A 37-year-old male with a medical history of nephrolithiasis, latent tuberculosis, and a 20+ pack-year smoking history initially presented in February 2021 with complaints of hematuria, right flank pain, and new onset clot passage. A renal and bladder ultrasound was then done which showed numerous irregular cysts in the right kidney, a normal left kidney, a heterogeneous mass in the bladder, and clot passage. A cystoscopy was performed which visualized the clot but detected no cancerous lesions or stones. Cytology from the bladder washing was negative. Urine cultures and an acid-fast bacteria stain were negative. A CT chest, abdomen, and pelvis with contrast was performed which demonstrated perinephric stranding, marked hydronephrosis, and marked thinning of the right renal parenchyma (Figure 1(a)). A nuclear medicine renal scan indicated impaired right kidney function (33%) with preserved left kidney function (67%). These findings were consistent with right-sided XGP, but a formal diagnosis could not be made without the pathology of a specimen. Given the normal creatinine and preserved left renal function, a simple right nephrectomy was recommended. The patient declined the operation and was discharged against medical advice.
He returned to the ER two months later with similar complaints as before of right flank pain, dysuria, and hematuria. He was able to find relief with over-the-counter nonsteroidal anti-inflammatory drugs and agreed to undergo a nephrectomy. A CT abdomen/pelvis showed significant progression of the right XGP as well as a new infiltrative process of the right renal pelvis with possible right renal vein thrombosis (Figure 1(b)). The patient underwent an open right radical nephrectomy to treat the extensive XGP during this hospital admission. Pathology of the specimen showed UC with squamous differentiation in a background of XGP. Specimen margins were negative for invasive carcinoma without evidence of tumor in regional lymph nodes. A CT abdomen/pelvis two months later in September 2021, however, was significant for multiple new poorly defined hepatic hypodensities with concern for metastatic disease versus abscesses related to disseminated infection (Figure 1(c)). The patient also later endorsed the onset of bone pain.
CT-guided liver biopsy was ordered which confirmed metastatic UC. However, nuclear medicine bone scan and CT chest with contrast were negative for osseous metastasis and thoracic lesions or lymphadenopathy, respectively. The patient was then evaluated by medical oncology and was started on gemcitabine and cisplatin (GC) palliative chemotherapy given the progression to metastatic disease.
Within one week of chemotherapy induction, the patient required hospital admission to treat sepsis secondary to mucositis. Following discharge, he was able to resume his chemotherapy regimen. A CT chest, abdomen, and pelvis performed after the third cycle of GC demonstrated interval reduction in the size of liver lesions without any appreciable change in abdominal lymphadenopathy. Given the patient's ongoing clinical response, the decision was made to complete 6 cycles of platinum-based chemotherapy. He was eventually treated with avelumab maintenance. Despite this, the patient had rapid disease progression. Given his overall critical status and poor prognosis, the decision was made to transition patient to hospice, and he eventually passed away due to the disease.