Multifocal transitional cell carcinoma associated with renal cell carcinoma in a patient on long-term haemodialysis
Kousuke Takehara1,
Masaharu Nishikido1,,
Shigehiko Koga1,
Yasuyoshi Miyata1,
Takashi Harada2,
Naoe Tamaru3 and
Hiroshi Kanetake1
1 Department of Urology and
2 Renal Care Unit, Nagasaki University School of Medicine and
3 Department of Pathology, Nagasaki University Hospital, Nagasaki, Japan
Keywords: dialysis; renal cell carcinoma; transitional cell carcinoma
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Introduction
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Patients with end-stage renal disease who require chronic dialysis are at high risk of developing malignancy. There are many reported cases of the development of renal or urothelial cancer in such patients [18]. We report the first case, to our knowledge, of multifocal, invasive transitional cell carcinoma (TCC) and unilateral renal cell carcinoma (RCC) with acquired cystic disease, occurring simultaneously in a patient on haemodialysis treated by complete urinary tract exenteration. Our patient was managed successfully with an aggressive treatment.
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Case
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A 69-year-old man was referred to our institution because of intermittent, asymptomatic gross haematuria. Risk factors of TCC and RCC such as long-term analgesic abuse, smoking, chemical exposure, and taking Chinese herbs were not present in this patient. He had a history of hypertension, which was diagnosed in 1976, and chronic glomerulonephritis in 1985. His renal function steadily deteriorated and haemodialysis was started in 1989. Aanemia was treated with recombinant human erythropoietin. Asymptomatic gross haematuria occurred after 11 years of regular haemodialysis. Cytological examination of urine revealed TCC; however, cystourethroscopy showed redness and oedematous change of the bladder mucosa without any previous masses. The left ureteric orifice could not be found. Right retrograde pyelography demonstrated a patent upper urinary tract and washing cytology was negative. Multiple, random cold-cup biopsies revealed multiple grade 3 TCCs, of the bladder and prostatic urethra. Computed tomography (CT) scan demonstrated a left renal tumour (2.5 cm) with enhanced tumour tissue heterogeneity and atrophic kidneys with multiple cysts. Metastatic survey was negative. Preoperative examinations could not evaluate any abnormal findings in the right kidney and right upper urinary tract. Bilateral nephroureterectomy and total cystourethrectomy were performed in the same session on the 8 March, 2000. Intraoperative blood loss was 750 ml and required a transfusion of 1 U. Histologic findings confirmed grade 3 TCC of the bladder with muscle layer invasion (Figure 1A
), and of the urethra. TCC also existed in the prostatic duct without extending into the stroma of the prostate. TCC was found in both ureter (Figure 1B
) and right renal pelvis; TCC of the left renal pelvis infiltrated the renal parenchyma (Figure 1C
). Microscopic examination of the left kidney revealed RCC containing clear cells (Figure 1D
), with multiple cystic changes. RCC appeared to arise from within the non-cystic renal parenchyma. There were no postoperative complications including severe anaemia or hypotension. The patient received no adjuvant therapy and has remained free of recurrence for 1 year.

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Fig. 1. Microscopic appearance. (A) TCC, grade 3 of the bladder (H&E stain, bar=100 µm). (B) Carcinoma in situ of the right ureter (H&E stain, bar=100 µm). (C) Tumour of the left renal pelvis infiltrating the renal parenchyma (H&E stain, bar=100 µm). (D) RCC of the left kidney (H&E stain, bar=100 µm).
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Discussion
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Acquired renal cysts and RCC are common complications of long-term dialysis. The widespread use of ultrasonography and CT scan has increased the incidental detection of asymptomatic RCC in dialysis patients. In such cases, RCC can be multicentric and bilateral in contrast to a single and large tumour arising in a kidney without acquired renal cyst. Development of RCC in acquired cystic disease of kidney correlates well the with duration of dialysis [2,3]. Some long-term dialysis patients with RCC develop generalized metastasis; the metastatic rate is around 16% [4].
In end-stage renal disease patients, a high risk also exists for urothelial cancer [1,58]. However, simultaneous occurrence of TCC and RCC in a patient on dialysis is very rare, although this association has been reported previously in a renal transplant patient [9]. Gross haematuria is the main sign for urothelial cancer and early detection of haematuria is important to prevent disease progression. Ou et al. [5] recommended surveying for haematuria in dialysis patients, using ultrasonography, cystoscopy, retrograde pyelography, and washing cytology. In the present case, the duration from initial gross haematuria to tumour diagnosis was short; however, histologic findings revealed multifocal and invasive tumours. This case may illustrate the need of not only periodic radiological surveillance but also regular cytological examination to detect early TCC in dialysis patients, even when asymptomatic.
In our patient, preoperative radiological examination did not reveal any abnormal findings in the right kidney and right upper urinary tract. However, total urinary tract exenteration was carried out, because the patient had been anuria. The frequency of urothelial cancers in haemodialysis patients was high and Kanatani et al. [6] suggested urothelial cancers in Japanese haemodialysis patients tended to high grade and advanced stage. When radical surgery is indicated for a dialysis patient with multiple or invasive bladder tumour, total urinary tract exenteration may be a useful treatment option. Jiann et al. [7] suggested that the management of dialysis patients with urothelial cancers should be the same as that of non-dialysis patients because aggressive surgical treatment may improve their quality of life and prolong their survival. But the indication for surgery should be determined carefully as there are more risks for postoperative complications.
Our patient was managed successfully without postoperative complications including hypotension and progressive anaemia. At this short follow-up our patient had no evidence of recurrent disease, but a close follow-up will be necessary because of the recent history of the high grade and advanced TCC associated with RCC.
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Notes
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Correspondence and offprint requests to: Masaharu Nishikido, MD, Department of Urology, Nagasaki University School of Medicine, 1-7-1 Sakamoto Nagasaki City, Nagasaki, Japan 852-8501. Email: nishiki@net.nagasaki-u.ac.jp 
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References
|
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- Maisonneuve P, Agodoa L, Gellert R et al. Cancer in patients on dialysis for end-stage renal disease: an international collaborative study. Lancet1999; 354: 9399[ISI][Medline]
- Sasagawa I, Nakada T, Kubota Y, Suzuki Y, Ishigooka M, Terasawa Y. Renal cell carcinoma in dialysis patients. Urol Int1994; 53: 7981[ISI][Medline]
- Lin JI, Saklayen M, Ehrenpresis M, Hillman N. Acquired cystic disease of kidney associated with renal cell carcinoma in chronic dialysis patients. Urology1992; 39: 190193[ISI][Medline]
- Ishikawa I, Saito Y, Nakazawa T, Shiroma K, Suzuki K. Local recurrence of renal cell carcinoma and acquired cysts 10 years after tumour nephrectomy. Nephrol Dial Transplant1998; 13: 32363239[Abstract]
- Ou JH, Pan CC, Lin JS et al. Transitional cell carcinoma in dialysis patients. Eur Urol2000; 37: 9094[ISI][Medline]
- Kanatani I, Okumura K, Asazuma A et al. Synchronous multifocal development of invasive transitional cell carcinoma of the urinary tract in a patients with renal failure receiving long-term hemodialysis: a case report. Acta Urol Jpn1998; 44: 821824
- Jiaan BP, Yu CC, Lee YH, Huang JK. Uraemia with concomitant urothelial cancer. Br J Urol1993; 72: 458461[ISI][Medline]
- Boon NA, Michael J. Multiple neoplasia in a patient on dialysis presenting with haematuria. Br J Urol1984; 56: 96[ISI][Medline]
- Gomez E, Portal CG, Seco MA, Alvarez-Grande J. Multiple solid malignancies in a renal transplant patient. Nephrol Dial Transplant1999; 14: 803804[Free Full Text]
Received for publication: 27.11.01
Accepted in revised form: 5. 6.02