|Year : 2021 | Volume
| Issue : 2 | Page : 59-60
Bladder metastasis of renal cell carcinoma. A case report and review of the literature
Panagiotis Velissarios Stamatakos1, Loannis Glykas1, Charalampos Fragkoulis1, Georgia Theodoropoulou2, Sofia Pappa2
1 Department of Urology, General Hospital of Athens, “G. Gennimatas”, Athens, Greece
2 Department of Pathology, General Hospital of Athens, “G. Gennimatas”, Athens, Greece
|Date of Submission||03-Aug-2021|
|Date of Decision||25-Aug-2021|
|Date of Acceptance||28-Aug-2021|
|Date of Web Publication||26-May-2022|
Panagiotis Velissarios Stamatakos
Krevvata 44, Piraeus, Athens
Source of Support: None, Conflict of Interest: None
Renal cell carcinoma (RCC) metastasis to the urinary bladder is an exceedingly rare entity. In this paper, we present a case of a 78-year-old male presented in our department with painless gross hematuria, 2 years after he underwent a left open nephrectomy that revealed a clear cell RCC. Imaging examination revealed a sessile mass on the bladder wall. The patient underwent a transurethral resection of the bladder tumor with the histological diagnosis of clear cell RCC. Pathogenesis and possible routes of such a metastasis are not well-documented and no treatment of choice has been established yet.
Keywords: Bladder metastasis of renal cell carcinoma, rare metastasis of renal cell carcinoma, rare sites of metastasis of renal cell carcinoma, renal cell carcinoma bladder metastasis, urinary bladder metastasis of renal cell carcinoma
|How to cite this article:|
Stamatakos PV, Glykas L, Fragkoulis C, Theodoropoulou G, Pappa S. Bladder metastasis of renal cell carcinoma. A case report and review of the literature. Hellenic Urology 2021;33:59-60
| Introduction|| |
Worldwide, kidney cancer is the third most common urological cancer, while renal cell carcinoma (RCC) constitutes approximately 70% of all primary malignant renal tumors. About 20%–25% of patients with RCC present with advanced disease at the initial diagnosis. The most common metastatic sites are lungs, lymph nodes, bones, and liver, while rare metastatic sites include the testis and the urinary bladder. Urinary bladder metastasis from RCC is extremely rare with few cases reported in the literature so far.
| Case Report|| |
A 78-year-old male with multiple comorbidities was referred to our department in October 2018 due to an accidentally found left renal tumor located in the upper pole. The computer tomography (CT) scan identified a 5 cm left renal tumor located in the upper pole of the kidney. There was no evidence of metastatic disease nor lymphadenopathy. A successful left open nephrectomy was performed by a retroperitoneal approach. The postoperative course was uneventful, and the patient was discharged 7 days after surgery. The pathology report revealed a well-delineated, solid, and elastic, white to orange mass of 4 cm × 5 cm × 4.5 cm, and the tumor was classified as pT1b clear cell RCC of Grade 3 according to ISUP 2012 and the 8th edition of the TNM Classification. The patient underwent the follow-up protocol of a chest and abdomen CT scan at 6 and 12 months which revealed no sign of recurrence or metastasis.
Two years after the operation, the patient presented to our department with painless gross hematuria. An ultrasound was performed which revealed a hyperechoic mass of 1 cm at the posterior wall of the urinary bladder. The patient underwent a flexible cystoscopy that revealed a sessile mass on the left lateral bladder wall. Transurethral resection of the bladder tumor was performed, and the histologic examination revealed a metastasis of the known patient's clear cell RCC [Figure 1]. A chest and abdominopelvic CT scan was followed for staging purposes. No sign of another metastatic lesion was described. The patient decided to undergo an open radical cystectomy within the rationale of a solitary metastasectomy. He had a good postoperative course. No systemic treatment was administered before or after surgery. The pathology report revealed the already known solitary, localized clear cell RCC metastasis of the urinary bladder.
|Figure 1: H and E stain original magnification ×50 and ×100 in the lower right quadrant. Section from the bladder tumor showing infiltration of the clear cell renal cell carcinoma|
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| Discussion|| |
Bladder metastasis of RCC is an uncommon condition that accounts <2% of all bladder tumors. The mean age of the patients at diagnosis is 60 ± 12 years. Bladder metastasis may occur either in a synchronous or metachronous setting with the primary renal cancer. The average period between primary RCC diagnosis and metastasis to the bladder ranges from 2 to 131 months in literature.
Routes of metastatic spread of RCC to the bladder remain unclear. Several underlying mechanisms have been proposed including hematogenous, lymphatic, and metastasis via the urinary stream. Hematogenous metastasis may occur through either systemic circulation or retrograde venous route. The last indicates the formation of tumor thrombus in the renal vein and the retrograde dissemination of malignant cells through the venous system. Infiltration of the muscular layer of the bladder wall without contact to the urothelial layer indicates a hematogenous spread. Another theory suggests tumor cells spread through lymphatic blood vessels. The synchronous finding of widespread disease including multiple metastatic sites is thought to result from these hematogenous or lymphatic metastatic pathways. The last mechanism of bladder metastasis is the direct extension of renal tumor to the ureter and bladder, as well as the transition of tumor cells through urine with implantation at the distal urothelium (“drop metastases”).
Clinical presentation of bladder metastasis consists of asymptomatic gross hematuria and symptoms of urinary obstruction. CT scan and cystoscopy reveal a sessile mass with spherical protuberances into the bladder lumen which is well enhanced after the use of intravenous contrast. Transurethral resection of the mass and pathology examination of the specimens establish the diagnosis of bladder metastasis of RCC.
Clear cell variant of RCC is the most common histopathologic subtype associated with bladder metastasis. Histologically, metastatic lesions must be differentiated from clear cell adenocarcinoma of the urinary bladder, lipoid-cell variant of urothelial carcinoma as well as clear cell carcinomas arising from other organs such as the prostate, lung, and breast. At last, pathologists should also consider the possibility of metastatic melanoma, clear cell sarcoma, and seminomas.
Due to the lack of evidence, there are no guidelines regarding the treatment of bladder metastasis of RCC. So far, transurethral resection of the tumor, partial or radical cystectomy, and systemic chemotherapy have been used. A suggestion of treatment in cases with solitary bladder metastasis is to perform transurethral resection as a part of cytoreductive management and to provide systemic therapy as soon as other metastatic sites are detected. In our case of a solitary bladder clear cell RCC metastasis, a radical cystectomy was performed in the rationale of a metastasectomy.
| Conclusion|| |
Bladder metastasis of RCC is a rare medical entity that medical community should be aware of it. More data should be obtained about its pathogenesis to provide the best therapeutic utilities to these patients.
Statement of ethics
The study complied with the principles of Declaration of Helsinki for the protection of human rights. The patient was informed in detail by the treating physician for inclusion in the case presentation and signed an informed consent before participation. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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