CASE REPORTS

Papillary renal carcinoma presenting as hydronephrosis

Hidronefrosis como cáncer papilar renal

Juan Carlos Regueiro López, Jesús Ruiz García, Manuel Leva Vallejo and Antonio López Beltran¹

Urology Department and Pathological Anatomy¹ Service. Surgery Department. Faculty of Medicine. Cordoba. University Regional Reina Sofia Hospital. Cordoba. Spain.

Correspondence

SUMMARY

Objective: We describe a new case of incidental renal papillary carcinoma. We perform a bibliographic review.
Methods: The papillary renal cell carcinoma is a variant of renal carcinoma. They classify in two subtypes that have relation with their prognosis. We presented one case of renal papillary carcinoma in a male of 76 years, play-acting as severe hydronephrosis.
Results/discussion: We describe the findings and final pathological result associated with a synchronic metastasis in the ipsilateral ureter.

Keywords: Papillary renal cell carcinoma. Renal carcinoma.

RESUMEN

Objetivo: Describir un nuevo caso de carcinoma papilar incidental. Revisión de la literatura.
Métodos: El carcinoma papilar renal (CRP) es una variante dentro del carcinoma renal. Se clasifican en dos subtipos que tienen relación con su pronóstico. Presentamos un caso de CRP en un varón de 76 años, simulando una hidronefrosis evolucionada.
Resultado/conclusiones: Se describen los hallazgos y el posterior resultado histológico asociado de una metástasis sincrónica en el uréter ipsilateral.

Palabras clave: Carcinoma renal papilar. Carcinoma renal.

Introduction

The papillary renal carcinoma (CRP) is a histological subtype 1 established of the renal carcinoma. The clinical and histological details were described in 1976 (1). It represents 7-15% in the total amount of renal cell carcinoma. The tumor predominates in males in 2:1 proportion. His age of presentation places himself between the 50 and 55 years (2, 3). Use to be multi-focal. Generally we found trisomies in 7, 16 and 1, with loss of the Y chromosome (4).

Presentation

Literatures have described histological variants that include trabecular, tubular, sclerosed, high grade and solid (5,6). His association with renal chronic insufficiency has been described (7). Carcinoma is named also chromofilic for the cytoplasm shown basofilia. They have defined two histological patterns, based at genetic abnormalities, tumor stage, number of mitosis and the rates of cell proliferation. The tumors use to be delimited, with eccentric location in the cortex, with hemorrhage and necrosis associated.

Case report

Male of 76 years without family record neither personal of concern, that we attended in urgencies for picture of diffuse abdominal pain of six months of evolution accompanied of sensation of abdominal mass, slow loss of weight but progressive. No urological symptoms associated. The physical exploration did not show abdominal peritonism, but a 20 cm's mass approximately that you locate in straight hypochondrium, overtaking the halfline. His analytical (hemogram with formulate and score, general biochemistry, study of coagulation) do not show abnormalities of entrance. The radiological basic study, the ultrasound scan shows an anechoic mass that occupies 37 cm's in right hemiabdomen, that displaces liver, pancreas and vena cava (Figure 1). The intervening findings confirm CT themselves, giving consideration to stenosis of ureter suspicion evolved with massive hydronephrosis without parenchyma working (Figure 2). We operated making right nephroureterectomy without data of renal or external infiltration. We did not find adenopathies. The histological diagnosis was papillary carcinoma of renal cells type 2 with height nuclear grade (Fuhrman 3) that substitute the parenchyma of complete form, infiltrating focally the renal capsule and perirrenal fat (pT3a) (Figure 3). The study of his ureter (Figure 4) evidenced metastasis of papillary carcinoma of renal cells that infiltrated extensively the muscular layers. Posoperative without incidences.

Discussion and conclusion

This neoplasia's type is correlated with other types of carcinoma of renal cells. His architecture is papillary or tubular-papillary with epithelial arranged stratified cells on fine vascular stems. Exist two types of CRP defined by Delahunt and Eble 8, like type 1 and 2. The type 1 is the most frequent with small cells, with scarce cytoplasm, being little his nuclei as well as nucleoles (grades 1 and 2 of Fuhrman ). The type 2 shows more irregular papillas with more big cells, with big nuclei and prominent nucleoles (grade 3 of Fuhrman). It is a classification that is correlated with the stage and evolution, being the type 2 the one belonging to worse prognosis.

Classically the CRP has associated with a most favorable prognosis than the Carcinoma of renal cells (1,9). There are contradictory results in another series themselves. The basic chromosome anomalies have found in localized tumors and no infiltrative, while the most aggressive forms in his presentation have more genetic correlated abnormalities, as it happens in the type 2 (6). The tumor stage upon the diagnosis is a important parameter. The actual tumor shows sign factors unfavorable prognosis: Invasion of perinephric fat, synchronic ureteral metastasis, nuclear grade 3 of Fuhrman, subtype 2, superior mass to 10 centimeters. The beneficial effect of the radical surgery like only treatment gets in patients with an only metastatic focus itself resectable and less than 60 years, with a level 0-1's ECOG. His best-suited treatment continues to be the radical surgery because does not seem to respond to quimio-immunotherapy. Literature have described ureteral and bladder metastasis of renal carcinoma of clear cells 10, but we have not found in literature the description of metastasis in ureteral having the origin in a CRP.

Correspondence:
Juan Carlos Regueiro López
Avda. Lagartijo, 22 - 3^o puerta 1.
14005 Córdoba. (Spain).
jcregueo@ono.com

Accepted for publication: October 18^th, 2008.

References and recomended readings (*of special interest, **of outstanding interest)

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