demirsoy State Hospital, İZMİR, TURKEY |
Keywords: Metastasis, Prognosis, Renal cell carcinoma, Urinary bladder |
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Renal cell carcinoma metastatic to the urinary bladder is a rare entity.
Few cases of renal cell carcinoma with solitary synchronous metastasis
to the urinary bladder have been reported. We report a case of renal
cell carcinoma with solitary synchronous metastasis to the urinary
bladder. A new metastasis developed in the right adrenal gland at the
24th month, and was resected. The patient is alive without any new
recurrences or metastasis 36 months after the initial diagnosis. The
follow up duration of our case is the longest of published cases. |
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Approximately one third of the patients with renal cell
carcinoma (RCC) exhibit metastatic disease at initial
diagnosis 1. Renal cell carcinoma has a potential to
metastasize to almost any site. The most common expected
sites of metastases are the lungs, liver, bone and soft
tissue 2. Urinary bladder is an extremely unusual site of
metastasis, and was only mentioned in a few case reports 3-5.
The prognosis of metastatic RCC is poor and seems not to
be related to the type of treatment. It has been reported that
patients with metastatic RCC and a solitary metastasis may
benefit from nephrectomy with resection of the metastatic
lesion6. In general, an improved prognosis has been
observed when the solitary resected metastatic lesion
involved the lung, adrenal gland, or brain7. Many reports
suggest that surgical resection is the choice of treatment
for bladder metastasis because it is more effective than
other treatment modalities including chemotherapy and
immunotherapy3,5,8.
The urinary bladder is not a common site of metastasis for
RCC. A solitary urinary bladder metastasis from RCC has
only rarely been described. To our knowledge there are less
than five cases of synchronous solitary metastasis of renal
cell carcinoma to the urinary bladder including ours. |
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Abstract
Introduction
Case Presentation
Disscussion
References
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A 57-year-old man was referred to our hospital with
a painless macroscopic hematuria. Ultrasonography
showed a solitary large bladder tumor and a right renal
mass. Computed tomography revealed a large tumor
at the mid-portion of the right kidney and a polypoid
mass originating from the left lateral wall of the bladder.
(Figures 1, 2). Cystoscopy revealed a solitary, non-papillary
tumor in the urinary bladder. Right radical nephrectomy
and transurethral resection of the bladder tumor were
performed since there were no other systemic metastases.
Histopathological diagnosis of the renal tumor was renal
cell carcinoma (clear cell carcinoma, Fuhrman grade 2,
pT2) (Figure 3). Histological examination revealed that the bladder tumor was clear cell carcinoma similar to the right
renal tumor. The morphology and immunohistochemical
staining profile of the bladder tumor was the same as the
primary renal tumor (positive staining with pancytokeratin,
cytokeratin 7, CD10 and vimentin, and negative staining
with cytokeratin 20, chromogranin and high molecular
weight keratin) (Figure 4A-C). The tumor cells were of
the same grade (Fuhrman grade 2) as the primary tumor.
The case was therefore accepted as solitary synchronous
metastasis to urinary bladder from RCC. Adjunctive
therapy was given postoperatively (Interferon alpha-2a;
9 million unit, 3/week). The patient was well until right
surrenal metastasis developed at 24 months of follow-up.
Right adrenalectomy was performed, and the tumor was
diagnosed as RCC metastasis. The patient is alive without
any new recurrences at 36 months.
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Figure 1: A solid renal mass is observed at the mid-portion of the
right kidney (arrows). |
Click Here to Zoom |
Figure 2: A polypoid mass originating from the left lateral wall of
the bladder is seen (arrow). |
Click Here to Zoom |
Figure 4: Metastatic renal cell carcinoma in the bladder (A:
H&E, x100; B: Keratin immunoreactivity, and C: Vimentin
immunoreactivity; x200). |
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Abstract
Introduction
Case Presentation
Disscussion
References
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RCC is a tumor with an unpredictable clinical course and
behavior. Metastases have been reported to develop 17 years
or more after the primary lesion is removed 9. Although
renal cell carcinoma may involve any organ, synchronous
or metachronous urinary bladder metastasis is rare. Most
metastases appear within one year 10. Synchronous
solitary bladder metastasis from RCC is extremely rare.
Synchronous detection of solitary metastasis with primary
tumor is also considered as an unfavorable feature 11.
Most patients with RCC metastasized to the bladder die
within the first year of diagnosis 5,10. It has been reported
that patients presenting with a primary and metastatic
lesion at the same time do not do as well as patients who
present with metastasis after nephrectomy. The prognosis
is uniformly poor in patients presenting with the primary
and secondary lesion together, regardless of the mode of
the therapy 11. Although there have been several longterm
survivors 10, an average survival of 4 months may be
expected in patients with synchronous metastases and only
10% will survive for one year 12.
Rodriguez et al. reported that the survival time in patients
who developed a solitary metastasis after surgical removal
of the primary tumor was better than those who exhibited
a solitary metastasis in the presence of a primary tumor6. In contrast, Manabu et al. reported that the mean
survival time was 17.5 months for synchronous urinary
bladder metastasis and 15.8 months for metachronous
urinary metastasis. They suggested that the prognosis was
not related to the interval between nephrectomy and the
appearance of urinary bladder metastasis8.
Almost all studies recommend surgical resection in the
presence of solitary urinary bladder metastases. On the other hand, immunoreactive cytokines have been the mainstay
of treatment of metastatic RCC. Interferon is one of the
cytokines known to be effective against RCC. Shiraishi et al.10 have proposed that additional systemic therapy against
metastasis should be performed in most cases. In their
study, progression of another metastasis was suggested to be
manageable and long-term survival possible in combination
with surgical resection and immunostimulant therapy used
in an outpatient setting. The long-term survival obtained
in our patient after resection may be explained by the
association with immunotherapy. Surgical resection should
therefore not be considered the only therapeutic tool against
urinary bladder metastasis from RCC. A combined therapy
should also be considered in the treatment of a solitary
synchronous metastasis from RCC.
In conclusion, although rare, RCC can metastasize to the
urinary bladder. The case reported here confirms that the
unusual sites of metastasis from RCC should be considered.
A combination of surgery with medical treatment should
be considered in all patients with metastatic renal cell
carcinoma since combined therapy may induce synergic
antitumor activity. Investigation of this intriguing topic in
the near future would be interesting. |
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Abstract
Introduction
Case Presentation
Discussion
References
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Abstract
Introduction
Case Presentation
Discussion
References
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