ORIGINAL ARTICLE
Metastatic Renal Cell Carcinoma to the Urinary Bladder A Report of 11 Cases Miao Zhang, MD, PhD,* Cheuk Wah, MBBS,w and Jonathan I. Epstein, MD*z
Abstract: Metastatic renal cell carcinoma (RCC) to the urinary bladder is rarely seen. Herein, we report the histologic subtypes, immunohistochemical characteristics, and prognosis of 11 patients with metastatic RCC to the urinary bladder. The mean age at the time of diagnosis of metastatic RCC to the bladder was 66 years (range, 58 to 79 y). There were 9 male and 2 female patients. Four patients presented with hematuria, 2 with urinary retention/obstruction, and 1 with bladder calculi. Four patients were asymptomatic and presented for surveillance cystoscopy, wherein they were found to have bladder masses. Nine patients had prior histories of RCC. The remaining 2 patients presented with metastatic clear cell RCC to the bladder and were subsequently found to have renal masses. The average time between nephrectomy and metastasis to the bladder was 20.7 months (range, 0 to 87 mo). Of the 10 patients with radical/partial nephrectomy, 7 cases were clear cell (2 with sarcomatoid features), 2 papillary, and 1 chromophobe with histologic fidelity between the primary and metastasis. Of cases with available data, the primaries’ ISUP nucleolar grades were 2 (n = 2), 3 (n = 4), and 4 for the 2 cases with sarcomatoid features. In 8 cases, the bladder RCC undermined overlying urothelium with extensive urothelial denudation, and in 3 cases the RCC was free floating without attachment to the urothelium. The 1 chromophobe RCC metastasized with pagetoid spread to a preexisting urothelial papilloma. PAX8 immunohistochemistry was used to confirm the diagnosis in 2 cases. Three patients have no evidence of disease (7, 9, and 13 mo). Two are alive with disease after chemotherapy (30, 37 mo). Six patients are dead of disease with multiorgan metastases; 4 are dead after therapy (5, 8, 25, 28 mo), and two died without radiation or chemotherapy at 10 and 71 months. Metastatic RCC to the urinary bladder is uncommon, with most cases clear cell RCC. In some cases, evidence supports “drop metastases” as the mechanism of spread and patients have relatively long survival. However, in other cases spread to the bladder is in the setting of metastases to other sites, and these
From *The Department of Pathology; zUrology and Oncology, The Johns Hopkins Hospital, Baltimore, MD; and wDepartment of Pathology, Queen Elizabeth Hospital, Hong Kong, PR China. Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Jonathan I. Epstein, MD, Department of Pathology, The Johns Hopkins Hospital, 401N. Broadway Street, Room 2242, Weinberg Building, Baltimore, MD 21231 (e-mail: jepstein@ jhmi.edu). Copyright r 2014 by Lippincott Williams & Wilkins
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patients tended to die relatively shortly after their bladder metastases. Key Words: renal cell carcinoma, metastasis, bladder tumor (Am J Surg Pathol 2014;38:1516–1521)
R
enal cell carcinoma (RCC) can virtually metastasize to any organ. It has been reported that approximately one third of patients with RCC have metastatic disease at the time of initial diagnosis, and 40% to 60% will develop distant metastases after the initial diagnosis.1–3 Metastatic RCC to the urinary bladder, however, is extremely rare, with
Metastatic Renal Cell Carcinoma to the Urinary Bladder A Report of 11 Cases Miao Zhang, MD, PhD,* Cheuk Wah, MBBS,w and Jonathan I. Epstein, MD*z
Abstract: Metastatic renal cell carcinoma (RCC) to the urinary bladder is rarely seen. Herein, we report the histologic subtypes, immunohistochemical characteristics, and prognosis of 11 patients with metastatic RCC to the urinary bladder. The mean age at the time of diagnosis of metastatic RCC to the bladder was 66 years (range, 58 to 79 y). There were 9 male and 2 female patients. Four patients presented with hematuria, 2 with urinary retention/obstruction, and 1 with bladder calculi. Four patients were asymptomatic and presented for surveillance cystoscopy, wherein they were found to have bladder masses. Nine patients had prior histories of RCC. The remaining 2 patients presented with metastatic clear cell RCC to the bladder and were subsequently found to have renal masses. The average time between nephrectomy and metastasis to the bladder was 20.7 months (range, 0 to 87 mo). Of the 10 patients with radical/partial nephrectomy, 7 cases were clear cell (2 with sarcomatoid features), 2 papillary, and 1 chromophobe with histologic fidelity between the primary and metastasis. Of cases with available data, the primaries’ ISUP nucleolar grades were 2 (n = 2), 3 (n = 4), and 4 for the 2 cases with sarcomatoid features. In 8 cases, the bladder RCC undermined overlying urothelium with extensive urothelial denudation, and in 3 cases the RCC was free floating without attachment to the urothelium. The 1 chromophobe RCC metastasized with pagetoid spread to a preexisting urothelial papilloma. PAX8 immunohistochemistry was used to confirm the diagnosis in 2 cases. Three patients have no evidence of disease (7, 9, and 13 mo). Two are alive with disease after chemotherapy (30, 37 mo). Six patients are dead of disease with multiorgan metastases; 4 are dead after therapy (5, 8, 25, 28 mo), and two died without radiation or chemotherapy at 10 and 71 months. Metastatic RCC to the urinary bladder is uncommon, with most cases clear cell RCC. In some cases, evidence supports “drop metastases” as the mechanism of spread and patients have relatively long survival. However, in other cases spread to the bladder is in the setting of metastases to other sites, and these
From *The Department of Pathology; zUrology and Oncology, The Johns Hopkins Hospital, Baltimore, MD; and wDepartment of Pathology, Queen Elizabeth Hospital, Hong Kong, PR China. Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article. Correspondence: Jonathan I. Epstein, MD, Department of Pathology, The Johns Hopkins Hospital, 401N. Broadway Street, Room 2242, Weinberg Building, Baltimore, MD 21231 (e-mail: jepstein@ jhmi.edu). Copyright r 2014 by Lippincott Williams & Wilkins
1516 | www.ajsp.com
patients tended to die relatively shortly after their bladder metastases. Key Words: renal cell carcinoma, metastasis, bladder tumor (Am J Surg Pathol 2014;38:1516–1521)
R
enal cell carcinoma (RCC) can virtually metastasize to any organ. It has been reported that approximately one third of patients with RCC have metastatic disease at the time of initial diagnosis, and 40% to 60% will develop distant metastases after the initial diagnosis.1–3 Metastatic RCC to the urinary bladder, however, is extremely rare, with
