The simultaneous presence of primary carcinomas in the same patient is uncommon and synchronous primary tumors involving the kidney and pancreas are extremely rare. There are a few reports in the English literature of synchronous primary malignancies of the kidney and pancreas. We present a 62-year-old man who had weight loss of 9 kg and epigastric pain. Findings showed a Furhman grade II renal papillary carcinoma confined to the kidney and a synchronous well differentiated pancreatic ductal adenocarcinoma.Key Words: Synchronous double cancer, renal cell carcinoma, pancreatic carcinom

Abbar, M

Albouzidi, A

Ameur, A

Bekkali, S

Chafiki, J

Dekkak, Y

Eloundou, J

Ghadouane, M

Hajji, F

Ismail, TO

Janane, A

Jira, H

Lahrech, Y

Qamous, O

Qarro, A

Sossa, J

English

AJOL - African Journals Online

African Journal of Urology1110-5704Vol. 16, No. 4, 2010128        128-131Case Report Synchronous Primary Tumors of the Kidney and Pancreas: Case ReportT . O. Ismail1, A. Janane1,F. Hajji1, Y. Dekkak1, S. Bekkali1, J.Sossa1, J.Chafiki1, J.Eloundou1, Y. Lahrech1,  O. Qamous2, A. Qarro1, H. Jira1, M. Ghadouane1, A. Ameur1, A. Albouzidi2 and M. Abbar1Departments of 1Urology and 2Pathology, Military Hospital for Instruction MEDV, Rabat, MoroccoABSTRACTThe simultaneous presence of primary carcinomas in the same patient is uncommon and synchronous primary tumors involving the kidney and pancreas are extremely rare. There are a few reports in the English literature of synchronous primary malignancies of the kidney and pancreas. We present a 62-year-old man who had weight loss of 9 kg and epigastric pain. Findings showed a Furhman grade II renal papillary carcinoma confined to the kidney and a synchronous well differentiated pancreatic ductal adenocarcinoma. Key Words: Synchronous double cancer, renal cell carcinoma, pancreatic carcinoma                                            Corresponding Author: Dr. Taher Ould Ismail, Department of Urology, Military Hospital for Instruction MEDV, Rabat, Morocco, Email: rghib96@eyahoo.frArticle Info : Date received: 5/8/2010                           Date accepted (after revision): 17/8/2010INTRODUCTION                                                    Renal cell carcinoma accounts for approximately 3% of adult malignancies1. Reports of synchronous or metachronous cancers of the kidney and pancreas are very rare and poorly documented2. We observed an unusual case of a 62-year-old man showing the contemporaneous presence of papillary carcinoma of the kidney and pancreatic ductal adenocarcinoma.CASE REPORT                                      A 62-year-old non-smoking male presented with a 4-month history of epigastric pain and episodes of nausea and vomiting associated with weight loss of 9 kg. He had no hematuria or other urinary symptoms. He had no family history of renal or pancreatic diseases or familial genetic syndromes. On physical examination, no palpable mass or tenderness was revealed. Laboratory investigations showed a normal carcinoembryonic antigen (CEA) level and increased serum  carbohydrate antigen (CA) 19-9 level (166 IU/ml). Abdominal ultrasound (US) revealed a solid mass (4 cm in diameter) in the body of the pancreas. Abdominal computed tomography (CT) confirmed the presence of a 57 mm diameter heterogeneous and irregular mass in the body and tail of the pancreas, encasing the celiac trunk. Celiac lymph nodes and dilatation of Wirsung’s duct were present. CT also revealed the presence of a demarcated, heterogeneously enhancing right renal mass 52 x 40 x 54 mm in size (Fig. 1 and 2).The patient underwent right radical nephrectomy and pancreatic biopsy (the reason for this management was the encasement of the celiac trunk). The operation was uneventful, with no postoperative complications. Histopathologic examination showed a Furhman grade II renal papillary carcinoma confined to the kidney, stage pT1b in the 2004 TNM classification (Fig. 3).The pancreatic biopsy showed a well differentiated pancreatic ductal adenocarcinoma (Fig. 4).129SYNCHRONOUS PRIMARY TUMORS OF THE KIDNEY AND PANCREASDISCUSSION                                                             Multiple  primary  malignancies  in the same patient represent 1.8% to 3.9% of all cancers, but synchronous multiple primary tumors are extremely rare3, 4. Most synchronous primary tumors involve the genitourinary and the gastrointestinal tract, followed by both breast and genitourinary tract or breast and gastrointestinal tract3,5. Second malignancies associated with renal cancer include bladder tumors, non-Hodgkin’s lymphoma, multiple myeloma, chronic lymphocytic leukaemia, melanoma and cancer of the prostate, breast, rectum and lung with an incidence that varies from 5% to 27%2. A Japanese autopsy study of pancreatic cancer found associated malignancies in 134 of 2394 (5.6%) autopsies, including 7 with renal cell cancer (0.29%)6. Fig. 1: Abdominal computed tomography (CT) showingheterogeneous enhancing right renal mass.Fig. 2: Abdominal CT:  presence of a heterogeneous and irregular mass lesion in the pancreatic body and tail.Fig. 3: Microscopy of renal tumour showing tubulo-papillary proliferation of the renal glands (H&E x 100).Fig. 4: Microscopy of pancreatic biopsy showing tumoral proliferation of the glands and fibrous desmoplasia of the stroma (H&E x 40).Fig. 5: Immunohistochemical analysis showing positivity of pancreatic tumoral glands to anti-cytokeratin (AE1, AE2).Immunohistochemistry showed positivity of the pancreatic tumoral glands to anti-cytokeratin (AE1, AE2) (Fig. 5). The patient was referred to the oncology department for chemotherapy containing gemcitabine.130SYNCHRONOUS PRIMARY TUMORS OF THE KIDNEY AND PANCREASAnalysis of the Connecticut tumour re-gistry for the period 1935-1982 revealed that 19% of 4176 patients with renal cell cancer developed a second primary mali-gnancy (relative risk= 1.2; p<0.05)7. There were also 6 cases (0.14%) of pancreatic cancer but there was no significant asso-ciation (relative risk=1.0)7. In a series from Memorial Sloan Kettering Cancer Center, New York comprising 763 patients who un-derwent surgery for renal cell cancer during 1988-1999, there was a significantly increased incidence of prostate, colorectal and bladder cancers and non-Hodgkin’s lymphoma, but not pancreatic ductal adenocarcinoma8. Toshiyuki et al9 reported a case of synchronous cancer of the kidney and pancreas. Pathologically, the renal tumor was a renal cell carcinoma (clear cell type) and the pancreatic tumor was a well differentiated tubular carcinoma. Alexakis et al2 reported two patients with a pancreatic ductal adenocarcinoma who also presented Authors                          Type of study                                                   Number of cases                                 Temporal associationMakino et al6                  Analysis of annual autopsy                                        7                                                         All 7cases                                                                                                                                                                               Synchronous at autopsy Sasaki et al10                  Single case report                                                       1                                                        Patient with PDAC                                                                                                                                                                             RCC and polyposis coliKantor et al7                   4176 patients with RCC                                             6                                       PDAC metachronous to RCC                                           Collected by the Connecticut Tumour RegistryRabbani et al8                763 patients undergoing resection for RCC                 3                                       All 3 cases with synchronous                                            in a single unit                       PDAC   and RCC                    Alexakis et al2               373 patients with pancreatic tumours treated               2                                              Single patient with                                            in a single unit                                                                                                synchronous PDAC and RCCOlgyai et al11                 Single case report                                                         1                                 Synchronous PDAC and RCCToshiyuki et al9             Single case report                                                          1                                           Synchronous RCC and                                                                                                                                                                    pancreatic tubular carcinomaNobili et al12                  Single case report                                                      1                         A case of pancreatic heterotopy   of                                                                                                                                                              duodenal wall, intraductal papillary                                                                                                                                                            mucinous tumor and intraepithelial                                                                                                                                                                 neoplasm of pancreas, papillary                                                                                                                                                                             carcinoma of the kidneyPresent case                   Single case report                                                         1                                 Synchronous PDAC and renal                                                                                                                                                                                    papillary carcinomaPDAC: pancreatic ductal adenocarcinoma; RCC: renal cell carcinoma               Table 1: Reported cases of double pancreas-kidney primary cancers.131SYNCHRONOUS PRIMARY TUMORS OF THE KIDNEY AND PANCREASwith renal cell carcinoma 9 months following nephrectomy in one case and synchronously in the other. Previous reports that  mention an asso-ciation between pancreatic ductal adeno-carcinoma and renal cell cancer were based on a small cohort of patients with pancrea-tic cancer, and few studies provided clinical details2, 6-8, 10 (Table 1). In 2004, Olgyai et al11 reported a new case of synchronous renal and pancreatic body cancers. Histology verified primary pancreatic ductal adenocarcinoma with synchronous primary renal clear cell carcinoma. Recently, Nobili et al12 reported a case of coexistence of two histologically dif-ferent pancreatic neoplasms, one renal cancer (papillary carcinoma) and one embryogenic duodenal anomaly in a single patient.  In five cases, the majority of the patients were males over 60 years2, 9, 11, 12. Possible causes for such an association include shared environmental risk or genetic factors. Cigarette smoking could be a major environmental risk factor for both pancreatic ductal adenocarcinoma and renal cell cancer, accounting for an approximate 2-fold relative risk2. Genetic changes linked to the development of synchronous tumors were investigated in some studies. Satake13 found a mutation in codon 12 of the k-ras gene in a patient with a synchronous tumors of the kidney and pancreas. Molecular investigations were not considered in our case because of absence of known familial genetic syndromes, but genetic analysis of synchronous tumors in different organs may provide information about the etiology of genetic changes that occur during carcinogenesis13. There may be a novel genetic link in patients with pancreatic ductal adenocarcinoma and renal cell cancer dual primaries2.CONCLUSION                                                       Synchronous double kidney-pancreas cancers are very  rare.  This association demands more detailed epidemiological and molecular investigation.                         REFERENCES                                                        Linehan W, Shipley W, Parkinson D. Cancer of the 1. kidney and ureter. Cancer principles and practice of oncology. Philadelphia: Lippincott; 1993. p. 1362-95.Alexakis N, Bosonnet L, Connor S, Ellis I, Sutton R, 2. Campbell F, et al. Double resection for patients with pancreatic cancer and a second primary renal cell cancer. Dig.Surg. 2003;20(5):428-32.Balat O, Kudelka AP, Ro JY, Edwards CL, Balbay D, 3. Dinney C, et al. Two synchronous primary tumors of the ovary and kidney: A case report. Eur.J.Gynaecol.Oncol. 1996;17(4):257-9.Wong C, Plante M, Eltabbakh G. Synchronous renal 4. cell carcinoma and gynecologic malignancies. Gynecol.Oncol. 2003; Jan;88(1):66-8.Warren S, Gates,0. Multiple primary malignant tumors. 5. A survey of the literature and a statistical study. Am.J.Cancer. 1932;16:1358-414.Makino T, Konishi Y, Takahashi S, Maruyama H, Kohara 6. T, Yokose Y, et al. Clinicopathology of pancreatic cancer analyzed from annual of the pathological autopsy cases in Japan (in Japanese). Tan To Sui. 1984;5:716-68.Kantor AF, McLaughlin JK, Curtis RE, Flannery JT, 7. Fraumeni JF,Jr. Risk of second malignancy after cancers of the renal parenchyma, renal pelvis and ureter. Cancer. 1986; Sep 1;58(5):1158-61.Rabbani F, Reut8. er VE, Katz J, Russo P. Second primary malignancies associated with renal cell carcinoma: Influence of histologic type. Urology. 2000; Sep 1;56(3):399-403.Toshiyuki M, Hiroshi K, Shuichi I, Masaru T. A case with 9. synchronous double cancer of the pancreas and kidney. J.Jpn.Surg.Assoc. 1998;59(12):3205-8.Sasaki E, Kushida S, Okinaka T, Sasaki K, Abe S. Case 10. report of double cancer of the pancreas and the kidney with polyposis of the large intestine. Gan no Rinsho. 1969;15(2):203-6.Olgyai G, Haulik L, Oláh A. Double resection for 11. synchronous pancreatic and renal cell cancer--case report [Primer pancreas- és vesetumor szinkron reszekciója--esettanulmány]. Magy.seb. 2004;57(5):287-9.Nobili C, Franciosi C, Degrate L, Caprotti R, Romano 12. F, Perego E, et al. A case of pancreatic heterotopy of duodenal wall, intraductal papillary mucinous tumor and intraepithelial neoplasm of pancreas, papillary carcinoma of kidney in a single patient. Tumori. 2006;92(5):455-8.Satake K. Gene expression in synchronous tumors 13. in different organs: Pancreas and other organs. J.Hepatobiliary.Pancreat.Surg. 1996;3(2):167-71.

Synchronous Primary Tumors of the Kidney and Pancreas: Case Report

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Synchronous Primary Tumors of the Kidney and Pancreas: Case Report

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