The patient, an 85-year-old woman, presented to the emergency department with right-sided abdominal pain and new-onset gross hematuria. Her medical history included hypertension, hysterectomy for benign disease, and osteoporosis, with no history of smoking or chemical exposure. She was hemodynamically stable and did not require bladder irrigation. Ultrasonography suggested a right renal mass.
Subsequent investigations included urine cytology, which was atypical but not diagnostic for malignancy, normal cystoscopy and normal blood work, including liver studies and calcium. A computed tomography (CT) scan confirmed the presence of a 5.5-cm solid mass on the anterior aspect of the upper pole of the right kidney (). Renal vein, lymph nodes and contralateral kidney were normal. Delayed views of the collecting system were suspicious for protrusion or extension of the mass into the renal pelvis (). The working diagnosis based on imaging studies was RCC with invasion into the collecting system.
Computed tomography scan showing a 5.5-cm solid mass on the anterior aspect of the upper pole of the right kidney (asterisk).
Computed tomography scan with delayed pyelogram view, concerning for protrusion or extension of the mass into the renal pelvis (asterisk).
The patient was eager for definitive management of her renal mass, and so was scheduled for laparoscopic right radical nephrectomy, which was performed uneventfully. Titanium clips were placed on the distal ureter in close approximation before cutting, and there was no spillage of urine. The operating surgeon accompanied the gross specimen to the pathology department and requested that it be bivalved immediately, based on the atypical cytology and the suggestion of possible renal pelvic extension of the mass.
Upon opening the kidney, it was clear that there were 2 geographically and morphologically distinct masses in the kidney: a 5.5-cm mass corresponding clearly to the radiographic lesion, and a 2.5-cm papillary mass in the superior aspect of the renal pelvis (). Intraoperative frozen section of the papillary mass confirmed a UC of the renal pelvis. The surgical team was alerted, and the patient’s Pfannenstiel incision was extended to allow a right ureterectomy to be performed.
Radical nephrectomy specimen demonstrating synchronous pelvic urothelial carcinoma (long arrow) and renal cell carcinoma (arrowheads).
Final pathology confirmed the presence of 2 distinct malignancies. A cortical RCC of primarily clear cell histology was present, with Fuhrman nuclear grade 3 of 4, and no invasion of the renal capsule (). There was, however, microscopic invasion of a medium-sized renal vein. The second tumour was a high-grade UC with invasion through the muscularis propria of the renal pelvis and extension into renal sinus fat (). Surgical margins and the right ureter were negative for malignancy.
Invasive, high-grade, papillary urothelial carcinoma of the renal pelvis (hematoxylin–phloxine–saffron stain, original magnification × 40).
Photomicrograph of renal cell carcinoma, combined clear cell/chromophobe type (hematoxylin–phloxine–saffron stain, original magnification × 200).