Sarcomatoid Transitional Cell Carcinoma of the Renal Pelvis Case Report
Sarcomatoid Transitional Cell Carcinoma of the
Renal Pelvis: A Case Report
Yu-Li Lin, Qiang-Sheng Ke, Yuan-Ming Liaw, Hann-Chorng Kuo
Department of Urology, Buddhist Tzu Chi General Hospital, Hualien, Taiwan
Sarcomatoid transitional cell carcinoma (TCC) of the renal pelvis is a rare tumor with sarcoma-like components
arising from the malignant transitional epithelium. The prognosis, according to previous reports, is very poor. Due to its
rarity, there have been few studies concerning the treatment efficacy. We herein report a case of sarcomatoid TCC aris-
ing from the renal pelvis. A 67-year-old female was admitted with the chief complaint of bilateral flank pain. A right-
renal heterogeneous mass measuring about 5 x 7 x 10 cm was incidentally found on a clinical image. A right radical
nephrectomy was performed. Histologically, a TCC in situ and another sarcoma-like area with prominent spindle cells
were identified. Immunohistochemistry was positive for cytokeratin. Sarcomatoid TCC of the renal pelvis was confirmed.
In spite of no ample evidence of an effective treatment, we recommend a radical, aggressive operation for early localized
disease. For the tumor with advanced stage or metastasis, systemic chemotherapy with a gemcitabine-based regimen
may be considered for this uncommon renal pelvic tumor due to its urothelial origin in nature. (JTUA 19:48-51, 2008)
Key words: renal cancer, sarcomatoid, spindle cell carcinoma, carcinosarcoma.
CASE REPORT ing chest x-ray, an abdominal-to-pelvic computed to-
mographic (CT) scan, and whole-body bone scan were
This 67-year-old female patient with a past history performed. The CT scan showed a heterogeneous mass
of right ureteral stone 20 years ago presented to our clinic measuring about 5 × 7 × 10 cm occupying the right re-
with bilateral flank pain for several years. Moreover, nal pelvis and several enlarged para-aortic lymph nodes
intermittent gross hematuria was also noted. On physi- were also noted (Fig. 1). A chest x-ray and bone scan
cal examination, bilateral mild knocking tenderness was showed no evidence of lung or bone metastasis.
noted, but there was no palpable abdominal mass. Urine
analysis showed predominant occult blood and 6~8 red
blood cells (RBCs) per high-power field. Renal
sonography revealed bilateral stones and moderate bi-
lateral hydronephrosis. The kidney, ureter, and bladder
(KUB) X-ray study revealed multiple radiopaque stones
in the bilateral kidney. Under the impression of bilateral
renal stones, she was admitted to our ward.
On the day of admission, bilateral percutaneous
nephrostomy drainage was performed to relieve the
hydronephrosis. Antegrade pyelography showed bilat-
eral caliectasis and multiple renal stones. A ureteroscopic
examination incidentally found a right renal pelvic tu-
mor with stone encrustation. A biopsy was taken, and
spindle cell sarcoma was our initial diagnosis.
In the following days, a metastatic survey includ-
Address reprint requests and correspondence to: Fig. 1. Computed tomographic scan demonstrating a right
Hann-Chorng Kuo, MD. renal heterogeneous mass measuring about 5 x 7 x
Department of Urology, Buddhist Tzu Chi General Hospital, 707
Chung Yang Road, Section 3, Hualien, Taiwan 970, R.O.C. 10 cm (white arrows) with enlargement of several
Tel: 886-3-8561825 ext. 2117 Fax: 886-3-8560794 para-aortic lymph nodes. Bilateral hydronephrosis
E-mail: firstname.lastname@example.org and a right renal stone were also noted.
QU JTUA 2008 19 No. 1
Y. L. Lin, et al
One week after the initial operation, a radical ne-
phrectomy was performed. A large whitish, intracapsular
solid right renal tumor with invasion to the renal sinus
and calyceal system was noted during the operation.
Several lymphadenopathies over the aortovenous area
were also identified. Gross examination revealed a huge
solid mass measuring 8.0 × 7.0 × 5.0 cm occupying the
renal pelvis which was whitish, gelatinous, and focally
necrotic on cutting (Fig. 2). Microscopic examination
revealed 2 main components of the tumor: 1 component
with TCC in situ and another sarcoma-like area with
prominent spindle cells. Some multinucleated giant cells
were also seen. Immunohistochemistry was positive for
cytokeratin, indicating an epithelial origin (Fig. 3A-D).
Fig. 2. Gross appearance of the tumor showing a solid mass
In addition, there was involvement of 2 lymph nodes in
measuring 8.0 x 7.0 x 5.0 cm occupying the renal
4 para-aortic lymph nodes. Sarcomatoid TCC of the re- pelvis with whitish, gelatinous, and focal necrosis
nal pelvis with para-aortic lymph node involvement was on the cut surface.
Fig. 3. Sarcomatoid transitional cell carcinoma (TCC) of the renal pelvis. (A) TCC in situ, (B, C) the sarcomatoid component
with prominent spindle cells and some multinucleated tumor cells, and (D) a sarcomatoid area showing immunoreactivity
JTUA 2008 19 No. 1 QV
Sarcomatoid Transitional Cell Carcinoma of the Renal Pelvis
Fig. 4. Computed tomographic (CT) scan at 3 months after the operation showing (A) a recurrent bulky tumor with direct liver
invasion and involvement of multiple lymph nodes; (B) tumor expansion from the previous percutaneous nephrostomy
tract (white arrow).
the ultimate diagnosis (pT3N2M0). One course of adju- is a term frequently confused with sarcomatoid
vant chemotherapy with gemcitabine was given. carcinoma. It has a malignant epithelial component as
Unfortunately, the patient's condition gradually does a sarcomatoid carcinoma. In addition, it has spe-
deteriorated, and a follow-up CT scan 3 months after cific features of mesenchymal differentiation, such as
the radical operation showed recurrent bulky tumor with chondrosarcomas, osteosarcomas, rhabdomyosarcomas,
liver invasion and multiple lymph node involvement. and liposarcomas, which differ from a sarcomatoid
Direct tumor expansion from the previous percutaneous carcinoma. However, these 2 tumors have frequently
nephrostomy tract was also noted (Fig. 4A,B). presented diagnostic difficulties because their morpholo-
gies are similar in microscopic appearance with hema-
DISCUSSION toxylin and eosin staining. As a result, an immunohis-
tochemical study is usually necessary for a diagnosis.
Sarcomatoid carcinoma is a high-grade epithelial Immunoreactivity to cytokeratins and CD68 is specific
neoplasm characterized by a biphasic appearance with for cells of epithelial origin and diagnostic for a sarco-
1 part of an epithelial component and another area with matoid carcinoma. Carcinosarcomas do not stain for
a sarcoma-like appearance, which is largely composed epithelial markers.4,5
of non-specific spindle and/or pleomorphic tumor gi- Most renal pelvis malignancies consist of TCC.
ant-cells.1 The actual histogenesis of sarcomatoid carci- However, a sarcomatoid carcinoma of transitional cell
noma is still unclear. In 1 study, because they found that origin in the renal pelvis is very rare. In a clinicopatho-
the sarcomatous component exhibited diffuse and in- logic study of 108 cases of high-grade urothelial carci-
tense p53 oncoprotein expression, whereas the carcino- nomas of the renal pelvis, only 8 cases were shown to
matous component showed a weaker and focal positivity, be sarcomatoid carcinomas.6 Lopez-Beltran et al. re-
they assumed that this alteration of the p53 gene might ported 13 cases of sarcomatoid TCC of the renal pelvis
be related to the sarcomatous transformation of the since 1961.7 Metastatic disease or advanced tumor in-
tumor.2 In another study, it was thought that the sarco- volvement of the parenchyma was noted with the diag-
matoid component of sarcomatoid carcinomas may re- nosis in all 13 patients. The prognosis was very poor
sult from either anaplastic changes or de-differentiation with 8 patients dying within 2 years of diagnosis and a
related to the process of losing cell adhesion mole- mean survival time of 11.2 months. Moreover, adjuvant
cules.3 chemotherapy appeared to offer no response or survival
In addition to the kidney and bladder, sarcomatoid advantage.
carcinoma can also occur in the breast, larynx, pharynx, The Mayo Clinic reviewed 26 cases of sarcomatoid
oral cavity, esophagus, and genital tract. Carcinosarcoma carcinomas of transitional cell origin in the bladder dur-
RM JTUA 2008 19 No. 1
Y. L. Lin, et al
ing a 59-year period. Sarcomatoid carcinoma of the blad- chemotherapy with a gemcitabine-based regimen seems
der was more common in men than in women (with a 4: to be reasonable for this uncommon renal pelvic tumor
1 ratio), and the mean survival was 9.8 months. The due to its urothelial origin in nature.
pathologic stage was the main predictor of patient
survival. Chemotherapy offered little response and no REFERENCES
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