Squamous cell carcinoma located in the renal caliceal system: A

Turkish Journal of Cancer
Vol.32/ No. 1/2002
Squamous cell carcinoma located
in the renal caliceal system: A case report
and review of the literature
AYHAN KARABULUT1, LEVENT EMİR1, MEHMET GÖNÜLTAŞ2,
NAZMİ İNCEL1, CANKON GERMİYANOĞLU1, DEMOKAN EROL1
Departments of 1Urology and 2Pathology, The Ministry of Health Ankara
Education and Research Hospital, Ankara-Turkey
Squamous cell carcinoma of the urinary tract is a very rarely
encountered tumor. It is more frequently reported in bladder and
male urethra than in renal pelvis. With the addition of new cases
in the literature, the impact of its features, such as the location
and the stage of the tumor, on the outcome will be highlighted.
Here, we present a case with renal squamous cell carcinoma
located in the upper caliceal system and discuss it in the light of
current literature. [Turk J Cancer 2002;32(1):20-24]
Key words: Squamous cell, kidney, carcinoma
Primary neoplasms of the renal collecting system are uncommon,
accounting for only 4-5% of all urothelial tumors (1,2). The transitional cell type
is the most frequently diagnosed (85% to 95%), followed by squamous cell
carcinoma (6% to 15%) and adenocarcinoma (7%) (3,4). In the present paper,
we report a 62 years old women who had lithiasis and squamous cell carcinoma
in her right non-functioning kidney.
Case report
A 62 year old female patient presented with intermittent, mild, right flank
pain. She had a history of urolithiasis for a long time. Physical examination
revealed a slight tenderness on right costovertebral angle and a palpable mass
on upper right quadrant of abdomen. Complete blood count, erythrocyte
sedimentation rate, biochemical analysis and urinalysis were all within the
normal ranges. Intravenous urogram revealed a non-functioning right kidney
and a 22x20 mm radioopacity located at the right renal area. Ultrasonography
revealed an obstructing calculi located in the renal pelvis and a solid mass in
the upper pole calyx. Computed tomography demonstrated a huge, nonfunctioning, hydronephrotic right kidney with a calculi of diameters 23x21 mm
located in the renal pelvis and a solid mass of approximately 25x21 mm in size,
located at the inner surface of the upper dilated calyx (Figure 1). There was an
adipose tissue obliteration between the liver and the adjacent right kidney.
20
KARABULUT et al.
21
Fig 1. Tomographic view of intraluminal solid mass in the right kidney
On the basis of these findings a radical right nephroureterectomy was
performed. The convalescence was uneventful.
Histopathologic examination revealed a tumoral tissue with atypical
squamous epithelial cells and intensive necrotic areas which invaded the renal
parenchyma (Figures 2 and 3).
Fig 2. Tumoral tissue with atypical squamous epithelial cells (H&E X100)
RENAL SQUAMOUS CELL CARCINOMA
22
Figure 3. Intensive necrotic areas and atypical squamous epithelial cells which
invaded the renal parenchyma (H&E X20)
The intact renal tissue showed tubular dilatation, thyroidisation and
lymphocytic infiltration that were all consistent with pyelonephritis. Tumor
invaded renal capsule and fascia of Gerota but not beyond the perirenal
adipose tissue. No metastasis was detected in the hilar lymph nodes. The
patient is under the follow-up for 4 months with no evidence of relapse or
metastasis of the disease.
Discussion
Primary squamous cell carcinoma of the renal collecting system is a very
rare entity. The incidence of renal squamous cell carcinoma among malignant
renal tumors ranged widely from 0.5% to 8% in the previous reports (5,6). In
general, these tumors are highly aggressive and are at high stage when
detected and can be expected to have a poor clinical course.
The lack of characteristic presentation like hematuria, pain and palpable
mass causes delay in diagnosis. Most of the detected tumors are histologically
high grade, 84% of the tumors were locally advanced or metastatic (7).
KARABULUT et al.
23
Squamous cell carcinoma of the renal pelvis is often associated with phenacetin
consumption, chronic renal calculi or infection. The incidence of co-existing
urinary stone was reported in a wide range between 18% (6) and 100% (5).
Squamous metaplasia invades mucosa adjacent to the carcinoma in 17% to
33% of the patients (8). Whether the occurrence of squamous metaplasia is due
to the presence of the calculus that leads ultimately to the development of
carcinoma or existence of squamous cell carcinoma causes the formation of
calculus is not clear yet. This dilemma is particularly valid for the co-existence
of the tumor and calculus at the renal pelvis. As renal squamous cell carcinoma
is frequently associated with infected staghorn calculi existing for a long
duration, it is recommended for the patients with renal stone disease who don’t
need intervention or patients under extracorporeal shock wave lithotripsy
treatment or patients with non-functioning kidney due to stone disease to be
carefully examined with imaging modalities (9).
The tumor can be documented by conventional radiological imaging
modalities. Filling defects or obstructive lesions in the renal pelvis by
intravenous/retrograde urography or detection of a solid mass by
ultrasonography can be the signs of the tumor (10). Tomographic imaging
reveals these findings more specifically (10,11).
Recently in a retrospective study of Lee et al (9), 15 patients with squamous
cell carcinoma of the kidney were classified into two groups according to
localisation of the tumors as central and peripheral type. They stated that the
central renal squamous cell carcinoma presents more intraluminal components
and is usually associated with lymph node metastasis whereas peripheral renal
squamous cell carcinoma presents with prominent renal parenchymal
thickening and might invade the perirenal fat tissue before lymph node or
distant metastasis could be identified. The survival of patients with central renal
squamous cell carcinoma was reported to be significantly shorter than those
with peripheral renal squamous cell carcinoma.
In the report of Nativ et al (7), patients with renal squamous cell carcinoma
were divided into three groups on the basis of tumor staging criterias outlined
by Peterson (12). Nativ et al reported that patients with locally invasive renal
squamous cell carcinomas had 1 and 2 year-survival rates of 33% and 22%,
respectively. They have also reported that the treatment modalities like
nephrectomy, nephroureterectomy, adjuvant radiotherapy or chemotherapy,
irrespective of tumor stage, did not affect the survival of the patients.
The current primary treatment of renal squamous cell carcinoma is
nephroureterectomy. If metastasis develops, adjuvant chemotherapy or
irradiation has little effect on the unfavourable prognosis (10).
The case that we mention here is consistent with the peripheral type renal
squamous cell carcinoma as reported by Lee et al (9). The tumor was locally
advanced like most of the tumors in the literature. The co-existence of renal
calculus and renal squamous cell carcinoma was also present in this case.
Patients with renal stone disease who don’t need intervention or patients under
extracorporeal shock wave lithotripsy treatment or patients with non-functioning
kidney due to stone disease must be carefully examined with imaging
modalities and by this way the early detection of the tumor may provide a better
outcome for the patients.
RENAL SQUAMOUS CELL CARCINOMA
24
Despite the tumor of our patient has invaded the fascia of Gerota, we are in
an expectation of a better survival with respect to the central type renal
squamous cell carcinoma. We decided to follow-up the patient until the
evidence of metastatic disease would be demonstrated. We are planning to
start a combination chemotherapy including methotrexate, cisplatin and
bleomycin as reported by Corral et al (13) recently if the signs of metastatic
disease are revealed. Corral reported a high but short lived overall response
rate with this chemotherapy regimen.
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