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Year : 2006  |  Volume : 16  |  Issue : 4  |  Page : 907-909
Renal and ureteral transitional cell carcinoma: A case report


Honorary Asst Prof. Radio-Diagnosis IGMC and Mayo Hospital, Nagpur, Amarjyoti x-ray and sonography clinic, Wardha Road, Dhantoli, Nagpur 440012 Maharashtra state, India

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Date of Submission12-Sep-2005
Date of Acceptance10-Oct-2006
 

Keywords: Urothelial tumors, Renal neoplasms, Transitional cell carcinoma -Computerized Tomography, Renal Tumors

How to cite this article:
Phatak S V, Kolwadkar P K. Renal and ureteral transitional cell carcinoma: A case report. Indian J Radiol Imaging 2006;16:907-9

How to cite this URL:
Phatak S V, Kolwadkar P K. Renal and ureteral transitional cell carcinoma: A case report. Indian J Radiol Imaging [serial online] 2006 [cited 2019 Aug 24];16:907-9. Available from: http://www.ijri.org/text.asp?2006/16/4/907/32381

   Case report Top


A seventy-year lady presented with painless hematuria from last six months. Radiograph of abdomen was normal. No radio-opaque calculi or calcification was seen. Sonography revealed a hypoechoic lesion in Right renal pelvis. Intravenous urography indicated poorly functioning right kidney. CT of abdomen revealed a large soft tissue mass in right renal pelvis and upper ureter(Fig 1-4). Nephrectomy was done with excision of upper ureter. Specimen was subjected for histopathology which confirmed findings of TCC in renal pelvis and upper ureter.


   Introduction Top


The urothelium is the mucosal lining of renal collecting system. (Calyces, infundibula and renal pelvis), ureters, Urinary bladder and portions of urethra. This epithelial lining has a typical microscopic appearance that is midway between squamous and glandular leading to its designation as transitional epithelium [1]. The urothelium is a target tissue for carcinogens that leads to the development of Transitional cell carcinomas [2] Multicentricity and bilaterality either as synchronous or as metachronous lesions occur in a significant number of instances. Therefore in case of the presence of one TCC anywhere in collecting system requires a careful and thorough initial evaluation of entire urinary tract system and appropriate periodic follow up is a must [3]. Tobacco, exposure to aniline, Benzedrine, aromatic amine and azo dyes used in rubber, plastic, printing and textile industry, cyclophosphamide therapy are associated with development of TCC.Also associated with TCC is nephropathy of Balkan states called Balkan Nephritis. [2] Malignant urothelial tumors include TCC (85-90%), squamous cell carcinoma, adenocarcinoma, small cell undifferentiated carcinoma, carcinosarcoma and metastasis. [1]


   Discussion Top


Urothelial tumors originate much more often (30-50times) in the bladder than renal pelvis where as pelvic tumors are two to three times more common than ureteral ones. Tumors of urothelium are far less common than RCC by a ratio of 9:1.Where as primary ureteral tumors constitute only 1%of all cancers of upper urinary tract. The peak occurrence is 6th or 7th decades with predominance in men in a ratio of 3:1or4: 1 but when tumor occurs in analgesic abuses or with Balkans nephropathy where both sexes are equally affected. [1] TCC of kidney may arise from any portion of the renal pelvis but the extrarenal pelvis is most frequently affected. Renal pelvic and ureteral tumors occur simultaneously in 6-38%of cases. Distal ureter is a common site of ureteral TCC.(50-73% of reported cases). On gross examination the majority of renal TCC 's have exophytic papillary appearance. Some are exophytic and endophytic both minority are purely endophytic. This later group is usually high grade [4] Plain films are of limited value and may show calcification (.7-7% cases). Urography may show filling defects, filling defects in distended calyceas, calyceal obliteration or amputation, hydronephrosis with renal enlargement and absent or decreased renal function. On sonography a most common appearance is a discrete hypoechoic mass that separates the central echo complex may be associated with dilated infundibulum and calyces. [1] Excretory phase CT scanning is the examination mainstay for patients with known or suspected TCC.Images are routinely obtained 3-4 minutes after injection of contrast material. This delay is necessary for collecting system opacification. CT findings of early TCC consists of a central solid mass in renal pelvis that expands centrifugally with compression of renal sinus fat. TCC's are typically slightly hyperdense to water density renal pelvis ranges from 5-30 H.Therefore they can be detected as masses with density less than that of renal parenchyma but greater than urine. The density of TCC is usually sufficiently different from other causes of renal pelvis filling defects (renal stones, blood clots, and sloughed papillae) to suggest an accurate diagnosis. Renal calculi show HU>100 and attenuation of blood clot ranges from 50-75H.At times differentiation between blood clot and tumor is difficult a follow up CT scan is useful because blood clots often change configuration with time. TCC typically show minimal enhancement after intravenous contrast.stage I and II tumors usually present as discrete renal pelvic masses with normal peripelvic fat and appear separated from renal parenchyma either by renal sinus fat or excreted contrast material [5] The diagnosis of invasive (stageIII) TCC depends upon visualization of infiltration into the renal parenchyma or peripelvic fat. A stage IV tumor is defined by local extrarenal extension, lymphnode involvement or distal metastasis. More advanced tumors can invade renal parenchyma and can mimic primary RCC. But can be differentiated from RCC is by relatively central location of tumor and by its centrifugal expansion or invasion of kidney.or both. Advanced TCC preserve the shape of kidney. After contrast TCC show less enhancement than does the hypervascular RCC.Extrarenal spread can occur at or through the hilum. Common sites of metastasis are lungs, retroperitoneum, Lymphnodes and bones. Rarely TCC can invade renal vein and IVC. [6] In MRI on T1Wimages tumors have signal intensity equal to or slightly less than that of renal parenchyma. There is a slight increase in signal intensity on T2W images. Dynamic scanning after intravenous contrast show enhancement of the lesion. CT is particularly useful for further evaluation of possible ureteral TCC.Ureteral TCC may result in an intraluminal soft tissue mass or thickening of ureteral wall. Such thickening may be eccentric or circumferential. Periureteral invasion and regional lymphadenopathy both easily demonstrated on CT are important elements of staging and surgical planning. [2]

 
   References Top

1.Parvati Ramchandani, Howard H.Pollack Tumors of the urothelium Seminars in RoentgenologyVol XXX, No.2, April 1995:149-167.  Back to cited text no. 1    
2.Jade I Wong-You-cheong, BrentJWagner Charles j DavisTransitional cell carcinoma of the Urinary tract: Radiologic-Pathologic correlation Radiographics1998; 18:123-142.  Back to cited text no. 2    
3.Standford M GoldmanMarkEBohlman, Olga MB Gatewood Neoplasms of Renal collecting system Seminars in Roentgenology Vol XXII, No.4, (October) 1987:284-291.  Back to cited text no. 3    
4.John E Tomaszewski The pathology of renal tumors Seminar in Roentgenology vol XXX, No.2 April 1995:116-127.   Back to cited text no. 4    
5.Bruce A Urban, JulieBuckley, Philippe Soyer, AntoioneScherrer, Elliot K Fishman CT appearance of Transitional cell carcinoma of renal pelvis part 1,early stage diseaseAJR July 1997; 169:157-161.  Back to cited text no. 5    
6.Bruce A Urban, JulieBuckley, Philippe Soyer, AntoioneScherrer, Elliot K FishmanCT appearance of Transitional cell carcinoma of renal pelvisPart 2,Advanced stage disease AJR, July 1997:163-169.  Back to cited text no. 6    

Top
Correspondence Address:
S V Phatak
Consultant Radiologist, Honorary Asst Prof. Radio-Diagnosis IGMC and Mayo Hospital, Nagpur, Amarjyoti x-ray and sonography clinic, Wardha Road, Dhantoli, Nagpur 440012 Maharashtra state
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.32381

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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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