EUF Vol. 1 No. 1

90 96

Clinical Case Discussion
Case Presentation: A Man with Two Synchronous and
Symptomatic Malignancies Related to Smoking
Alberto Briganti Gianluca Giannarini
a Division of Oncology/Urology Unit, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy; bUrology Unit, Academic Medical Centre
Hospital Santa Maria della Misericordia, Udine, Italy
A 77-yr-old man presented in the emergency room with
abdominal pain, fatigue, jaundice, and gross haematuria.
The patient had no significant comorbidities and had been
in good general condition. The patient was on alfuzosin
and dutasteride for symptomatic benign prostatic hyper-
plasia. He had moderate alcohol consumption and was a
heavy smoker (approximately 40 cigarettes per day since
age 20 yr).
The man became symptomatic roughly 2 mo prior to
hospital admission. Over this time, he lost approximately
5 kg in weight, and his abdominal pain became more
severe. He rated it 5 on a scale from 0 to 10, with
10 indicating the most severe pain. The pain was chronic
with exacerbation and was located in the mesogastric area.
Approximately 5 d before hospital admission, he developed
jaundice associated with increasing pain and persistent
gross haematuria.
On admission to the hospital, he received blood
examinations, abdominopelvic ultrasound, and urine anal-
ysis. Complete blood count and renal function were normal,
as were blood levels of electrolytes, glucose, calcium,
phosphorus, magnesium, total protein, and albumin;
however, increasing values of total bilirubin, conjugated
bilirubin, aspartate aminotransferase, alanine aminotrans-
ferase, alkaline phosphatase, andg-glutamyl transpeptidase
were found. The ultrasound showed dilation of the biliary
ducts and bilateral 4- to 6-cm Bosniak I cysts. At urine
analysis, high erythrocyte levels were found.
Abdominal and thoracic contrast-enhanced computed
tomography scans were performed ). Intrahepatic
biliary distension was evident, and the common biliary
ducts in prepancreatic and intrapancreatic areas appeared
thickened. Hydropic gallbladder was also noted. A small
nodule (<1 cm) in the inferior left pulmonary lobe was
found. Moreover, in addition to bilateral Bosniak I renal
cysts, an endophytic contrast-enhanced mass highly suspi-
cious for upper urinary tract carcinoma infiltrating the renal
pelvis was found in the left kidney (maximum diameter
4 cm). No retroperitoneal lymphadenopathies were noted.
Endoscopic ultrasound was performed, and intrahepatic
biliary and common bile duct distension was found with a
complete occlusion of the hepatic hilum. Hypoechoic
lesions were reported on the gallbladder, duodenum, and
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Fig. 1 – Cross-section computed tomography image showing a filling
defect in the left renal pelvis, in keeping with urothelial cell carcinoma
(white arrowhead), and a mass around the common bile duct (with
internal drainage) is seen (white arrow).
* Corresponding author. Division of Oncology/Urology Unit, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
E-mail address: (A. Briganti).
2405-4569/# 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved.