Three cancers in the renal pelvis, bladder, and colon: A case report

Abstract

BACKGROUND

Multiple primary cancers are rare occurrences that can involve either metachronous or synchronous development. It is particularly rare for an individual to have more than two primary cancers. In this report, we present a case study of an elderly man who was diagnosed with three heterochronous cancers in the renal pelvis, bladder, and colon.

CASE SUMMARY

On December 30, 2014, a 51-year-old Chinese man was admitted to our hospital with complaints of intermittent painless gross hematuria for the preceding week. A computed tomography (CT) scan revealed wall thickening in the left ureter’s upper segment, while a CT urography revealed a left renal pelvis tumor. A successful laparoscopic radical resection of the left renal pelvis tumor was subsequently performed at Shanghai Zhongshan Hospital in January 2015. The pathological findings after the surgery revealed a low-grade papillary urothelial carcinoma of the renal pelvis. The final pathological tumor stage was pT1N0M0. After surgery, this patient received 6 cycles of intravenous chemotherapy with gemcitabine and carboplatin, as well as bladder infusion therapy with gemcitabine. On December 18, 2017, the patient was admitted once again to our hospital with a one-day history of painless gross hematuria. A CT scan showed the presence of a space-occupying lesion on the posterior wall of bladder. Cystoscopic examination revealed multiple tumors in the bladder and right cutaneous ureterostomy was performed under general anesthesia on December 29, 2017. The postoperative pathological findings disclosed multifocal papillary urothelial carcinoma of the bladder (maximum size 3.7 cm × 2.6 cm). The bladder cancer was considered a metastasis of the renal pelvis cancer after surgery. The pathological tumor stage was pT1N0M1. The patient refused chemotherapy after surgery. After another six years, the patient returned on February 28, 2023, complaining of periumbilical pain that had lasted six days. This time, a CT scan of the abdomen showed a tumor in the ascending colon, but a subsequent colonoscopy examination indicated a tumor in the descending colon. On March 12, 2023, a subtotal colectomy and an ileosigmoidal anastomosis were carried out under general anesthesia. Postoperative pathological findings revealed that all three tumors were adenocarcinomas. The final pathological tumor stage was pT3N0M0. The patient had an uneventful postoperative recovery and was discharged without complications.

CONCLUSION

The case of this elderly man presents a rare occurrence of metachronous primary cancers in the renal pelvis and colon. Bladder cancer is considered a metastasis of renal pelvis cancer after surgery. Optimal treatment can be implemented by evaluating the patient’s histological features, clinical history, and tumor distribution correctly.

Key Words: Metachronous primary carcinoma, Renal pelvis carcinoma, Bladder carcinoma, Colon carcinoma, Case report

Core Tip: In this report, we present a case study of an elderly man who was diagnosed with three heterochronous cancers in the renal pelvis, bladder, and colon. The case of this elderly man presents a rare occurrence of metachronous primary cancers in the renal pelvis and colon. The bladder cancer is considered to be metastasis of renal pelvis cancer after operation. Optimal treatment can be implemented by evaluating the patient’s histological features, clinical history, and tumor distribution correctly.

INTRODUCTION

The occurrence of multiple primary cancers (MPCs) was originally described by Billroth in 1889 as the development of two or more tumors in a single individual with varied histological characteristics and originating from different body parts, each with their own metastatic deposits. MPCs are classified into two groups, namely synchronous and metachronous[1]. Metachronous MPCs manifest as cancers occurring six months or more after the first primary cancer[2,3]. Most MPCs manifest as double primary cancers, while triple primary cancers are extremely rare. This article describes an unusual case of metachronous primary cancers involving the urinary system and digestive system in a single patient.

CASE PRESENTATION

Chief complaints

A 51-year-old male Chinese citizen was admitted to our hospital on December 30, 2014, with intermittent painless gross hematuria.

History of present illness

The patient’s symptoms began one week earlier when he experienced intermittent painless gross hematuria.

History of past illness

The patient had been diagnosed with liver cysts and gallbladder stones, but had no history of surgery.

Personal and family history

The patient had no family history of cancer.

Physical examination

Upon hospitalization, the patient’s vital signs were stable. The patient’s temperature was 36.7 °C, the heart rate was 90 beats per minute, the respiratory rate was 20 breaths per minute, the blood pressure was 162/96 mmHg, and the oxygen saturation in room air was 100%. A physical examination did not reveal any pathological signs.

Laboratory examinations

Routine laboratory testing showed an elevation of urinary protein (1+), urinary occult blood (3+), urinary red blood cells (374/μL), and urinary white blood cells (29/μL). Other laboratory test results, including tumor markers, were within normal limits.

Imaging examinations

A computed tomography (CT) scan of the abdomen yielded results indicating local wall thickening in the upper segment of the left ureter. CT urography (CTU) revealed a tumor involving the left renal pelvis (Figure 1A and B). Surgery was advised, but the patient requested a transfer to Shanghai Zhongshan Hospital. Laparoscopic radical resection of the left renal pelvis tumor was performed under general anesthesia in January 2015, after excluding surgical contraindications and the surgery was successful. The postoperative pathological findings revealed urothelial carcinoma of the renal pelvis.

Figure 1 Computed tomography urography of the abdomen. A: Filling defect from upper segment of left ureter (orange circle); B: A tumor involving the left renal pelvis (orange circle); C: Filling defect from the bladder (orange circle); D: The right urinary tract is unobstructed.

Hospital course

The patient recovered without complications after surgery and was discharged from Shanghai Zhongshan Hospital. The pathological findings revealed a noninvasive low-grade papillary urothelial carcinoma of the renal pelvis. The final pathological tumor stage was pT1N0M0. After surgery, this patient received 6 cycles of intravenous chemotherapy with gemcitabine and carboplatin, as well as bladder infusion therapy with gemcitabine. Regular outpatient follow-up appointments at our hospital were scheduled in order to detect any recurrence.

Three years later, on December 18, 2017, the patient was readmitted to our hospital because of painless gross hematuria lasting for one day. Routine laboratory tests showed an elevation of urinary protein (1+), urinary occult blood (2+), and urinary red blood cells (133/μL). A CT scan of the abdomen showed a space-occupying lesion on the posterior wall of the bladder. A CTU revealed a filling defect from the bladder (Figure 1C and D). Cystoscopic examination revealed a tumor on the left wall of the bladder, adjacent to the right ureteral opening and the specimen was biopsied. The pathological result was urothelial carcinoma (Figure 2). On December 29, 2017, laparoscopic total cystectomy and right cutaneous ureterostomy were performed after excluding surgical contraindications. The patient was placed under general anesthesia and the surgery was successful. The postoperative pathological findings revealed papillary urothelial carcinoma of the bladder (multifocal, maximum 3.7 cm × 2.6 cm) (Figure 2). The bladder cancer was considered a metastasis of the renal pelvis cancer after surgery. The pathological tumor stage was pT1N0M1. The patient refused postoperative chemotherapy.

Figure 2 Histopathological findings of cystoscope biopsy and postoperative pathology. A: Bladder urothelial carcinoma (× 400). B: Tumors were recognized as papillary urothelial carcinoma on the excised bladder (× 400).

After six years, on February 28, 2023, the patient was readmitted to our hospital due to periumbilical pain over six days. A CT scan of the abdomen showed a tumor of the ascending colon. Colonoscopy examination, on the other hand, suggested a tumor in the descending colon (Figure 3). The pathological result of the colonoscopic biopsy specimen was adenocarcinoma of the descending colon (Figure 4). The contraindication for surgery was removed. On March 12, 2023, a subtotal colectomy and an ileosigmoidal anastomosis were performed under general anesthesia, and the operation was successful. The length of the colon removed was 65 cm. Three tumors were detected on the excised colon; one was 2 cm away from the distal margin and had a size of 3.5 cm × 2.5 cm, the other was adjacent to the ileocecal region and had a size of 2 cm × 2 cm, and the final tumor was 11 cm away from the proximal margin and had a size of 5.5 cm × 3.5 cm. All three tumors were recognized as adenocarcinoma based on the postoperative pathological findings (Figure 4). The final pathological tumor stage was pT3N0M0. The patient recovered smoothly after the operation and was discharged without any complications.

Figure 3 Computed tomography of the abdomen and colonoscopy examination. A: A tumor of the ascending colon (orange circle); B: A tumor in the descending colon.

Figure 4 Histopathological findings of colonoscopy biopsy and postoperative pathology. A: Adenocarcinoma of the descending colon (× 400); B: Tumors were recognized as adenocarcinoma on the excised colon (× 400).

FINAL DIAGNOSIS

The patient’s final diagnosis revealed that he had three types of carcinoma, namely, renal pelvis cancer, bladder cancer, and colon cancer.

TREATMENT

After conducting a thorough preoperative evaluation and finding no surgical contraindications, we performed three surgeries on the patient. However, after a discussion involving with the entire hospital’s multidisciplinary team, and after considering the fact that the patient had only one kidney and the renal impact of chemotherapy, chemotherapy was deemed temporarily unsuitable for this patient.

OUTCOME AND FOLLOW-UP

The patient was not provided with any adjuvant therapy and after an uneventful recovery, he was discharged without any complications. A follow-up one month later showed no evidence of tumor recurrence.

DISCUSSION

Although MPCs are a rare occurrence, it is crucial to consider and exclude the possibility of metastasis from another cancer[4,5]. To distinguish between MPCs and metastatic tumors, several essential points should be accounted for. These include identifying each cancer as malignant through a histologic evaluation, as well as ensuring that each cancer is both geographically separate and distinct. Finally, the possibility of metastasis must be eliminated[6,7]. Additionally, tumors should be considered as MPCs when the first primary tumor presents without relapse.

Regarding the occurrence of bladder metastasis after primary renal pelvis cancer resection, it has been found that this incidence ranges from 13% to 35.7%[8,9]. The differentiation between primary and metastatic bladder cancer can be a challenge, and there are two proposed mechanisms for the occurrence of these cancers[10,11]. These include the monoclonal hypothesis, where a single genetic tumor cell causes tumors to emerge in different areas of the urinary tract. Alternatively, the regional canceration hypothesis proposes that exposure to carcinogens leads to synchronous and metachronous occurrences of unrelated tumors in various parts of the urinary tract.

In our case report, the patient was found to have bladder cancer three years after undergoing radical nephrectomy. The cancer showed evidence of multifocal growth and local interstitial invasion. However, there were no findings indicating any metastasis of cancer cells in the peripheral lymph nodes. While there are reports that the postsurgical metastasis of bladder cancer from renal pelvis cancer usually occurs within two years, the thin walls of the renal pelvis and ureter, surrounded by abundant lymphatic drainage, make lymphatic infiltration in renal pelvis cancer a crucial factor in bladder metastasis. Based on the information presented in this case, the renal pelvis and bladder cancers were dependent on one another, constituting a case of metastasis.

The incidence of dual primary cancer concurrent colorectal with cancer has been found to be between 5% and 17%, with the most common site of onset being the rectum and right colon[12-15]. Double primary cancer patients with concomitant colorectal cancer have a higher incidence of microsatellite instability-high (MSI-H) when compared with single colorectal cancer[16]. In clinical practice, nearly 15% of colorectal cancers are caused by MSI resulting from mismatch repair (MMR) gene mutations. The MMR gene encodes four primary proteins, including Mut-S homolog 2 (MSH2), MSH6, Mut-L homolog 1 (MLH1), and postmeiotic segregation increased 2 (PMS2). If two or more of these proteins are not present, the cancer is MSI-H[17,18].

In our case report, colon cancer was discovered in a patient five years after radical surgery for bladder cancer. The colon cancer was classified as adenocarcinoma and was noted for its ulcerative growth accompanied by infiltration into the subserosa. No metastasis of cancer cells in the peri-intestinal lymph nodes was discovered. According to the diagnostic criteria for MPC, the colon cancer was a metachronous primary cancer. We determined the expression of MSH2, MSH6, MLH1, and PMS2 in carcinoma by immunohistochemical staining. The results were as follows: MSH2 (+), MSH6 (+), MLH1 (-), and PMS2 (-). The stable state of microsatellites can determine the prognosis of patients with MSI-H. Usually, these patients have a good prognosis. The MSI test can only be conducted through next generation sequencing and this patient has not had such testing, so the patient’s prognosis is not very clear.

CONCLUSION

The preoperative examination of the present patient revealed two tumors in the colon, and an additional tumor was discovered during the surgery. Thus, performing an adequate preoperative examination and a careful intraoperative exploration can prevent a missed diagnosis. Early detection of MPCs can greatly improve patient survival rates and quality of life.