|Year : 2017 | Volume
| Issue : 2 | Page : 115-117
Incidental upper tract urothelial carcinoma presenting as pyonephrosis
K Manjula, Geethanjali Nagaraj, Krishna Shetty, CSBR Prasad
Departments of Pathology and Urology, Sri Devaraj Urs Medical College, Kolar, Karnataka, India
|Date of Submission||13-Mar-2017|
|Date of Acceptance||12-Jun-2017|
|Date of Web Publication||15-Dec-2017|
Dr. K Manjula
Sri Devaraj Urs Medical College, Tamaka, Kolar - 563 101, Karnataka
Source of Support: None, Conflict of Interest: None
Upper tract urothelial carcinomas (UTUCs) are uncommon and account for only 5%–10% of urothelial carcinomas. The most common symptom of UTUC is gross or microscopic hematuria (70%–80%). A 55-year-old woman admitted with the history of fever and pain in abdomen for the past 20 days. Her history was not significant. She underwent right nephroureterectomy with the provisional clinical diagnosis of pyonephrosis with nonfunctioning kidney. Histopathological examination of nephrectomy specimen showed features of high-grade urothelial carcinoma with renal parenchyma invasion (T3N0M0). Here, we present a rare case of incidental UTUC presenting as pyonephrosis.
Keywords: Hematuria, pyonephrosis, urothelial carcinoma
|How to cite this article:|
Manjula K, Nagaraj G, Shetty K, Prasad C. Incidental upper tract urothelial carcinoma presenting as pyonephrosis. BLDE Univ J Health Sci 2017;2:115-7
Primary urothelial carcinoma originating in the ureter or renal pelvis is collectively called upper tract urothelial carcinomas (UTUCs). UTUCs are uncommon and account for only 5%–10% of urothelial carcinomas., UTUCs have a peak incidence in older age, and they are three times more prevalent in men than in women. Tobacco and occupational exposure are the main risk factors., The most common symptom of UTUC is gross or microscopic hematuria (70%–80%); other common symptoms are flank pain and presenting as a lumbar mass. Grade and stage are the most important prognostic factors in UTUCs. UTUCs presenting as pyonephrosis in female with kidney invasion are very rare.
| Case Report|| |
A 55-year-old woman admitted with the history of fever and pain in abdomen for the past 20 days. Her history was not significant. On examination, she had right hypochondriac and flank tenderness. Urine analysis showed albumin - 1+, pus cells - 10–12/hpf, red blood cell - nil, epithelial cells - 16–18/hpf, and casts/crystals - nil; blood analysis showed blood urea - 40 mg/dl and serum creatinine - 1.3 mg/dl. Ultrasound examination showed gross hydropyonephrosis. The patient underwent right nephroureterectomy with the provisional clinical diagnosis of pyonephrosis with nonfunctioning kidney.
Right nephrectomy specimen, measured 10 cm × 6 cm × 2 cm, weighed about 96 g. Capsule was thick and adherent. External surface was uneven and showed scars with nodular areas. Cut section showed obliteration of corticomedullary junction and dilatation of pelvicalyceal system [Figure 1]. Also, we noted a well-defined gray-white area measuring about 1.2 cm at the corticomedullary junction. Ureter measured 3 cm. Lumen was dilated, showed papillary excrescence.
Sections studied from the well-defined gray-white area revealed tumor cells arranged in papillary architecture; tumor cells were pleomorphic and polygonal in shape with vesicular nucleus, moderate amount of eosinophilic cytoplasm [Figure 2] and [Figure 3]. Occasional mitotic figures were also noted. Sections studied from the ureter also revealed similar features [Figure 4]. Sections studied from the other areas of the kidney showed xanthogranulomatous pyelonephritis. Thus, features were suggestive of high-grade urothelial carcinoma with renal parenchyma invasion (T3N0M0).
|Figure 2: Well-defined tumor with papillary architecture within kidney parenchyma (H and E, ×100)|
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|Figure 3: Polygonal cells with pleomorphic vesicular nucleus, moderate clear to acidophilic cytoplasm (H and E, ×400)|
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| Discussion|| |
Epidemiology of urothelial carcinoma of upper tract is similar to bladder carcinoma but has a different natural history. Sixty percent of UTUCs are invasive at diagnosis, whereas bladder carcinoma invasion at diagnosis accounts to 15%–20%. Long-term high-dose analgesic abuse (phenacetin) produces a nephropathy called capillosclerosis, and it is associated with increased risk of development of UTUCs. Balkan nephropathy More Details and Chinese herb nephropathy are also associated with the development of UTUCs. Certain plant derivatives endemic to the Balkans have mutagenic action.,, Certain aromatic amines used in dye industry also act as risk factors. UTUC is also linked to hereditary cancer syndromes such as Lynch syndrome and Muir–Torre syndrome and also to black foot disease.,
The most common symptom of UTUC is gross or microscopic hematuria present in more than 75% of patients.,,, Patients may also come with symptoms of flank pain, or flank mass, increased urinary frequency. In 10%–15% of patients, the lesion may be asymptomatic.,,
UTUC is discovered incidentally in <5% of patients., Unusual clinical manifestations such as our case presenting as incidental tumor with hydronephrosis accounts to 7%. The standard lines of investigation for hematuria are urine for cytology, upper tract imaging, and cystoscopy. Computed tomography urography is the imaging technique with the highest accuracy for UTUCs., Development of hydropyonephrosis indicate bad prognosis. Degree of hydronephrosis independently correlates with a bad prognosis. Tissue diagnosis using ureteroscope before surgery helps in diagnosis as well as patients' future management.
The classification, morphology, and grading scheme of UTUCs are similar to those of bladder carcinomas.,, Low-grade and low-stage tumors have a more favorable disease course than higher stage and grade. The most important prognostic factors are tumor grade, stage, and patient age.,,,, Other important prognostic factors include architecture, lymphovascular invasion, multifocality, and the presence of tumor necrosis. The presence of hydronephrosis, presence of systemic symptoms at presentation, history of urothelial carcinoma of bladder, obesity, and advanced age negatively affect the prognosis in UTUCs.,,
UTUC is an important differential diagnosis for poorly differentiated carcinomas presenting as a renal mass. Focal presence of urothelial differentiation helps in diagnosis. Immunohistochemistry is of limited value, though co-expression of cytokeratin (CK) 7 and CK20 and/or p63, combines with absence of reactivity for paired box (PAX)-2 or PAX-8, would support urothelial carcinoma.
The gold standard surgical management for localized UTUC is radical nephroureterectomy with bladder cuff excision.,, Lymphadenectomy is often performed in patients with high-grade invasive tumors. Despite surgical treatment, 5-year cancer-specific mortality rates remain relatively high in these patients. Patients with UTUCs require more intense surveillance, as they have a lifelong increased risk of developing urothelial tumors in the contralateral upper urinary tract or bladder.,
| Conclusion|| |
UTUCs are rare tumors, can present as pyohydronephrosis, and require intense surveillance because of increased risk of development of metachronous bladder tumors, local recurrence, and distant metastasis.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]