Akademik Veri Yönetim Sistemi
Cumhuriyetimizin 100. yılı Üroloji Toplantısı, Ankara, Türkiye, 26 - 29 Ekim 2023, ss.44-48, (Tam Metin Bildiri)
INTRODUCTION
Urothelial carcinomas are tumors that can be seen in the renal pelvis, ureter, bladder and
urethra in the urinary system. Upper urinary tract tumors constitute approximately %5-10%
of all urothelial carcinomas [1]. When the upper urinary system is evaluated; pelvicalyceal
tumors are twice as common as ureteral tumors, and the rate of being multifocal in upper
urinary tract tumors is %10-20 [2]. In this article, a case of upper urinary tract tumor at a locally
advanced stage due to difficulty in diagnosis will be described.
CASE PRESENTATION
A 72-year-old male patient was admitted to the hospital with left lumbar pain after a fall. In
the patient's medical history; there was a diagnosis of hypertension, previous left open
pyelolithotomy (1975) and left percutaneous nephrolithotomy operations (2002) history. He
had 30 package-year smoking history. On physical examination, there was a palpable lesion in
the left lumbar region at the level of the 11th costa. In ultrasonography, there was a 4 cm
hypoechoic lesion. Tru-cut biopsy pathology was evaluated as urothelial carcinoma
(Cytokeratin 7: (+) Cytokeratin 20: (+) TFT1: (-) GATA-3: (+)).
In the FDG-PET imaging (Figure 1) of the patient, a mass lesion showing FDG uptake at the
level of malignancy in the left 10-11th intercostal space, multiple calculus images in the lower
pole of the left kidney, and focal hypermetabolism (Urine accumulation? Malignancy?) in the
cortical area in the posterior part of the calculus were detected. DMSA scintigraphy revealed
%35 separation function for the left kidney and an uptake defect (Scar?) in the lower pole of
the left kidney.
We performed left flexible ureterorenoscopy (F-URS) on the patient. No tumor formation was
detected in the ureter and pelvicalyceal system. In the lower pole, completely obstructed calyx
with calculus was observed. Thereupon, the patient underwent total excision of the mass,
including the 11th and 12th costa. Result of the pathology was urothelial carcinoma with
squamous differentiation (surgical margin negative) (GATA-3: (+), Cytokeratin 7: (+), P40: (+))
was detected.
Thereupon, the patient received 4 cycles of gemcitabine + cisplatin neoadjuvant
chemotherapy. In the current FDG-PET (Figure 2); a hypermetabolic lesion in the lower pole
of the left kidney, where urinary accumulation/urothelial carcinoma could not be excluded,
was detected in a partially regressed appearance compared to the previous study. In the
abdominal MRI+MR-urography (Figures 3-1 and 3-2) and CT-urography (Figure 4), grade 3-4
dilatation in the left kidney, 10 mm in diameter calculus image in lower pole calyces and a
lesion of 11x11 mm was detected in the lower pole, where FDG uptake was detected. As a
result of urine cytology, atypical urothelial cells were detected (Paris system).
The patient underwent laparoscopic left nephroureterectomy. The pathology result was
reported as high-grade, anaplastic, pT3 urothelial carcinoma (Tumor large diameter: 2 cm,
pelvis invasion (+), renal sinus invasion (+), surgical margins (-), ureteral tumor negative). In
the pathology examination, it was seen that the stone in the lower pole of the left kidney was
covering the tumor. (Figure 5) Probably the tumor behind the stone could not be seen in the
previous F-URS operation.