Abstract
Transitional cell carcinoma of the renal pelvis is initially a slow growing tumor arising from the transitional epithelium of the mucous membrane of the renal pelvis. Recurrences occur in two forms: superficial bladder cancer and distant metastases. The common metastasis is in the lung, liver, brain and bone. Oral metastasis is seldom reported. The authors report an unusual case of transitional cell carcinoma of the renal pelvis metastasized to the oral cavity and lung simultaneously in a 74-year-old man, which occurred 1 year after a left nephroureterectomy. The patient underwent six courses of chemotherapy (gemcitabine, oxaliplatin, fluorouracil and nedaplatin), and received radiotherapy for the oral lesion. The symptoms were alleviated, but the tumor recurred in the oral cavity 2 years later. Brain and liver metastases were confirmed by CT. Repeated radiotherapy for oral metastasis was performed, but the patient died 4 years after the initial nephroureterectomy due to multiple metastases.
Transitional cell carcinoma (TCC) of the renal pelvis is initially a slow growing tumor arising from the transitional epithelium of the mucous membrane of the renal pelvis. It is relatively uncommon, accounting for 5% of all urothelial tumors and 10% of all renal cancers . The male–female ratio is 3:1 and, although persons of any age may be affected, it is most common between the fifth and the seventh decades. The standard treatment for localized renal pelvic cancer is nephroureterectomy. Recurrences occur in two forms: superficial bladder cancer and distant metastases. The common metastasis is in the lung, liver, brain and bone. Metastases to the oral region are seldom reported.
Metastatic tumors to the oral and maxillofacial region from distant sites are rare, accounting for approximately 1% of all oral malignant tumors. The kidney is one of the most frequent sites of primary neoplasm in cases of metastases to the jaws, and 91 cases related to metastatic renal cancer in the oral region have been reported in the literature . Among them, the most common neoplasm is renal cell carcinoma, while oral metastasis of TCC has been reported in only 3 cases . The authors present an unusual case of TCC of the renal pelvis metastasized to the oral cavity. There were also metastases to the lung, liver and brain.
Case report
A 74-year-old man was referred in October 2006 complaining of a painless ulcer in the left retromolar region and limitation of mouth opening. Oral examination revealed one mucous ulcerated lesion overlying the left retromolar region. It measured 1.0 cm × 2.0 cm and was red, non-tender, callous and fixed. The maximum incisal opening was 10 mm. The superficial cervical lymph nodes were not palpable. The patient had been treated in another hospital 1 year previously for TCC of the left renal pelvis by nephroureterectomy. No other therapy, such as chemotherapy and radiotherapy, had been given before and/or after nephroureterectomy. Histologic examination of the excised specimen showed that the typical neoplastic cells were arranged mainly in nests or in a papillary manner. They looked like the transitional cells with a round or polygonal shape and abundant cytoplasm and deeply stained nuclei. Heterotypic and mitotic nuclei were common. Subsequent immunohistochemical study confirmed that the oral lesion was positively correlated with the primary TCC of the renal pelvis ( Fig. 1 ). A subsequent CT revealed that the lung was covered with white spots, thought to be typical metastases. The diagnosis of oral and pulmonary metastases of TCC of the renal pelvis was established. The patient was referred for six courses of chemotherapy (Gemcitabine, Oxaliplatin, fluorouracil and Nedaplatin), and linear accelerator radiation was applied to the lesion in the oral region.
The oral lesion was obviously reduced 2 months after radiation, but the movement of mandible was still limited. 2 years later, the oral lesion in the retromolar region recurred and slowly enlarged. A skin ulcerated nodule was also noted in the left cheek. Magnetic resonance imaging (MRI) revealed that the left mandible, maxilla and adjacent soft tissues were all involved ( Fig. 2 ). Brain and liver metastases were confirmed by CT. The patient underwent intracavitary irradiation of I 131 for oral lesions. The patient’s condition worsened, he developed a pleural and peritoneal effusion and died 4 years after the initial nephroureterectomy.
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