|Year : 2019 | Volume
| Issue : 4 | Page : 588-590
Aggressive squamous cell carcinoma of the renal pelvis
I Kartal1, S Uysal1, A Adabag2, A Gok1, AL Sagnak1, H Ersoy1
1 Department of Urology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
2 Department of Pathology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
|Date of Acceptance||10-Dec-2018|
|Date of Web Publication||11-Apr-2019|
Dr. I Kartal
Ziraat Mahallesi, Sehit Ömer Halisdemir Cad., Diskapi-Altindag, Ankara - 06110
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Squamous cell carcinoma (SCC) of the renal pelvis is a particularly rare tumor that accounts for a minor portion of renal malignancies and is aggressive with an unfavorable prognosis. It is usually diagnosed after surgery and at advanced stages as it does not possess specific clinical and radiological properties. The pathological examination of a 38-year-old female patient who had undergone nephrectomy due to a nonfunctioning right kidney caused by long-standing staghorn calculus revealed moderately differentiated renal pelvis SCC invading the renal parenchyma. The patient who experienced severe lumbar pain in the second postoperative month presented lymphadenopathy, which could not be detected with ultrasonography but was diagnosed with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FDG PET/CT). The patient received systemic treatment following the early diagnosis and survived past the average survival time. It was concluded that in cases where SCC was diagnosed after nephrectomy, investigating metastasis with 18FDG PET/CT and initiating early systemic treatment in the presence of metastasis could contribute to survival.
Keywords: 18F-fluorodeoxyglucose positron emission tomography/computed tomography, renal pelvis, staghorn calculus, squamous cell carcinoma
|How to cite this article:|
Kartal I, Uysal S, Adabag A, Gok A, Sagnak A L, Ersoy H. Aggressive squamous cell carcinoma of the renal pelvis. Niger J Clin Pract 2019;22:588-90
| Introduction|| |
Squamous cell carcinoma (SCC) of the renal pelvis is particularly rare and accounts for 0.5% of renal malignancies and <10% of renal pelvis tumors. Predisposing factors include chronic infection, long-term exposure to calculi, hormonal deficiency, endogenous and exogenous chemicals, radiotherapy, and vitamin A deficiency. It manifests a quite aggressive course and is usually diagnosed after surgery and at advanced stages. This case presents a renal pelvis SCC diagnosed following surgery in a young female patient with a staghorn calculus and metastases that developed over a very short time and were detected with 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18FDG PET/CT).
| Case Report|| |
A 38-year-old female patient presented to our clinic due to a right-side pain which had existed for a long time but increased in severity in the past month. The patient who had been suffering from the recurrent stone disease for the past 20 years had right percutaneous nephrolithotomy in her history, performed in the year 2007. The physical examination of the patient, who had no systemic diseases and reported using anti-inflammatory medication, revealed no findings other than right costovertebral angle tenderness. Laboratory tests detected her creatinine level as 69.84 μmol/L, and abdominal computed tomography (CT) scan was ordered. The CT scan revealed a 6 × 4 × 4-cm staghorn calculus in the right kidney that filled all calyces, along with thinning of parenchyma particularly in the inferior region of the kidney, lesions in the lower pole, and moderate hydronephrosis. Dynamic renal scintigraphy reported the contribution of the right kidney to total kidney function as 14%. The patient provided consent and surgery was performed through a right subcostal incision. During operation, it was seen that the renal pelvis was enfolded in a yellow crust and there were densely scattered pus foci in the kidney. Because the medial edge of the kidney was in close contact with the vena cava inferior and their borders could not be distinguished, it was separated through sharp dissection, and a decision was made to conclude the procedure with radical nephrectomy. Histological evaluation revealed a moderately differentiated 4.5 × 4.5 × 5-cm SCC that was invading the renal parenchyma, corresponding to the region where the calculi were found, manifested large areas of necrosis, and did not present lymphovascular invasion [Figure 1]. The patient was discharged on the third postoperative day with no problems, however, presented with severe lumbar pain on the 45th day. Abdominal ultrasonography (US) was taken and provided normal results. However, since the patient experienced severe pain and did not respond to opioids, an 18FDG PET/CT was performed on the 50th day. This revealed paracaval lymphadenopathy (SUVmax: 14.7) of 19 mm size with increased F-FDG uptake [Figure 2]. In the second postoperative month, an increase in lymphadenopathy size could be seen in the CT scan and metastasis was detected in the T11 vertebra. The patient was referred to the oncology clinic and died on the 17th postoperative month, despite undergoing repeated cycles of gemcitabine/cisplatin chemotherapy.
|Figure 1: Squamous cell carcinoma focus on the right, kidney glomeruli on the left (40×, H and E)|
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|Figure 2: Paracaval metastatic lymph nodes in the 18F-fluorodeoxyglucose positron emission tomography/computed tomography performed on the 50th postoperative day|
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| Discussion|| |
In renal SCC, which is unusually encountered in the kidney and is closely related to chronic irritation and inflammation, 50% of the patients present a history of long-term exposure to calculi, as seen in our patient. Neoplasia forms on the basis of squamous metaplasia that develops due to chronic irritation.
Imaging methods, particularly CT and the US, usually demonstrate the calculi and obstruction-induced hydronephrosis, causing renal SCC to go often undetected. While SCC was atypically encountered in a young female patient in our case, it is seen more commonly in late adulthood and males, probably due to the higher prevalence of stone disease in men.,, Since renal SCC does not possess any specific clinical or radiological characteristics, it is usually diagnosed after nephrectomy. As surgical treatment is the main and primary treatment of SCC, this situation is not considered to be a problem concerning the course of the treatment. However, due to the aggressive quality of a tumor, most patients are diagnosed at stage pT3 or further stages and the average survival time is seven months. Considering the aggressive nature of renal SCC and the short survival time, the stage of the disease must be verified following nephrectomy, and early systemic treatment must be ensured. While the effectiveness of 18F-FDG PET/CT for renal malignancies is lower than for extrarenal malignancies due to the low activity of radioactive urine and renal neoplasms, it was reported to be useful in the diagnosis of SCC originating from the renal pelvis. Routine preoperative use of 18F-FDG PET/CT imaging in patients with chronic staghorn renal calculi to eliminate the possibility of SCC must also be considered regarding cost-effectiveness. In addition to being primarily used for the diagnosis of SCC, 18F-FDG PET/CT is also practical for the diagnosis of early metastases as presented in our case.
| Conclusion|| |
Renal SCC, which develops as a result of chronic irritation caused by renal stone disease, is usually diagnosed histologically after nephrectomy due to lack of clinical and radiological findings. In cases that SCC, which has an aggressive course, is diagnosed after nephrectomy, investigating the presence of metastasis with 18F-FDG PET/CT and initiating early systemic treatment if needed may contribute to survival.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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