Case Report: Metachronous bilateral upper tract and bladder urothelial carcinoma: a long-term follow-up

Abstract

Background: Upper tract urothelial carcinoma (UTUC) is a malignant disease of the urothelial cell lining the upper urinary tract from renal calyces, pelvises, and ureter down to the ureteral orifice. Urothelial carcinoma is a multifocal malignant tumor which tends to reoccur after treatment. Radical cystectomy shows that upper tract recurrence occurs in 0.75% to 6.4% of patients. The occurrence of contralateral UTUC after nephroureterectomy is rarer with a prevalence of 0.5%. Case presentation: The case of a 43-year-old male with metachronous bilateral UTUC was reported. The patient had undergone gemcitabine-cysplatine neoadjuvant chemotherapy followed by radical cystectomy and orthotopic neobladder for urothelial carcinoma of the bladder cT2N0M0. Left hydronephrosis was discovered three months after the procedure. The patient was diagnosed with left UTUC cT4N0M0 of renal pyelum after a series of examinations. A left open radical nephroureterectomy was conducted to remove the mass followed by adjuvant chemotherapy. This was followed up with routine ultrasound and magnetic resonance imaging (MRI) every three months with a "tumor-free" period of 26 months. Meanwhile, the patient was re-admitted with fever and an increase in creatinine value of 4.3. After further workups, the patient was diagnosed with UTUC cT2N0M0 of the right renal pyelum. A kidney sparring approach with laser evaporation of the tumor was conducted followed by eight cycles of Gemcitabine intracavity antegrade per nephrostomy. After the regimen was finished, an MRI evaluation was conducted to assess treatment results, and the mass had decreased. Conclusions: This report showed a rare case of urothelial cell carcinoma recurrences. From bladder urothelial carcinoma to left UTUC and then to contralateral UTUC. It is important to evaluate the upper tract to reduce the risk of recurrence.

Keywords: Keywords: Upper Tract Urothelial Carcinoma; Urothelial cancer recurrence; intracavity chemotherapy; kidney sparing surgery; metachronous bilateral UTUC.

Figure 1.. Timeline of the case report.

Figure 2.

(a) Ultrasound in March 2020. An isoechoic lesion with irregular edges, on the left inferolateral bladder wall, and appears to be obstructing the left ureter with its distal part dilated. (b) Contrast computed tomography (CT) scan in December 2019 showing isodens mass that enhanced after contrast administration in the bladder. (c) The initial diagnosis was infiltrative high-grade urothelial carcinoma. The pictures show tumor cells with round/oval nuclei, pleomorphic, coarse chromatin, vesicular with nuclei, Hematoxylin and Eosin (H&E) stain 400×. (d) A follow-up biopsy showing urethra with minimal inflammatory infiltration. The picture showed that no tumor was found, chronic inflammatory, fibrinoid necrosis, H&E stain 100×.

Figure 3.

(a) Abdominal magnetic resonance imaging (MRI) with Gadobutrol 5 ml contrast, shown hyperintense lesions were seen on T1-T2WI and FS on the left intrapelviocalyceal and extracapsular perirenal, which were enhanced after the contrast was administered. (b) High-grade infiltrative urothelial carcinoma. (c) The picture shows papillary-arranged tumor mass, Hematoxylin and Eosin (H&E) stain 400×.

Figure 4.

(a) Nephroscopy examination in pelviocalyceal system inserted through the right flank reveals a tumor sized about 3 cm. (b) Ureter post evaporation using laser shows some tumor residue even after laser procedure. (c) Tissue fragments containing papillary, infiltrative epithelial malignant tumors with fibrovascular stalk Hematoxylin and Eosin stain (H&E) stain 40×.

Figure 5.

Abdominal magnetic resonance imaging (MRI) May 2021 shows benign calyx dilatation suspicious due to stricture, heterogeneous renal parenchyma.