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| Year : 2012 | Volume
: 23
| Issue : 4 | Page : 786-789 |
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| Synchronous primary cancers of urinary bladder and kidney and prostate |
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Punit Tiwari, Astha Tripathi, Punit Bansal, Mukesh Vijay, Aman Gupta, Anup Kumar Kundu
Department of Urology, IPGMER and SSKM Hospital, Kolkata, WB, India
Click here for correspondence address and email
| Date of Web Publication | 9-Jul-2012 |
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 Abstract | | |
Synchronous occurrence of two or more than two primary cancers of the urinary tract is quite rare, and poses a difficult treatment challenge. Here, we present a case of synchronous renal cell carcinoma, transitional cell carcinoma of urinary bladder and adenocarcinoma of prostate diagnosed within a short period. To the best of our knowledge, this is the first case reported from India and the youngest patient reported in the literature having this combination of urinary cancers.
How to cite this article:
Tiwari P, Tripathi A, Bansal P, Vijay M, Gupta A, Kundu AK. Synchronous primary cancers of urinary bladder and kidney and prostate. Saudi J Kidney Dis Transpl 2012;23:786-9 |
How to cite this URL:
Tiwari P, Tripathi A, Bansal P, Vijay M, Gupta A, Kundu AK. Synchronous primary cancers of urinary bladder and kidney and prostate. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2013 May 25];23:786-9. Available from: http://www.sjkdt.org/text.asp?2012/23/4/786/98161 |
| Introduction | |  |
The phenomenon of multiple primary malignant neoplasms in the same individual was first described by Billroth et al at the end of the 19th century. [1] Since then, many cases of double or triple primary malignant neoplasms have been reported in the literature. The incidence of transitional cell carcinoma (TCC) urinary bladder, adenocarcinoma of prostate and renal cell carcinoma (RCC) is high in the elderly age group. However, synchronous occurence of three different urological malignancies in the same patient is rare and represents a difficult treatment challenge.
Here, we report a case of synchronous renal cell carcinoma of the right kidney and TCC in the urinary bladder and adenocarcinoma of the prostate in a young man. This is, to the best of our knowledge, the 15 th case reported with this combination in the literature, [2] and is the youngest patient reported having triple malignancy with this combination.
| Case Report | | |
A 55-year-old man presented to the emergency department with a painless, gross hematuria with passage of clots that required bladder irrigation. He had a history of lower urinary tract symptoms of six months duration and he was chronic smoker. His laboratory investigations were within normal limits, except having anemia and prostate specific antigen (PSA) of 12 ng/mL. Urine cytology was positive for malignant cells. ultrasound showed papillary tumors arising from the postero-lateral wall of the bladder and right renal mass [Figure 1] and [Figure 2]. Double cancer, consisting of renal cancer and carcinoma of urinary baldder, was suspected. On cystoscopy, multiple vascular lesions arising from the postero-lateral wall of the bladder with active bleeding were present in the bladder. There was no bleeding from either of the ureteric orifices. Patient underwent trans-uretheral resection of the bladder tumor (TURBT) in the same sitting. The bladder tumor was completely excised and sent for histopathological examination. Computed tomography of abdomen was performed, which revealed a thickened wall of the urinary bladder and a contrast-enhancing mass lesion in the upper pole of the left kidney [Figure 2]. The patient underwent right radical nephro-ureterctomy with hilar lymphdenectomy after four weeks of TURBT in view of the upper polar lesion extending through the whole thickness of the kidney and to avoid leaving a ureteral stump in the setting with TCC of the bladder. The operation was performed by a midline transperitoneal incision. The ureter was separated from the bladder with a bladder cuff and the right kidney was removed with gerota fascia and whole length of ureter. At the same time, we performed the biopsy of the prostate. The histopathology showed a clear cell renal cell carcinoma of the left kidney, stage T1N0M0, and TCC grade II with muscle invasion of the urinary bladder. The histological diagnosis of the prostate biopsy showed moderately differentiated adenocarcinoma [Figure 3]. The patient underwent total cysto-prostactomy with pelvic lymphedenectomy with ileal conduit urinary diversion as a radical treatment three weeks later. On histological examination, all lymph nodes were negative for malignancy. The patient has been on regular follow-up with semiannually liver function tests, renal function test, chest X-ray, urine cytology, CT scan of the abdomen and pelvis and PSA. He has remained recurrence-free in two year of follow-up. | Figure 1: An ultrasound film showing solid renal mass on the left kidney and multiple tumors arising from the postero-lateral wall of the urinary bladder.
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 | Figure 2: Computed tomography showing SOL on the posterior aspect of the upper pole of the left kidney.
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 | Figure 3: (A) Transitional cell carcinoma with the presence of muscle infiltration H/E 10X. (B) Renal cell carcinoma showing diffuse sheets of clear cells with centrally placed hyperchromatic nuclei and also showing atypia. H/E 40X. (C) Ca prostate – adenocarcinoma gland in prostatic tissue gland; lining cells are highly pleomorphic with presence of nuclear atypia H/E 40X* (moderately differentiated adenocarcinoma).
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| Discussion | | |
The generally accepted definition of multiple primary malignancies is that of Warren and Gates, who stated that each tumor must be present as a definite picture of malignancy, each must be distinct and the possibility that one is a metastasis of another must be excluded. [3] Because this case fulfilled the criteria of Warren and Gates, it was classified as a synchronous triple urinary tract cancer. Review of the literature revealed 17 cases of synchronous triple uro-genital cancer, of which 14 were reported as a combination of renal, bladder and prostatic cancer. [2]
Our patient developed three histologically distinct malignancies, i.e. primary bladder carcinoma, adenocarcinoma of the prostate and renal cell carcinoma, diagnosed within a short period. There are several predisposing or causal factors for each malignancy. A cancer patient may have an increased risk of another malignancy due to common carcinogenic exposure, such as tobacco and alcohol, genetic predisposition or as a side-effect of treatment with chemotherapy or radiotherapy. [3] For our patient, there was only one common causal factor, the fact that he was a chronic smoker. No other predisposing factor or a family history was found that might have contributed to his disease. The presence of bladder and prostate carcinomas in the same patient is not a rare event. Patients with carcinoma prostate have a higher incidence of bladder cancer, and those with bladder cancer have a higher incidence of carcinoma of prostate. [4]
Although bladder and prostate carcinoma can frequently coexist in the same individual, the rare event is the appearance of a third malignancy. Renal cell carcinoma in particular has been reported to be associated with prostate or bladder or rectal cancer, non-Hodgkin's lymphoma, melanoma and lung cancer on longterm follow-up. [3] However, the association of renal cell carcinoma with these cancers in a synchronous way is very rare. There is a case report by Satoh et al referring to a patient with three primary malignancies. The first tumor was urinary bladder tumor, which was followed by a carcinoma of the kidney and then by an incidental finding of adenocarcinoma of the prostate. Their patient was managed by radical nephrectomy and total cystoprostatectomy with ileal conduit diversion. [5] More recently, in 2007, Funahashi also reported the same combination of multiple primary malignancies in a patient along with opposite renal pelvic tumor, for which the patient required total resection of the urinary tract, i.e. radical nephrectomy and opposite nephroureterctomy with radical cystectomy. [6] The incidence of multiple primary malignancies with synchronous occurrence of two or more primary carcinomas in the urinary tract is quite rare, and there is a great need for careful diagnostic work-up to detect others in the presence of one. Knowledge of an association helps the clinician to be suspicious and to screen for the presence of another cancer. In case of a synchronous presentation of different tumors, the points of concern are the biological behaviors of the different tumors, their stages and the co-morbid conditions, which affect the treatment strategies. To the best of our knowledge, our case was the youngest patient reported in the literature with this combination of cancers. He had a muscle-invasive TCC bladder (T2N0M0) and renal cell carcinoma of the left kidney (T1N0M0) and adenocarcinoma of the prostate (T1 N0M0). We have offered him radical nephro-ureterectomy for the renal tumor and complete transurethral resection of the bladder tumor followed by radical cystoprostactomy with pelvic lymphadenectomy after biopsy reports of muscle-invasive bladder cancer in the TURBT specimen. The ureter was removed completely as the patient had already manifested with TCC bladder to avoid recurrence of TCC in the ureteral stump. The prognosis for a patient with multiple malignancies is most likely influenced by the most aggressive of the tumors and, in our case, it was dependent upon the carcinoma of the bladder (T2N0M0).
| References | | |
| 1. | Koutsopoulos AV, Dambaki KI, Datseris G, Giannikaki E, Froudarakis M, Stathopoulos E. A novel combination of multiple primary carcinomas: Urinary bladder transitional cell carcinoma, prostate adenocarcinoma and small cell lung carcinoma- report of a case and review of the literature. World J Surg Oncol 2005;3:51. 
[PUBMED] [FULLTEXT] |
| 2. | Takada T, Honda M, Momohara C, Komori K, Fujioka H. Synchronous triple urogenital cancer (renal cancer, bladder cancer, prostatic cancer): a case report. Hinyokika Kiyo 2002;48:239-42.
[PUBMED] |
| 3. | Rabbani F, Grimaldi G, Russo P. Multiple primary malignancies in renal cell carcinoma. J Urol 1998;160:1255-9.
[PUBMED] [FULLTEXT] |
| 4. | Singh A, Kinoshita Y, Rovito PM Jr, et al. Higher than expected association of clinical prostate and bladder cancers. J Urol 2008; 179(5 Suppl):S2-5.
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| 5. | Satoh H, Momma T, Saito S, Hirose S. A case of synchronous triple primary carcinomas of the kidney, bladder and prostate. Hinyokika Kiyo 2003;49:261-4.
[PUBMED] |
| 6. | Funahashi Y, Kamihira O, Kasugai S, Kimura K, Fukatsu A, Matsuura O. Triple cancer in the urinary system: A case report. Hinyokika Kiyo 2007;53:813-5.
[PUBMED] [FULLTEXT] |
Correspondence Address:
Punit Tiwari
Senior Resident, Department of Urology, IPGMER and SSKM Hospital, Kolkata - 20, WB
India
DOI: 10.4103/1319-2442.98161
[Figure 1], [Figure 2], [Figure 3] |
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