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Journal of Cancer Research and Therapeutics, Vol. 7, No. 3, July-September, 2011, pp. 350-352 Letter to the Editor - Documenting a Case Synchronous primary gall bladder carcinoma and renal transitional cell carcinoma in the same patient: A rare case Gaurav Aggarwal, Bhakti Sarang, Nobhojit Roy, Satish Mishra, Anita Gadgil Department of Surgery, BARC Hospital, Mumbai, India Sir, The prevalence of carcinoma of the gall bladder varies from 1 to 2% of biliary tract surgeries, in different parts of the world. Carcinoma of the gall bladder is usually diagnosed at an advanced stage, thus found to be unresectable at the time. [1] Primary renal transitional cell carcinoma (TCC) is an equally rare disease. It accounts for less than 1% of genitourinary neoplasms and 5-7% of all urinary tract tumors. [2] The simultaneous occurrence of these two tumors, notorious for their late detection, is a rarity. We report such a case, wherein simultaneous co- existence of the above tumors was incidentally detected in a patient, and to the best of our knowledge, this is probably the index case. A 65-year-old lady presented to us with complaints of dull right hypochondriac pain, since 2 months. She was not a known case of any medical or surgical illness in the past. Per abdominal examination revealed tenderness in the right hypochondriac region, murphy′s sign being positive. However, a routine chest radiograph done on admission shockingly revealed cannon ball lung lesions [Figure - 1]. All her blood investigations were within normal limits. Ultrasound examination performed showed sludge in the gall bladder, mild fullness of the right pelvicalyceal system and coarse hepatic echotexture. Thereafter, as a part of metastatic workup, the patient was subjected to a triple-phase CT scan of the chest, abdomen and pelvis which revealed a mass lesion in the fundus of the gall bladder with contiguous involvement of segment 4b of liver [Figure - 2], highly suggestive of adenocarcinoma of the gall bladder, with extensive retroperitoneal adenopathy and bilateral pulmonary infiltrates. Incidentally, a mass lesion in the right renal pelvis and lower pole calyx of the right kidney was also visualized, with the reported possibility of being a TCC [Figure - 3]. The patient and her family were counselled regarding the nature of the disease and further line of management, as well as the prognosis, but the patient was unwilling for the same. Carcinoma of the gall bladder is an aggressive malignancy occurring predominantly in the elderly with a mean age of 65.2 years. [2] It constitutes nearly two-thirds of biliary tract malignancies, being the most common biliary tract tumor and is also the fifth most common gastrointestinal tumor. [2] It is common in women as also ethnic background and geographical locations are important predictors of the incidence. [2] Gall bladder cancers have a strong association with cholelithiasis. [3] The risk of developing gall bladder carcinoma is higher in patients with cholelithiasis, porcelain gall bladders, anomalous pancreatic duct-biliary duct junction and typhoid carriers. Other risk factors include adenomatous polyps, post-partial gastrectomy, obesity, exposure to azotoluene, estrogen, methyldopa, isoniazide or nitrosamine. Strong dietary association has also been reported. [3] Carcinoma of the gall bladder however, is usually diagnosed when advanced, thus unresectable at that time. [1] The laboratory findings may show anemia, leukocytosis, elevated bilirubin and alkaline phosphatase levels with occasionally elevated tumor markers like CEA and CA 19-9. Ultrasound is the first diagnostic modality with other modalities like CT scan, MRI, EUS and ERCP used to assess disease spread. [3] More than 85% of gall bladder cancers are adenocarcinomas the remaining 15% being adenosquamous, squamous or undifferentiated carcinomas. Sarcomas, neuroendocrine carcinomas or lymphomas make up to less than 1%. [3] Major route of spread is locoregional. One-fourth of patients have lymphatic involvement and 70% have direct extension of the disease into the liver. [3] Gall bladder carcinoma staging is done primarily during surgery and the staging is determined by the depth of invasion, extension into adjacent structures, lymph node involvement and presence of metastasis. [3] Relatively few patients with gall bladder cancers are diagnosed preoperatively. Surgical management depends upon local spread of the tumor. Radical surgery appears to improve survival. Patients with unresectable disease have poor prognosis. Some patients may benefit from nonsurgical palliative procedures such as biliary drainage and stenting. External radiation therapy may provide palliative benefit. Responses to chemotherapy are infrequent and of short duration. Survival rate in gall bladder cancers is directly related to the stage of the disease. The median survival of patients with metastatic gall bladder disease is around 6-12 months. [4] TCC arises from the lining surface epithelium of the ureters, renal pelvis and urinary bladder. [5] The etiology of TCC of the renal pelvis includes heavy cigarette smoking, chronic use of laxatives or NSAIDs, occupational exposure to organic chemicals. [6] Endemic nephropathies such as ′Balkan nephropathy′ and genetic factors like ′Lynch syndrome′ are also reported to increase the risk of upper urinary tract tumors. [7] Urinary symptoms like flank pain, dysuria, macroscopic and microscopic hematuria are the presenting features in most of the cases of TCC. [8] Physical examination is generally normal with the exception of a palpable flank mass in a few cases. [8] TCC of renal pelvis or ureter may spread by direct extension to adjacent structures or may be disseminated by hematogenous or lymphatic pathways. [9] Detection of primary tumor is by urinary cytology, intravenous pyelography and/or ureterorenoscopy. [9] Routine staging includes chest radiograph and thoracoabdominal CT combined with the assessment of hepatic, renal and hematological chemistry. Multifocal tumors may be present arising from the ureter, bladder or on the contralateral side. Radionuclide bone scan is recommended to exclude bony metastases in locally advanced disease. [9] The treatment of renal pelvis and ureteric tumors is open or endoscopic/laproscopic surgery, ranging from conservative to more extensive surgical procedures i.e., radical nephroureterectomies. [10] Adjuvant radiotherapy and chemotherapy is administered in a few cases with debatable benefits. [10] These two entities, by themselves are extremely rare. Moreover, their concomitant, unrelated occurrence and that too in the same individual, is even rarer, probably the index case, in this regard. Thus, clinicians must maintain a high index of vigil for appropriate as well as timely diagnosis and adequate management. Carcinomas of the gall bladder and renal TCC are both rare entities. Both these tumors occurring concomitantly in an individual is even rarer, yet possible. This is what should be borne in mind, for ′What the mind knows is what the eyes see′. References
Copyright 2011 - Journal of Cancer Research and Therapeutics The following images related to this document are available:Photo images[cr11087f3.jpg] [cr11087f2.jpg] [cr11087f1.jpg] |
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