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Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient with Urethral Deposit - A Case Report
 

Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient with Urethral Deposit - A Case Report

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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 ...

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 carcinoma. The lesion was excised with clear margins. We present this case because it is rare and to discuss adjuvant management.







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    Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient with Urethral Deposit - A Case Report Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient with Urethral Deposit - A Case Report Document Transcript

    • Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient with Urethral Deposit - A Case Report
    • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 7 4 e7 6 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/apme Case Report Squamous cell carcinoma in the native kidney of a renal transplant recipient with urethral deposit e A case report Bhargavi Ilangovan a,*, Janos Stumpf a, Rathna Devi a, Salim Thomas b a b Department of Radiation Oncology, 320, Padma Complex, Apollo Cancer Hospitals, Cenotaph Road, Teynampet, Chennai 35, India Department of Surgery, Apollo Cancer Hospitals, Chennai, India article info abstract Article history: We are reporting a case of squamous cell carcinoma of the native kidney in a renal Received 26 October 2012 transplant recipient. A 54-year-old gentleman, a renal transplant recipient for three years, Accepted 7 December 2012 presented with flank pain. On evaluation he was found to have a mass in the upper pole of Available online 16 December 2012 the left native kidney. Renal angiogram was done which showed a functioning transplanted kidney with a large mass arising from the upper pole of the left native kidney. He Keywords: underwent nephrectomy. The histopathology reported a squamous cell carcinoma. He was Squamous cell carcinoma given adjuvant radiotherapy to the tumor bed using image guided radiotherapy thereby Renal transplant delivering a differential dose to the high risk areas and preserving the surrounding normal Immunosupression structures. He developed a urethral nodule which was found to be a squamous cell car- Radiotherapy 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 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 carcinoma of the left native kidney. Primary treatment was straight forward; adjuvant management is debatable of 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 he was found to have a large ill defined enhancing necrotizing mass in the left kidney measuring 87 Â 84 Â 81 mm apparently arising from the upper interpolar region of the renal cortex. It was found to * Corresponding author. Tel.: þ91 9840720910 (mobile). E-mail address: anuilangovan@yahoo.co.in (B. Ilangovan). 0976-0016/$ e see front matter Copyright ª 2012, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2012.12.001
    • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 7 4 e7 6 75 Fig. 1 e CT angio of the case and CT reconstruction, tumor, vessels, calcification. have calcific specks within and was encasing the distal segment 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 dissection, the kidney tumor was slowly induced. The renal artery 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 squamous cell carcinoma almost completely replacing the renal parenchyma. The tumor had infiltrated the capsule, but, perirenal fat was not involved and the ureter and the adrenal gland too were uninvolved. Patient was referred for postoperative adjuvant radiotherapy. Dose of 60 Gy to the higher risk area and 54 Gy to the rest of the target volume was prescribed (Fig. 2). 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 development 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 prognosis due to the fact that usually patients present at a late Fig. 2 e IGRT dose distribution.
    • 76 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 7 4 e7 6 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 adjuvant 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 heterogeneous 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 vicinity. A huge mass was bulging into the abdomen and postoperatively 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 usually 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 immunosuppressive state in this case and the vulnerability of the transplanted (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 adjuvant 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. references 1. Blacher EJ, Johnson DE, Abdul-Karim FW, et al. Squamous cell carcinoma of renal pelvis. Urology. 1985;25:124e126. 2. Kasiske Bertram L, Snyder Jon J, Gilbertson David T, Wang Changchun. Cancer after kidney transplantation in the United States. Am J Transplant. June 2004;4(6):905e913. 3. Li MK, Cheung WL. Squamous cell carcinoma of the renal pelvis. Division of Urology, Department of Surgery, University of Hong Kong, Queen Mary Hospital, Hong Kong. J Urol. 1987 Aug;138(2):269e271. 4. Erik Busby J, Brown Gordon A, Tamboli Pheroze, et al. Upper urinary tract tumors with nontransitional histology: a singlecenter experience. Urology. 2006 Mar;67(3):518e523. 5. Morath* Christian, Muellery Martina, Goldschmidtz Hartmut, Schwenger* Vedat, Opelzx Gerhard, Zeier* Martin. Malignancy in renal transplantation. Departments of *Nephrology, yGastroenterology, zHematology/Oncology, and xTransplant Immunology, University of Heidelberg, Heidelberg, Germany. J Am 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 case report and review of the Japanese literature. Department of Urology, Asahikawa Medical College. Hinyokika Kiyo. 1987 Dec;33(12):2103e2110. 7. Nativ O, Reiman HM, Lieber MM, et al. Treatment of primary squamous cell carcinoma of the upper urinary tract. Cancer. 1991;68:2575e2578. 8. Kao GD, Malkowicz SB, Whittington, et al. Locally advanced renal cell carcinomas: low complication rate and efficacy of post nephrectomy radiation therapy planned with CT. Radiology. 1994;193:725e730. 9. Yagoda A, Abi-Rached B, Petrylak D. Chemotherapy for advanced renal cell carcinoma. Semin Oncol. 1995;22: 42e60.
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