Squamous cell carcinoma in the native kidney of arenal transplant recipient with urethral deposit - A case report

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Case Report

Squamous cell carcinoma in the native kidney ofa renal transplant recipient with urethraldeposit e A case report

Bhargavi Ilangovan a,*, Janos Stumpf a, Rathna Devi a, Salim Thomas b

aDepartment of Radiation Oncology, 320, Padma Complex, Apollo Cancer Hospitals, Cenotaph Road, Teynampet, Chennai 35, IndiabDepartment of Surgery, Apollo Cancer Hospitals, Chennai, India

a r t i c l e i n f o

Article history:

Received 26 October 2012

Accepted 7 December 2012

Available online 16 December 2012

Keywords:

Squamous cell carcinoma

Renal transplant

Immunosupression

Radiotherapy

* Corresponding author. Tel.: þ91 9840720910E-mail address: anuilangovan@yahoo.co.

0976-0016/$ e see front matter Copyright ªhttp://dx.doi.org/10.1016/j.apme.2012.12.001

a b s t r a c t

We are reporting a case of squamous cell carcinoma of the native kidney in a renal

transplant recipient. A 54-year-old gentleman, a renal transplant recipient for three years,

presented with flank pain. On evaluation he was found to have a mass in the upper pole of

the left native kidney. Renal angiogram was done which showed a functioning trans-

planted kidney with a large mass arising from the upper pole of the left native kidney. He

underwent nephrectomy. The histopathology reported a squamous cell carcinoma. He was

given adjuvant radiotherapy to the tumor bed using image guided radiotherapy thereby

delivering a differential dose to the high risk areas and preserving the surrounding normal

structures. He developed a urethral nodule which was found to be a squamous cell car-

cinoma. The lesion was excised with clear margins. We present this case because it is rare

and to discuss adjuvant management.

Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved.

1. Introduction straight forward; adjuvant management is debatable of

More than 90% of malignant tumors arising from the renal

pelvis and ureter are transitional cell carcinomas. Squamous

cell carcinomas account for only a few percent though there is

an estimate of 7%e8%1 as well. Squamous cancers are often

locally advanced and associated with a high local recurrence

rate. Kidney transplant and long immunosuppression have

however increased the incidence of squamous cell carcinoma

in various parts of the body. Squamous cell cancer of the

kidney is not at all diagnosed frequently and its postoperative

treatment varies. We present a case of a renal transplant

recipient; transplanted 3 years back with squamous cell car-

cinoma of the left native kidney. Primary treatment was

(mobile).in (B. Ilangovan).2012, Indraprastha Medic

course.

2. Case report

A 54-year-old gentleman, a known diabetic for 35 years, with

a renal transplant and immunosuppression for three years

was evaluated for complaints of severe loin pain of 3 month

duration. He did not give a history of repeated urinary tract

infections or renal stones. On evaluation hewas found to have

a large ill defined enhancing necrotizing mass in the left kid-

ney measuring 87 � 84 � 81 mm apparently arising from the

upper interpolar region of the renal cortex. It was found to

al Corporation Ltd. All rights reserved.

Fig. 1 e CT angio of the case and CT reconstruction, tumor, vessels, calcification.

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 7 4e7 6 75

have calcific specks within and was encasing the distal seg-

ment of the left renal artery and renal vein (Fig. 1).

There was perinephric and pararenal fat stranding. There

were a few enhancing subcentimetric para aortic nodes

adjacent to the left renal hilum. There was no distinct fat

plane between the mass and the left psoas muscle.

He underwent nephrectomy. Intraoperatively there was

a hard mass in the upper pole of the left kidney adherent to

the psoas and to the peritoneum. With blunt and sharp dis-

section, the kidney tumor was slowly induced. The renal ar-

tery was identified, double ligated and divided. The renal vein

was also double ligated and divided. Ureter was ligated and

divided.

Histopathology showed a moderately differentiated squa-

mous cell carcinoma almost completely replacing the renal

parenchyma. The tumor had infiltrated the capsule, but, per-

irenal fat was not involved and the ureter and the adrenal

gland too were uninvolved.

Patient was referred for postoperative adjuvant radio-

therapy. Dose of 60 Gy to the higher risk area and 54 Gy to the

rest of the target volume was prescribed (Fig. 2).

Fig. 2 e IGRT dose

The patient had complaints of burning micturition shortly

after the surgery and when evaluated he was found to have

a urethral nodule. The biopsy of the nodule was suggestive of

squamous cell carcinoma. A cystoscopy was done which was

normal .He underwent a wide excision of the nodule with

perineal urethrostomy. The histopathology was confirmed.

The surrounding margins and the urethral margins were

negative for tumor and hence it was decided to observe the

patient.

3. Discussion

Renal transplant recipients are more prone for the develop-

ment of squamous cell carcinomas of the skin, tongue and

various other tumors in various sites.2 The more than usual

risk of development of renal cell carcinoma has been reported

in the native kidney in renal transplant recipients.2 Squamous

cell carcinoma is a rare occurrence in kidneys. They have been

associated with renal calculi3 and they have a very bad prog-

nosis due to the fact that usually patients present at a late

distribution.

a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 7 4e7 676

stage.4 The same has happened to our patient as well. The

presence of non-specific symptoms like hematuria that occurs

in renal stones also delays the diagnosis of the tumor. Prior

surgeries, analgesic abuse, or radiotherapy, chronic irritation

with superimposed infection are said to induce squamous

metaplasia. The immunosuppression associated with renal

transplant is said to be the cause for the increased occurrence

of the carcinoma.5 Data have shown the occurrence of renal

cell carcinomas in the transplant setting.

The primary treatment for squamous cell carcinoma of the

kidney is surgery.6,7 Radiotherapy has been used in the adju-

vant setting.8 In our case, despite the fact that perirenal fat

was not involved, the adherence of the tumor to the psoas,

size and aggressive, infiltrative nature of the tumor, young age

of the patient were all calling for postoperative radiotherapy

technique, dose and target had to be decided individually. It

was decided to use Image Guided Radiotherapy. A heteroge-

neous dose distribution within the target was prescribed

delivering a higher dose to the areas of higher risk, namely the

psoas muscle’s and spleen’s surface. Shape of the target was

quite irregular and radiosensitive organs were in close vicin-

ity. A huge mass was bulging into the abdomen and post-

operatively intestines have occupied the vacant place. They

were separated by the apparently non-infiltrated peritoneum.

Target volume was outlined accordingly. Using image guided

radiotherapy it was possible to deliver a differential dose

within the target volume thereby the high risk areas receiving

a higher dose than the rest. It was also possible to bring down

minimize the dose to the surrounding intestines which usu-

ally is the dose limiting factor for radiotherapy in the

abdomen.

Chemotherapy has also been tried in the adjuvant setting

with no survival benefits.9 But in view of the immunosup-

pressive state in this case and the vulnerability of the trans-

planted (functioning) kidney adjuvant chemotherapy was not

considered.

It was decided to observe the urethral lesion due to the

normal cystoscopy and negative circumferential and urethral

margins.

4. Conclusion

Our case was treated by a combination of surgery and adju-

vant radiotherapy. The aggressive character of the pathology

and high risk of microscopic seedlings qualified the case for

radiotherapy as an adjuvant measure. IGRT was advised

because of the irregular shape of the target and the vicinity of

other sensitive organs. The transplanted kidney could be

saved.

Conflicts of interest

All authors have none to declare.

r e f e r e n c e s

1. Blacher EJ, Johnson DE, Abdul-Karim FW, et al. Squamous cellcarcinoma of renal pelvis. Urology. 1985;25:124e126.

2. Kasiske Bertram L, Snyder Jon J, Gilbertson David T,Wang Changchun. Cancer after kidney transplantation in theUnited States. Am J Transplant. June 2004;4(6):905e913.

3. Li MK, Cheung WL. Squamous cell carcinoma of the renalpelvis. Division of Urology, Department of Surgery, Universityof Hong Kong, Queen Mary Hospital, Hong Kong. J Urol. 1987Aug;138(2):269e271.

4. Erik Busby J, Brown Gordon A, Tamboli Pheroze, et al. Upperurinary tract tumors with nontransitional histology: a single-center experience. Urology. 2006 Mar;67(3):518e523.

5. Morath* Christian, Muellery Martina, Goldschmidtz Hartmut,Schwenger* Vedat, Opelzx Gerhard, Zeier* Martin. Malignancyin renal transplantation. Departments of *Nephrology,yGastroenterology, zHematology/Oncology, and xTransplantImmunology, University of Heidelberg, Heidelberg, Germany. JAm Soc Nephrol. June 1, 2004;15(6):1582e1588.

6. Yamaguchi S, Nishihara M, Okamura K, Hashimoto H, Inada F,Yachiku S. Squamous cell carcinoma of renal pelvis: a casereport and review of the Japanese literature. Department ofUrology, Asahikawa Medical College. Hinyokika Kiyo. 1987Dec;33(12):2103e2110.

7. Nativ O, Reiman HM, Lieber MM, et al. Treatment of primarysquamous cell carcinoma of the upper urinary tract. Cancer.1991;68:2575e2578.

8. Kao GD, Malkowicz SB, Whittington, et al. Locally advancedrenal cell carcinomas: low complication rate and efficacy ofpost nephrectomy radiation therapy planned with CT.Radiology. 1994;193:725e730.

9. Yagoda A, Abi-Rached B, Petrylak D. Chemotherapy foradvanced renal cell carcinoma. Semin Oncol. 1995;22:42e60.

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