Transitional cell carcinoma of the renal pelvis in a long-term hemodialysis patient with autosomal dominant polycystic kidney

Case report of renal pelvis squamous cell carcinoma with tumor embolus in autosomal dominant polycystic kidney disease

INTRODUCTION

Autosomal dominant polycystic kidney disease (ADPKD) is a multisystem hereditary disease characterized by formation of cysts in the ductal organs. Renal pelvis malignancy in ADPKD is very rare and sporadically reported in the previous literature. Here, we report the first case of renal pelvis squamous cell carcinoma with tumor embolus in a 35-year-old ADPKD patient. The patient presented with 3 months of persistent backache and intermittent fever, and was initially diagnosed as intracystic hemorrhage with inferior vena cava thrombosis formation. As a result, he received anticoagulation therapy in a local hospital. However, his backache got worsened during the therapy, and he lost 10 kg of his body weight from the onset of illness. In our hospital, computed tomography demonstrated a heterogeneous right renal mass as well as emboli in the inferior vena cava and bilateral renal veins. Positron emission tomography computed tomography and biopsy were also performed, but the results were equivocal. Considering the patient's willingness and the potential malignancy, we performed thoracoabdominal nephrectomy and embolectomy, and histological examination made the diagnosis of renal pelvis squamous cell carcinoma. After adjuvant chemotherapy including paclitaxel and carboplatin, the patient obtained improved physical status and was disease free at the 6-month follow-up. Although rare, renal pelvis squamous cell carcinoma should be considered in the differential diagnosis of renal mass in ADPKD patients.

CONCLUSION

Our case suggested surgery combined with adjuvant chemotherapy might be effective treatments in such a condition.

Autosomal dominant polycystic kidney disease: prevalence of renal neoplasias in surgical kidney specimens

BACKGROUND

The role of autosomal dominant polycystic kidney disease (ADPKD) as a risk factor for renal cell carcinoma (RCC) is still under discussion. Data on prevalence of RCC in ADPKD are limited, especially on a large population scale. The aim of this study was to analyze the prevalence of RCC in ADPKD kidneys and characterize the clinical features of this coincidence.

METHODS

Based on our histopathological registry for ADPKD and the Else Kröner-Fresenius Registry, we retrospectively reviewed malignant and benign renal lesions in patients with ADPKD who had undergone renal surgery from 1988 to 2011.

RESULTS

240 ADPKD patients underwent 301 renal surgeries. Mean age at surgery was 54 years. Overall, 16 malignant and 11 benign lesions were analyzed in 301 kidneys (5.3%; 3.7%), meaning that 12/240 (5%; 1:20) patients presented with malignant renal lesions. 66.7% (8/12) of these patients had undergone dialysis prior to surgery. We found 10/16 (63%) papillary RCC, 5/16 (31%) clear cell RCC, and 1/16 (6%) papillary noninvasive urothelial cancer. Regarding all renal lesions, 6/17 (35.3%) patients had more than one histological finding in their kidneys. In 2 cases, metachronous metastases were removed. Mean follow-up was 66.7 months.

CONCLUSION

Kidney-related prevalence of RCC in ADPKD kidneys was surprisingly high. Whether or not this is due to chronic dialysis or due to the underlying disease is still speculative. Like other cystic renal diseases with an increased risk for RCC, the attending physician should be aware of the malignant potential of ADPKD, especially with concomitant dialysis.

Activation of the PI3K/AKT pathway induces urothelial carcinoma of the renal pelvis: identification in human tumors and confirmation in animal models

Urothelial carcinoma of the renal pelvis is a deadly disease with an unclear tumorigenic mechanism. We conducted gene expression profiling on a set of human tumors of this type and identified a phosphatidylinositol 3-kinase (PI3K)/AKT activation expression signature in 76.9% (n = 13) of our samples. Sequence analysis found both activating mutations of PIK3CA (13.6%, n = 22) and loss of heterozygosity at the PTEN locus (25%, n = 8). In contrast, none of the other subtypes of kidney neoplasms (e.g., clear-cell renal cell carcinoma) harbored PIK3CA mutations (n = 87; P < 0.001). Immunohistochemical analysis of urothelial carcinoma samples found loss of PTEN protein expression (36.4%, n = 11) and elevation of phosphorylated mammalian target of rapamycin (mTOR; 63.6%, n = 11). To confirm the role of the PI3K/AKT pathway in urothelial carcinoma, we generated mice containing biallelic inactivation of Pten in the urogenital epithelia. These mice developed typical renal pelvic urothelial carcinomas, with an incidence of 57.1% in mice older than 1 year. Laser capture microdissection followed by PCR confirmed the deletion of Pten exons 4 and 5 in the animal tumor cells. Immunohistochemical analyses showed increased phospho-mTOR and phospho-S6K levels in the animal tumors. Renal lymph node metastases were found in 15.8% of the animals with urothelial carcinoma. In conclusion, we identified and confirmed an important role for the PI3K/AKT pathway in the development of urothelial carcinoma and suggested that inhibitors of this pathway (e.g., mTOR inhibitor) may serve as effective therapeutic agents.

[Urothelial carcinoma in a woman with autosomal dominant polycystic kidney disease: description of a case and review of the literature]

We describe a case of urothelial carcinoma of renal pelvis in a 48 years old woman affected of autosomal dominant polycystic kidney disease (ADPKD). We discuss the difficulty of the radiological diagnostic and we revise the incidence of renal tumors in this entity. Association between urothelial carcinoma and ADPKD is highly infrequent and without apparently causal relation.

Urothelial differentiation in chronically urine-deprived bladders of patients with end-stage renal disease

BACKGROUND

It is unknown whether normal bladder voiding function, or soluble factors present in urine, contribute to the maturation and maintenance of the differentiated state of the uroepithelial cell lining of the lower urinary tract.

METHODS

We used the urothelium of anuric patients on long-term hemodialysis, sampled at the time of renal transplantation, to investigate the expression of urothelial differentiation-associated antigens, including uroplakins (UPIa, UPIb, UPII, and UPIIIa), cytokeratin isotypes (CK7, CK8, CK13, CK14, CK17, CK18, and CK20), nuclear hormone receptors [peroxisome proliferators activated receptor-gamma (PPAR-gamma) and retinoid X receptor-alpha (RXR-alpha)], and a cell cycle marker (Ki-67). To determine whether urinary metabolites of the arachidonic pathway could induce urothelial differentiation, cultured normal human urothelial (NHU) cells were treated with 15-deoxy-delta12, 14-prostaglandin J2 (15d-PGJ2) and prostaglandin J2 (PGJ2). The expression levels of the markers of differentiation, the uroplakins, were assessed by ribonuclease protection assay. Results. When compared in a blinded analysis against control normal urothelium, no significant changes were found in the expression or localization patterns of any of the antigens studied in the anuric patients. Furthermore, neither 15d-PGJ2 nor PGJ2 were able to induce expression of the UPII gene in NHU cells, in contrast to cultures exposed to the pharmacologic PPAR-gamma agonist, troglitazone. Conclusion. These data provide prima facie evidence that exogenous urine-derived factors do not modulate the differentiation program in urothelium, suggesting that other urothelial- or serum-derived factors are likely to be involved. These findings are important in understanding post-developmental maturation and functional relationships in urologic tissues of the adult organism.

Transitional cell carcinoma of the renal pelvis associated with hypercalcemia in a patient with autosomal dominant polycystic kidney disease

We present a case of transitional cell carcinoma (TCC) of the renal pelvis in a patient with autosomal dominant polycystic kidney disease (ADPKD) who presented with hypercalcemia. Hypercalcemia is rare in TCC and has not been independently associated with ADPKD. Preoperative magnetic resonance imaging findings suggested a diagnosis of TCC. The patient underwent left nephroureterectomy, which confirmed the diagnosis, and received adjuvant chemotherapy. The hypercalcemia had not recurred, and she was without evidence of disease recurrence at 36 months. This case is unique in that we did not find any previously reported cases of TCC associated with ADPKD and hypercalcemia.

Primary carcinoid tumor in a polycystic kidney

A case of a primary carcinoid tumor within a polycystic kidney is reported. A 51-year-old woman with autosomal dominant polycystic kidney disease (ADPKD) underwent a bilateral nephrectomy because of an infection in her polycystic kidneys. A tumor (1.5 cm in diameter) was incidentally found close to the hilum of the left kidney. Histologically, the tumor exhibited a predominantly trabecular pattern of cuboidal or columnar cells. Grimelius staining showed numerous silver-stained neurosecretory granules in most of the tumor cells; the tumor cells were also positive for chromogranin, synaptophysin, prostatic acid phosphatase (PAP) and neuron-specific enolase (NSE). The tumor was diagnosed as a primary carcinoid tumor of the kidney. Primary renal carcinoid is a very rare neoplasm, and this is the first report of such a lesion arising in a polycystic kidney.