Recurrent Colonic Cancer with Renal Pelvic Urothelial CancerCase Report and Review of Literature

Abstract

53 year old diabetic lady with bleeding per rectum in April 2008.She had past history of hysterectomy for uterine fibroids in 2004 and had family history of colon cancer in mother for which she underwent surgery and died of unrelated cause 20 years after surgery. She was evaluated was found to have colonic growth and underwent right hemicolectomy in April 2008, which was reported as poorly differentiated adenocarcinoma. This was followed by 8 cycles of chemotherapy with oxaliplatin, fluorouracil (5FU) and folinic acid (FOLFOX). In April 2016, she developed bleeding per rectum, and was found to have growth in colon. She underwent a subtotal colectomy with colorectal anastamosis, histopathology was reported as moderate to poorly differentiated adenocarcinoma. This was followed by 7 cycles of adjuvant chemotherapy with capecitabine. Immunohistochemical analysis was done in view of younger age of onset and recurrence of tumour. The study showed strong nuclear expression of MLH1, PMS2, MSH2 and MSH6 in the neoplastic cells. The immunoprofile was suggestive of intact DNA mismatch repair proteins/normal mismatch repair (MMR) function, consistent with microsatellite stable (MSS) phenotype. In February 2018, she presented with multiple episodes of painless hematuria with clots and hematochezia. She underwent MRI and colonoscopy for same. A colonoscopy and biopsy showed moderately differentiated adenocarcinoma in the rectum. A contrast MRI pelvis showed a soft tissue lesion in the right lateral wall of the upper rectum. It also showed a well defined lesion in the lower pole of the right kidney, extending into the renal pelvis. (Figure 1A & B). She underwent open subtotal colectomy with right radical nephroureterectomy. (Figure 2A&B). Histopathology showed well to moderately differentiated adenocarcinoma, single node metastasis, and discontinuous extramural deposits in mesorectal fat [UICC TNM pT3N1 (1/9), LVI] in colon and invasive high grade papillary urothelial carcinoma renal pelvis in nephroureterectomy specimen. [ pTNM: pT3 Nx Mx]. Abstract: The genetic association between colorectal cancer and renal pelvic urothelial cancer is well described as part of Lynch syndrome (Hereditary Non Polyposis Colorectal Cancer), an autosomal dominant genetic disorder characterized by defective DNA mismatch repair which leads to microsattelite instability. We are reporting a case with microsatellite stable phenotype and intact DNA mismatch repair proteins/normal mismatch repair function in a case of recurrent colonic cancer with renal pelvic urothelial cancer.