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CASE REPORT
Year : 2018  |  Volume : 34  |  Issue : 1  |  Page : 79-81
 

Papillary renal cell carcinoma with abscess formation: A report of three cases


1 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Submission14-Aug-2017
Date of Acceptance31-Oct-2017
Date of Web Publication29-Dec-2017

Correspondence Address:
Ravimohan S Mavuduru
Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/iju.IJU_234_17

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   Abstract 

We report three cases of renal cell carcinoma (RCC) associated with abscess formation. Such association has been reported uncommonly in literature. Our cases were unique in that final histopathological report was papillary RCC in all of the patients.



How to cite this article:
Bora GS, Panwar P, Mavuduru RS, Kakkar N. Papillary renal cell carcinoma with abscess formation: A report of three cases. Indian J Urol 2018;34:79-81

How to cite this URL:
Bora GS, Panwar P, Mavuduru RS, Kakkar N. Papillary renal cell carcinoma with abscess formation: A report of three cases. Indian J Urol [serial online] 2018 [cited 2019 Sep 21];34:79-81. Available from: http://www.indianjurol.com/text.asp?2018/34/1/79/221967



   Introduction Top


Renal cell carcinoma (RCC) can have varied presentations. Most RCCs are diagnosed incidentally.[1] In some cases, renal masses and inflammatory lesions may appear similar.[2],[3] Large RCCs tend to have necrosis at center and this provides a good ground for bacterial proliferation.[4] This necrosis compounded with bacterial infection can lead to abscess formation.[5] There are only isolated case reports of RCC presenting as renal abscess, and majority have been reported with upper tract urothelial cancers or clear cell RCC.[6],[7],[8],[9],[10] We report three cases of papillary RCC associated with abscess formation.


   Case Reports Top


Case 1

A 75-year-old gentleman with no comorbidities presented with complaints of the right flank pain, fever, and melena for the past 3 months. He has a normal blood workup (hemoglobin [Hb]: 13.8 gm/dl, total leukocyte count [TLC]: 8300/mm 3, and urea/creatinine: 37/0.94) with raised serum carcinoembryonic antigen (106 ng/ml); contrast-enhanced computed tomography (CECT) whole abdomen showed 4.4 cm × 4.8 cm exophytic, isoechoic, well-defined mass interpolar region of the left kidney and an asymmetrical circumferential mural thickening of the cecum and ascending colon [Figure 1]a and [Figure 1]b. Colonoscopy and biopsy showed poorly differentiated carcinoma right colon. Guided fine-needle aspiration cytology from renal mass was done to rule out possibility of metastases from the colon and revealed only necrotic material. The patient underwent en bloc resection of colonic mass with left adrenal sparing radical nephrectomy. The specimen showed extensive suppuration in a renal mass [Figure 1]c. Histopathological examination (HPE) was suggestive of mucinous adenocarcinoma of the colon and papillary carcinoma nuclear grade 1 of the left kidney [Figure 1]d.
Figure 1: Case 1. (a) Computed tomographic image showing a well-marginated, heterogeneous exophytic mass (4.86 cm × 5.49 cm) in the upper pole with foci of calcification. (b) Computed tomographic image showing markedly thickened wall of the cecum, ascending colon, and terminal ileum, forming mass of 9.9 cm × 7.83 cm. (c) Cut specimen showing extensive pus formation. (d) Photomicrograph showing the papillary renal cell carcinoma Grade 1

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Case 2

A 61-year-old gentleman, hypertensive on irregular treatment, presented with complaints of early satiety and right flank pain with fever for the past 10 days. Examination revealed tenderness in the right hypochondrium and the right costal angle. His blood work was normal (Hb: 12.2 gm/dl, TLC: 8300/mm 3, urea/creatinine: 34/1.1). CECT abdomen showed 8 cm × 9 cm well-defined mass arising from the lower pole of the right kidney with few anechoic areas and multiple echogenic foci [Figure 2]a and [Figure 2]b. The patient underwent laparoscopic right radical nephrectomy which required conversion to open surgery in view of dense adhesions between colon and parietal wall, right kidney, and diaphragm. On section, there was extensive suppuration inside the kidney [Figure 2]c. Final HPE showed it to be papillary carcinoma [Figure 2]d.
Figure 2: Case 2. (a) Computed tomographic image heterogeneous right Renal mass 13.2 cm × 8.5 cm, replacing entire right kidney, with mural calcifications. (b) Magnetic resonance imaging showing a 10 cm × 9 cm well-defined lobulated lesion with areas of necrosis which is hypo- or iso-intense on T2. (c) cut specimen showing extensive pus formation. (d) Photomicrograph showing papillary carcinoma with calcifications and osseous metaplasia

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Case 3

A 60-year-old woman presented with complaints of fever and hematuria for 2-month duration. Her physical examination and blood investigations were normal. CECT whole abdomen showed a 5 cm × 6 cm endophytic Bosniak Type 4 cyst at the upper pole of the right kidney with possible pelvicalyceal system involvement [Figure 3]a and [Figure 3]b. The patient underwent right radical nephrectomy. The specimen after surgery revealed a cystic mass full of purulent material [Figure 3]c which grew Escherichia col on culture. Postoperative recovery was uneventful. Her final HPE report was suggestive of papillary RCC, Fuhrman grade 2 capsular, and perinephric fat invasion [Figure 3]d.
Figure 3: Case 3. (a and b) Computed tomographic image showing Bosniak Type 4 cyst at the upper pole of the right kidney in axial section and coronal section. (c) Postright radical nephrectomy specimen showing cystic mass with purulent material inside. (d) Low-power photomicrograph (×10) showing the papillary architecture of tumor with fibrovascular core

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   Discussion Top


RCC with abscess is not a common presentation. In some patients, there may be frank clinical features mimicking a renal abscess in an underlying tumor, leading to misdiagnosis and delay in treatment.[6] We present three cases where the specimen showed extensive suppuration and all of them turned out to be papillary RCC. Thus, finding of pus should not be diagnosed as an infective pathology since it can have associated malignancy. Among the histological variants of RCC, necrosis is more commonly seen in the papillary variant.[11] Large size renal tumors can lead to necrosis at center, and this would be especially true for papillary cancers, which are known to be hypovascular with prominent central necrosis.[4],[12] This necrosis provides ground for the hematogenous bacteria to settle inside the tumor leading to abscess formation.[4],[5]

As imaging is the primary modality of diagnosing renal masses, imaging features in such cases may reveal confusing picture and it may be difficult to make diagnosis of RCC.[6],[11] Some fungal infections or chronic bacterial infections of kidney can have heterogeneous appearance with infiltrative mass-like picture on CT.[2] Thus, guided fine-needle aspiration or biopsy may be undertaken in such cases. However this may be misleading if it reveals only pus or necrotic material as in our index Case 1. We extensively reviewed the literature searching for such presentations. Only an isolated case report of papillary RCC with abscess formation was found in available literature.[13] We believe that knowledge of such an association will lead to careful screening of the gross specimen both by urologists and the pathologist to detect an underlying malignancy in cases with extensive suppuration in a renal lesion.


   Conclusion Top


Our current report suggests that RCC can coexist with abscesses. Therefore, aspirate/biopsy from renal mass that shows pus should not preclude coexisting cancer Extensive suppuration in a renal mass suggests an underlying papillary variety of RCC.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

 
   References Top

1.
Pantuck AJ, Zisman A, Belldegrun AS. The changing natural history of renal cell carcinoma. J Urol 2001;166:1611-23.  Back to cited text no. 1
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2.
Song Z, Papanicolaou N, Dean S, Bing Z. Localized candidiasis in kidney presented as a mass mimicking renal cell carcinoma. Case Rep Infect Dis 2012;2012:953590.  Back to cited text no. 2
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3.
Eltahawy E, Kamel M, Ezzet M. Management of renal cell carcinoma presenting as inflammatory renal mass. Urol Ann 2015;7:330-3.  Back to cited text no. 3
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4.
Vaupel P. Hypoxia in neoplastic tissue. Microvasc Res 1977;13:399-408.  Back to cited text no. 4
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Graham BS, Johnson AC, Sawyers JL. Clostridial infection of renal cell carcinoma. J Urol 1986;135:354-5.  Back to cited text no. 5
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Mete UK, Mandal AK, Kakkar N, Singh SK, Sharma SK. Co-existence of necrotic renal cell carcinoma and renal abscess: A diagnostic dilemma. Bull PGI 1997;31:99-101.  Back to cited text no. 6
    
7.
Gillitzer R, Melchior SW, Hampel C, Pfitzenmaier J, Thüroff JW. Transitional cell carcinoma of the renal pelvis presenting as a renal abscess. Urology 2002;60:165.  Back to cited text no. 7
    
8.
Van Poppel H, Vereecken RL, Wilms G. Bilateral renal cell carcinoma diagnosed as renal abscesses. Urology 1985;25:548-50.  Back to cited text no. 8
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Chintapalli K, Lawson TL, Foley WD, Berland LL. Perinephric abscess with renal cell carcinoma. Urol Radiol 1981;3:113-5.  Back to cited text no. 9
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Patel C, Goyal P, Gupta S, Bhageria A. Clear cell type of renal cell carcinoma presenting with emphysematous pyelonephritis in young non diabetic patient: A case report. Curr Med Res Pract 2017;7:67-9.  Back to cited text no. 10
    
11.
Sengupta S, Lohse CM, Leibovich BC, Frank I, Thompson RH, Webster WS, et al. Histologic coagulative tumor necrosis as a prognostic indicator of renal cell carcinoma aggressiveness. Cancer 2005;104:511-20.  Back to cited text no. 11
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12.
Pichler M, Hutterer GC, Chromecki TF, Jesche J, Kampel-Kettner K, Rehak P, et al. Histologic tumor necrosis is an independent prognostic indicator for clear cell and papillary renal cell carcinoma. Am J Clin Pathol 2012;137:283-9.  Back to cited text no. 12
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13.
Olson ES, Asmussen T, Vicca AF, Osborn DE. A case report of renal abscess caused by Salmonella Virchow phage type 1 associated with a papillary renal cell carcinoma. J Infect 1999;38:56-7.  Back to cited text no. 13
[PUBMED]    


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