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Case 49

Recurrent transitional cell carcinoma of the kidney

Recurrent haematuria

This patient presented with haematuria. A post contrast film from the IVP is provided. The control film (not shown) did not show any additional abnormality.

An enlargement of a further view shows the right kidney in more detail.

Findings

There are surgical clips overlying the left psoas.
The left kidney is absent. The patient has had a previous left nephrectomy.

There is an irregular, lobulated filling defect within the renal pelvis on the right. This appearance suggests a transitional cell carcinoma of the right kidney.

The additional view provided above is taken from a previous IVP some years earlier, immediately prior to the left nephrectomy. It demonstrates the previous left sided transitional cell carcinoma, as an irregular filling defect at the PUJ, with mild calyceal dilatation.

Diagnosis

Recurrent transitional cell carcinoma of the kidney

Discussion

This finding is important for the patient, as it requires a second nephrectomy, and consequently dialysis.

Transitional cell carcinoma (TCC) is the commonest urothelial tumour, accounting for 95% of bladder tumours. However it is rare in the kidney and ureter, causing only 7% of renal neoplasms (the majority of renal tumours are adenocarcinomas, ie. renal cell carcinomas). The frequency of location is related to surface area of epithelium, hence most are in the bladder. For the same reason most upper tract tumours are found in the renal pelvis, or in the lower ureter, having extended up from the bladder.

Upper tract TCC is more common in those with bladder TCC, and especially those with high grade bladder TCC or TCC in the presence of reflux, exposure to carcinogens (cyclophosphamide, smoking, aniline dyes) and analgesic abuse. It presents with haematuria, and may demonstrate an intraluminal filling defect, a stricture with hydronephrosis, or a renal mass (invasion of the kidney).

An IVP is often performed to exclude upper tract TCC when a bladder TCC is diagnosed, but will only demonstrate an upper tract tumour in 2%. However if a patient presents with an upper tract tumour, the incidence of a second, synchronous, tumour elsewhere is 25-40%. The risk of developing a second metachronous tumour (as in this case) is 10-15% in the next 2 years.

The differential diagnosis of a radiolucent filling defect within the renal pelvis includes:

• Tumour
• Blood clot (which may still be from a tumour, of course!)
• Non opaque calculus (eg. uric acid)
• Sloughed papilla (papillary necrosis)
• Cholesteatoma
• Fungus ball
• Air (fistula, infection, iatrogenic)

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