The document reports a rare case of squamous cell carcinoma in the native kidney of a 54-year-old renal transplant recipient who presented with flank pain and underwent nephrectomy. The tumor was treated with adjuvant radiotherapy, utilizing image-guided techniques due to its aggressive nature and proximity to sensitive organs. Post-surgery, the patient developed a urethral nodule, which was excised, and surveillance was recommended given negative margins from the biopsy.

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

2. 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

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 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.

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
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.

5. A o oh s i l ht:w wa o o o p a . m/
p l o p a : t / w .p l h s i lc
l
ts p /
l
ts o
T ie: t s / ie. m/o p a A o o
wt rht :t t r o H s i l p l
t
p /w t c
ts
l
Y uu e ht:w wy uu ec m/p l h s i ln i
o tb : t / w . tb . a o o o p a i a
p/
o
o
l
ts d
F c b o : t :w wfc b o . m/h A o o o p a
a e o k ht / w . e o k o T e p l H s i l
p/
a
c
l
ts
Si s ae ht:w wsd s aen t p l _ o p a
l e h r: t / w .i h r.e/ o o H s i l
d
p/
le
A l
ts
L k d : t :w wl k d . m/ mp n /p l -o p a
i e i ht / w . e i c c a y o oh s i l
n n p/
i
n no o
a l
ts
Bo : t :w wl s l e l . /
l ht / w . t a h a hi
g p/
e tk t n