Korean J Urol Oncol 2014;12(2):86-88 Metachronous Triple Genitourinary Tumors in a Single Patient Treated by Partial Nephrectomy, Retropubic Radical Prostatectomy, and Transurethral Resection of Bladder Tumor Jang Hee Han1, Jong Kyou Kwon1, Joo Yong Lee1, Kang Su Cho2, Won Sik Ham1, Young Deuk Choi1 1Department of Urology, Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, 2Gangnam Severance Hospital, Urological Science Institute, Yonsei University College of Medicine, Seoul, Korea A 75-year-old man was referred to our department for an incidentally detected right renal mass which was later treated by partial nephrectomy. Seven years later, a serum PSA level of 5.87ng/ml was detected and a digital rectal examination revealed a tiny, palpable nodule in the left lobe of prostate. The results of the prostate biopsy revealed prostate adenocarcinoma with a Gleason score of 7 (3＋4) in 5 of 12 cores. Retropubic radical prostatectomy was carried out. In follow-up imaging studies, positron emission tomography-computed tomography revealed a 1.3-cm papillary tumor located in the bladder and he underwent transurethral resection. To the best of our knowledge, this the first report of metachronous, triple primary, genitourinary malignant tumors in Korea. (Korean J Urol Oncol 2014;12:86-88) Key Words: Urogenital neoplasm; Neoplasms, Second primary Multiple primary cancers (MPC) in a single patient have be- niques have also attributed to the increase of this diagnosis. come a frequent finding in recent decades. However, MPC of To the best of our knowledge, there is little data reporting three or more sites is extremely rare reporting prevalence of the incidence and clinical features of this rare disease entity,4 0.029 to 1.7%.1-3 The etiologies of MPC appear to be complex and metachronous, triple primary, genitourinary malignant tu- and the main driving cause varies widely. Number of factors mors have not been reported in Korea so far. Herein, we pres- could interact with each other to cause this uncommon disease.4 ent a report of metachronous, triple primary, genitourinary ma- Furthermore, an aging society producing an increasing elderly lignant tumors occurring in the kidney, prostate, and bladder patient population, as well as advances in novel diagnostic tech- that were treated by an open partial nephrectomy (OPN), retro- pubic radical prostatectomy (RRP), and transurethral resection Received June 23, 2014, Revised August 7, 2014, of the bladder tumor(TURBT). Accepted August 11, 2014 Corresponding Author: Young Deuk Choi, Department of Urology CASE REPORT and Robot and Minimal Invasive Surgery Center, Severance Hospital, and Urological Science Institute, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul On December 2005, a 75 year-old male patient was referred 120-752, Korea. Tel: 82-2-2228-2317, Fax: 82-2-312-2538, to Severance Hospital, Yonsei University Health System, Seoul, E-mail: [email protected] Korea, department of urology for an incidentally detected renal 86 Jang Hee Han, et al：Triple Genitourinary Metachronous Tumors 87 Fig. 1. (A) Computed tomography revealed an approximately 2-cm, well-enhanced, exophytic, mass enri- ching blood flow located in the anterior aspect of the midportion of the right kidney (arrow head). (B) Upon preoperative magnetic reso- nance image, PCa was suspected in both peripheral zones without defi- nite extraprostatic extention or seminal vesicle invasion. Fig. 2. (A) A 1.3-cm focal enhan- cing mass lesion was detected at the left ureterovesical junction of the urinary bladder in the PET-CT suggesting a bladder tumor (arrow- head). (B) Multiple bladder tumors up to 2cm were noted in the whole bladder wall during cystoscopy. mass. He had a smoking history of 90 pack-years and had no resonance images, prostate cancer(PCa) was suspected in both other remarkable past medical history. Ultrasonography and peripheral zones without a definite extraprostatic extention or computed tomography (CT) revealed an approximately 2cm, seminal vesicle invasion (Fig. 1B). Considering his age, per- well-enhanced, exophytic mass enriching blood flow located in formance status (ECOG 0), and Charlson Comorbidity Index the right kidney (Fig. 1A). He had undergone partial neph- (CCI), the patient underwent RRP for PCa. In the CCI, the his- rectomy with preservation of the ipsilateral adrenal gland. tory of RCC was excluded because RCC had been diagnosed Pathological evaluation revealed a 2.5x2.2cm mass consistent 5 years ago and his score was 0. The pathological diagnosis with renal cell carcinoma (RCC), conventional type, Fuhrman revealed prostate adenocarcinoma, with a Gleason score of 7 grade 1, without involvement of the resection margin or peri- (3＋4) and extracapsular extention without focal surgical mar- nephric fat (pT1aN0M0). There was no reported evidence of gin involvement or pelvic lymph node invasion (pT3aN0Mx). post-operative complications or recurrence during the routine Three months after surgery the PSA decreased to 0.1ng/ml follow-up periods. without adjuvant androgen deprivation therapy. On March 2012, he visited again presenting with lower uri- On May 2013, positron emission tomography-CT (PET-CT) nary tract symptoms (LUTS). As part of the routine evaluation was performed to evaluate recurrence or progression of the for LUTS, prostate-specific antigen (PSA) and transrectal ultra- prostate cancer which revealed 1.3-cm focal enhancing mass le- sonography (TRUS) were performed. Serum PSA level was sion at the left ureterovesical junction of the urinary bladder. 5.87ng/ml and prostate volume was 16ml. During the digital (Fig. 2A). Multiple bladder tumors up to 2cm were noted in rectal examination, a tiny nodule was palpable on the left lobe the whole bladder wall during cystoscopy (Fig. 2B), and metic- of the prostate gland. Finally, a TRUS-guided biopsy of the ulous TURBT was carried out. The pathological results re- prostate was performed for confirmative diagnosis. The patho- vealed urothelial carcinoma, low grade, pTaN0M0. After 6 cy- logical report indicated prostate adenocarcinoma with a Gleason cles of intravesical BCG instillation, routine postoperative fol- score of 7 (3＋4) in 5 of 12 cores. From preoperative magnetic low-up studies have shown no complications or recurrence for 88 대한비뇨기종양학술지：제12권 제2호 2014 RCC, PC, or bladder tumors thus far. tween RCC, PCa, and bladder tumors in metachronous MPC. Recently, genetic factors have been associated with urological DISCUSSION malignancies. SNORD43 is a reference gene suitable for ana- lyzing circulating micro-ribonucleic acids in patients with po- MPCs are a relatively well-known phenomenon. The etiology tential urological malignancies including PCa, urothelial carci- of multiple primary malignant tumors is rather complex and in- noma, and RCC.10 cludes environmental factors like tobacco, occupation, pollu- We firstly reported extremely rare case of metachronous tri- tion, ultraviolet light, genetic predisposition, previous medical ple genitourinary gumors in a single patient and suggested that treatment like radiation therapy or chemotherapy, gender-specif- the primary tumors are not as advanced initially when com- ic factors, hormonal factors, and finally interactions between pared to the synchronous type, the secondary tumor may be these factors.5 A few cases of genitourinary MPCs have been more advanced and more aggressive treatment should be con- reported throughout the world; however, none of them were sidered for such patients. metachronous MPCs which were detected more than 5 years later since the first cancer had developed. 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