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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
Department of Radiation Oncology, 320, Padma Complex, Apollo Cancer Hospitals, Cenotaph Road, Teynampet, Chennai 35, India
b
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 trans-
planted 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 straight forward; adjuvant management is debatable of
course.
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 2. Case report
an estimate of 7%e8%1 as well. Squamous cancers are often
locally advanced and associated with a high local recurrence A 54-year-old gentleman, a known diabetic for 35 years, with
rate. Kidney transplant and long immunosuppression have a renal transplant and immunosuppression for three years
however increased the incidence of squamous cell carcinoma was evaluated for complaints of severe loin pain of 3 month
in various parts of the body. Squamous cell cancer of the duration. He did not give a history of repeated urinary tract
kidney is not at all diagnosed frequently and its postoperative infections or renal stones. On evaluation he was found to have
treatment varies. We present a case of a renal transplant a large ill defined enhancing necrotizing mass in the left kid-
recipient; transplanted 3 years back with squamous cell car- ney measuring 87 Â 84 Â 81 mm apparently arising from the
cinoma of the left native kidney. Primary treatment was 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

3. 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 seg- The patient had complaints of burning micturition shortly
ment of the left renal artery and renal vein (Fig. 1). after the surgery and when evaluated he was found to have
There was perinephric and pararenal fat stranding. There a urethral nodule. The biopsy of the nodule was suggestive of
were a few enhancing subcentimetric para aortic nodes squamous cell carcinoma. A cystoscopy was done which was
adjacent to the left renal hilum. There was no distinct fat normal .He underwent a wide excision of the nodule with
plane between the mass and the left psoas muscle. perineal urethrostomy. The histopathology was confirmed.
He underwent nephrectomy. Intraoperatively there was The surrounding margins and the urethral margins were
a hard mass in the upper pole of the left kidney adherent to negative for tumor and hence it was decided to observe the
the psoas and to the peritoneum. With blunt and sharp dis- patient.
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 3. Discussion
divided.
Histopathology showed a moderately differentiated squa- Renal transplant recipients are more prone for the develop-
mous cell carcinoma almost completely replacing the renal ment of squamous cell carcinomas of the skin, tongue and
parenchyma. The tumor had infiltrated the capsule, but, per- various other tumors in various sites.2 The more than usual
irenal fat was not involved and the ureter and the adrenal risk of development of renal cell carcinoma has been reported
gland too were uninvolved. in the native kidney in renal transplant recipients.2 Squamous
Patient was referred for postoperative adjuvant radio- cell carcinoma is a rare occurrence in kidneys. They have been
therapy. Dose of 60 Gy to the higher risk area and 54 Gy to the associated with renal calculi3 and they have a very bad prog-
rest of the target volume was prescribed (Fig. 2). nosis due to the fact that usually patients present at a late
Fig. 2 e IGRT dose distribution.

4. 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 and high risk of microscopic seedlings qualified the case for
presence of non-specific symptoms like hematuria that occurs radiotherapy as an adjuvant measure. IGRT was advised
in renal stones also delays the diagnosis of the tumor. Prior because of the irregular shape of the target and the vicinity of
surgeries, analgesic abuse, or radiotherapy, chronic irritation other sensitive organs. The transplanted kidney could be
with superimposed infection are said to induce squamous saved.
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. Conflicts of interest
The primary treatment for squamous cell carcinoma of the
kidney is surgery.6,7 Radiotherapy has been used in the adju- All authors have none to declare.
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 references
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- 1. Blacher EJ, Johnson DE, Abdul-Karim FW, et al. Squamous cell
neous dose distribution within the target was prescribed carcinoma of renal pelvis. Urology. 1985;25:124e126.
delivering a higher dose to the areas of higher risk, namely the 2. Kasiske Bertram L, Snyder Jon J, Gilbertson David T,
psoas muscle’s and spleen’s surface. Shape of the target was Wang Changchun. Cancer after kidney transplantation in the
United States. Am J Transplant. June 2004;4(6):905e913.
quite irregular and radiosensitive organs were in close vicin-
3. Li MK, Cheung WL. Squamous cell carcinoma of the renal
ity. A huge mass was bulging into the abdomen and post-
pelvis. Division of Urology, Department of Surgery, University
operatively intestines have occupied the vacant place. They of Hong Kong, Queen Mary Hospital, Hong Kong. J Urol. 1987
were separated by the apparently non-infiltrated peritoneum. Aug;138(2):269e271.
Target volume was outlined accordingly. Using image guided 4. Erik Busby J, Brown Gordon A, Tamboli Pheroze, et al. Upper
radiotherapy it was possible to deliver a differential dose urinary tract tumors with nontransitional histology: a single-
within the target volume thereby the high risk areas receiving center experience. Urology. 2006 Mar;67(3):518e523.
5. Morath* Christian, Muellery Martina, Goldschmidtz Hartmut,
a higher dose than the rest. It was also possible to bring down
Schwenger* Vedat, Opelzx Gerhard, Zeier* Martin. Malignancy
minimize the dose to the surrounding intestines which usu- in renal transplantation. Departments of *Nephrology,
ally is the dose limiting factor for radiotherapy in the yGastroenterology, zHematology/Oncology, and xTransplant
abdomen. Immunology, University of Heidelberg, Heidelberg, Germany. J
Chemotherapy has also been tried in the adjuvant setting Am Soc Nephrol. June 1, 2004;15(6):1582e1588.
with no survival benefits.9 But in view of the immunosup- 6. Yamaguchi S, Nishihara M, Okamura K, Hashimoto H, Inada F,
pressive state in this case and the vulnerability of the trans- Yachiku S. Squamous cell carcinoma of renal pelvis: a case
report and review of the Japanese literature. Department of
planted (functioning) kidney adjuvant chemotherapy was not
Urology, Asahikawa Medical College. Hinyokika Kiyo. 1987
considered. Dec;33(12):2103e2110.
It was decided to observe the urethral lesion due to the 7. Nativ O, Reiman HM, Lieber MM, et al. Treatment of primary
normal cystoscopy and negative circumferential and urethral squamous cell carcinoma of the upper urinary tract. Cancer.
margins. 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.
4. Conclusion Radiology. 1994;193:725e730.
9. Yagoda A, Abi-Rached B, Petrylak D. Chemotherapy for
Our case was treated by a combination of surgery and adju- advanced renal cell carcinoma. Semin Oncol. 1995;22:
vant radiotherapy. The aggressive character of the pathology 42e60.

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