Med Oncol (2014) 31:169 DOI 10.1007/s12032-014-0169-3
LETTER TO THE EDITOR
Metastatic parenchymal renal squamous cell carcinoma with hypercalcemia Yusuf Ac¸ıkgo¨z • Mehmet Ali Nahit S¸ endur ¨ zdemir • Sercan Aksoy • Nuriye Yıldırım O Nurullah Zengin
•
Received: 28 July 2014 / Accepted: 8 August 2014 / Published online: 19 August 2014 Ó Springer Science+Business Media New York 2014
To the Editor, Renal tumors originated from renal parenchyme or renal pelvis with different histological subtypes. The most common observed malign renal tumors are clear cell renal cell carcinoma (CCRCC), multilocular cystic renal cell carcinoma (MCRCC), papillary renal cell carcinoma (PRCC), chromophobe RCC and carcinoma of the collecting ducts of Bellini, respectively [1]. Primary squamous cell carcinoma (SCC) of the renal parenchyme or renal pelvis is very unusual and rare entity which accounts less than 1 % of renal malign tumors [2]. To our knowledge, there are only two renal parenchymal SCC cases reported until today [3]. This letter presents a case of metastatic renal parenchymal squamous cell carcinoma associated with hypercalcemia, which is not reported until now. A 53-year-old male patient was admitted to our clinic with severe left-sided flank pain and intermittent hematuria. The patient was non-smoker and had a history of intermittent flank pain due to nephrolithiasis. Laboratory evaluation revealed mild anemia and hypercalcemia with microscopic hematuria. Serum calcium level was 13.2 mg/ dl (normal range 8.6–10.2 mg/dl) and serum albumin was 2.9 g/dl (normal range 3.5–4.5 mg/dl) with suppressed Y. Ac¸ıkgo¨z Department of Internal Medicine, Ankara Numune Education and Research Hospital, Ankara, Turkey ¨ zdemir N. Zengin M. A. N. S¸ endur (&) N. Y. O Department of Medical Oncology, Faculty of Medicine, Yıldırım Beyazıt University, 06800 Bilkent, Ankara, Turkey e-mail: [email protected] S. Aksoy Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
parathyroid hormone levels and normal renal functions. Corrected calcium level was calculated as 14.1 mg/dl. By intense hydration and zoledronic acid treatment, serum calcium level was corrected to normal levels. Thoracic and abdominal computed tomography (CT) was performed, and multiple metastatic nodular lesions in both lung and multilocular metastatic hypodense masses with the largest 61 9 55 mm in the right posterior lobe of liver were revealed. Additionally, prominent parenchymal mass in the right kidney and perirenal multiple lymphadenopathies with the biggest size of 18 9 33 mm were found. The patient underwent cytoreductive nephrectomy and right hemicolectomy due to direct tumoral invasion. On the gross examination, the tumor measuring 6.2 9 4.2 9 3.1 cm diameter with multiple calculus was seemed as ulcerative and necrotic confined to the upper pole of right kidney. No tumoral invasion to the renal pelvis was found. Pathological examination of the surgical material revealed moderately differentiated SCC in the renal parenchyma directly invasive to the serosal surface of the right colon without mucosal involvement. Then, due to the extensive disease, patient was treated with six cycles of gemcitabine and carboplatin regimen every 3 weeks plus zoledronic acid. After six cycles of chemotherapy, the patient was progressively deteriorated and died. Squamous cell carcinomas are associated with chronic inflammatory conditions such as renal calculi, recurrent urinary tract infections and schistosomiasis. So, a patient with SCC should be evaluated for such predisposing risk factors that associated with squamous metaplasia and subsequently SCC [4]. In our case, renal calculi were established in both radiologic studies and gross examination of the surgical material. Due to the renal pelvis SCCs tend to be invasive and sessile, the diagnosis of the renal parenchymal SCC should be confirmed with the evaluation
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of the renal pelvis in terms of absence of invasion from the renal pelvis or of urothelial components [5]. In our case, the renal pelvis was clearly normal and only necrosis and ulceration were found in the pathologic examination of surgical material. There is no obvious pathophysiological mechanism for causing renal parenchymal SCC. It likely has the same causes as in the renal pelvis SCC. Renal parenchymal SCCs can be diagnosed at advanced stage due to tendency to be sessile and invasive as like our case that metastases to lung and liver. So, it has poorer prognosis compared to renal pelvis SCC at the same stage [5]. Surgery is the main treatment of renal SCCs, and the exact benefit of systemic chemotherapy was not known [6]. Due to the diagnosis of advanced stage, the curative surgery is generally impossible. Hypercalcemia associated with SCC is a well-known finding. Hypercalcemia has been reported in up to 30 percent of patients with SCC during the course of their disease [7]. Hypercalcemia in cancer patients usually associated with prostaglandin, osteoclast stimulating factor or parathormone-like substance production or pseudohyperparathyroidism. In renal pelvis SCC patients, hypercalcemia was rarely reported during the course of the disease, but until now hypercalcemia was not reported in patients with renal parenchymal SCC [8]. In our case, no relation was found between serum parathyroid hormone level and hypercalcemia. Hypercalcemia in our patient is probably related to parathormone-like substance as previous SCC cases. In conclusion, renal malignancies histologically have different subtypes. Of these subtypes, renal SCC exists less often and has poor prognosis. It usually arises from renal pelvis or ureter and strongly associates with chronic
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Med Oncol (2014) 31:169
inflammatory situation as renal or ureteral calculi. There is no prompt radiologic or laboratory signs to make differential diagnosis. Most of the renal SCC cases reported until now were arisen from renal pelvis or ureter. Differential diagnosis of SCC of the renal parenchyme or the other site of urinary system must be made with pathological examination and radiological studies. Treatment of renal SCC includes surgery and systemic chemotherapy. Conflict of interest interest.
The authors indicated no potential conflicts of
References 1. Lopez-Beltran A, Scarpelli M, Montironi R, Kirkali Z. 2004 WHO classification of the renal tumors of the adults. Eur Urol. 2006;49(5):798–805. 2. Li MK, Cheung WL. Squamous cell carcinoma of the renal pelvis. J Urol. 1987;138:269–71. 3. Ghosh P, Saha K. Primary intraparenchymal squamous cell carcinoma of the kidney: a rare and unique entity. Case Rep Pathol. 2014;2014:256813. 4. Paonessa J, Beck H, Cook S. Squamous cell carcinoma of the renal pelvis associated with kidney stones: a case report. Med Oncol. 2011;28(Suppl 1):S392–4. 5. Kulshreshtha P, Kannan N, Bhardwaj R, Batra S. Primary squamous cell carcinoma of the renal parenchyma. Indian J Pathol Microbiol. 2012;55:370–1. 6. Kose F, Bal N, Ozyilkan O. Squamous cell carcinoma of the renal pelvis. Med Oncol. 2009;26(1):103–4. 7. Sendur MA, Aksoy S, Arık Z, Yaman S, Ozdemir NY, Uncu D, Zengin N. Small cell carcinoma of the urinary bladder with hypercalcemia. Med Oncol. 2012;29(2):827–8. 8. Cadeddu JA, Jarrett TW. Hypercalcemia associated with squamous cell carcinoma of the renal pelvis. J Urol. 1998;160(5):1798.
LETTER TO THE EDITOR
Metastatic parenchymal renal squamous cell carcinoma with hypercalcemia Yusuf Ac¸ıkgo¨z • Mehmet Ali Nahit S¸ endur ¨ zdemir • Sercan Aksoy • Nuriye Yıldırım O Nurullah Zengin
•
Received: 28 July 2014 / Accepted: 8 August 2014 / Published online: 19 August 2014 Ó Springer Science+Business Media New York 2014
To the Editor, Renal tumors originated from renal parenchyme or renal pelvis with different histological subtypes. The most common observed malign renal tumors are clear cell renal cell carcinoma (CCRCC), multilocular cystic renal cell carcinoma (MCRCC), papillary renal cell carcinoma (PRCC), chromophobe RCC and carcinoma of the collecting ducts of Bellini, respectively [1]. Primary squamous cell carcinoma (SCC) of the renal parenchyme or renal pelvis is very unusual and rare entity which accounts less than 1 % of renal malign tumors [2]. To our knowledge, there are only two renal parenchymal SCC cases reported until today [3]. This letter presents a case of metastatic renal parenchymal squamous cell carcinoma associated with hypercalcemia, which is not reported until now. A 53-year-old male patient was admitted to our clinic with severe left-sided flank pain and intermittent hematuria. The patient was non-smoker and had a history of intermittent flank pain due to nephrolithiasis. Laboratory evaluation revealed mild anemia and hypercalcemia with microscopic hematuria. Serum calcium level was 13.2 mg/ dl (normal range 8.6–10.2 mg/dl) and serum albumin was 2.9 g/dl (normal range 3.5–4.5 mg/dl) with suppressed Y. Ac¸ıkgo¨z Department of Internal Medicine, Ankara Numune Education and Research Hospital, Ankara, Turkey ¨ zdemir N. Zengin M. A. N. S¸ endur (&) N. Y. O Department of Medical Oncology, Faculty of Medicine, Yıldırım Beyazıt University, 06800 Bilkent, Ankara, Turkey e-mail: [email protected] S. Aksoy Department of Medical Oncology, Hacettepe University Cancer Institute, Ankara, Turkey
parathyroid hormone levels and normal renal functions. Corrected calcium level was calculated as 14.1 mg/dl. By intense hydration and zoledronic acid treatment, serum calcium level was corrected to normal levels. Thoracic and abdominal computed tomography (CT) was performed, and multiple metastatic nodular lesions in both lung and multilocular metastatic hypodense masses with the largest 61 9 55 mm in the right posterior lobe of liver were revealed. Additionally, prominent parenchymal mass in the right kidney and perirenal multiple lymphadenopathies with the biggest size of 18 9 33 mm were found. The patient underwent cytoreductive nephrectomy and right hemicolectomy due to direct tumoral invasion. On the gross examination, the tumor measuring 6.2 9 4.2 9 3.1 cm diameter with multiple calculus was seemed as ulcerative and necrotic confined to the upper pole of right kidney. No tumoral invasion to the renal pelvis was found. Pathological examination of the surgical material revealed moderately differentiated SCC in the renal parenchyma directly invasive to the serosal surface of the right colon without mucosal involvement. Then, due to the extensive disease, patient was treated with six cycles of gemcitabine and carboplatin regimen every 3 weeks plus zoledronic acid. After six cycles of chemotherapy, the patient was progressively deteriorated and died. Squamous cell carcinomas are associated with chronic inflammatory conditions such as renal calculi, recurrent urinary tract infections and schistosomiasis. So, a patient with SCC should be evaluated for such predisposing risk factors that associated with squamous metaplasia and subsequently SCC [4]. In our case, renal calculi were established in both radiologic studies and gross examination of the surgical material. Due to the renal pelvis SCCs tend to be invasive and sessile, the diagnosis of the renal parenchymal SCC should be confirmed with the evaluation
123
169 Page 2 of 2
of the renal pelvis in terms of absence of invasion from the renal pelvis or of urothelial components [5]. In our case, the renal pelvis was clearly normal and only necrosis and ulceration were found in the pathologic examination of surgical material. There is no obvious pathophysiological mechanism for causing renal parenchymal SCC. It likely has the same causes as in the renal pelvis SCC. Renal parenchymal SCCs can be diagnosed at advanced stage due to tendency to be sessile and invasive as like our case that metastases to lung and liver. So, it has poorer prognosis compared to renal pelvis SCC at the same stage [5]. Surgery is the main treatment of renal SCCs, and the exact benefit of systemic chemotherapy was not known [6]. Due to the diagnosis of advanced stage, the curative surgery is generally impossible. Hypercalcemia associated with SCC is a well-known finding. Hypercalcemia has been reported in up to 30 percent of patients with SCC during the course of their disease [7]. Hypercalcemia in cancer patients usually associated with prostaglandin, osteoclast stimulating factor or parathormone-like substance production or pseudohyperparathyroidism. In renal pelvis SCC patients, hypercalcemia was rarely reported during the course of the disease, but until now hypercalcemia was not reported in patients with renal parenchymal SCC [8]. In our case, no relation was found between serum parathyroid hormone level and hypercalcemia. Hypercalcemia in our patient is probably related to parathormone-like substance as previous SCC cases. In conclusion, renal malignancies histologically have different subtypes. Of these subtypes, renal SCC exists less often and has poor prognosis. It usually arises from renal pelvis or ureter and strongly associates with chronic
123
Med Oncol (2014) 31:169
inflammatory situation as renal or ureteral calculi. There is no prompt radiologic or laboratory signs to make differential diagnosis. Most of the renal SCC cases reported until now were arisen from renal pelvis or ureter. Differential diagnosis of SCC of the renal parenchyme or the other site of urinary system must be made with pathological examination and radiological studies. Treatment of renal SCC includes surgery and systemic chemotherapy. Conflict of interest interest.
The authors indicated no potential conflicts of
References 1. Lopez-Beltran A, Scarpelli M, Montironi R, Kirkali Z. 2004 WHO classification of the renal tumors of the adults. Eur Urol. 2006;49(5):798–805. 2. Li MK, Cheung WL. Squamous cell carcinoma of the renal pelvis. J Urol. 1987;138:269–71. 3. Ghosh P, Saha K. Primary intraparenchymal squamous cell carcinoma of the kidney: a rare and unique entity. Case Rep Pathol. 2014;2014:256813. 4. Paonessa J, Beck H, Cook S. Squamous cell carcinoma of the renal pelvis associated with kidney stones: a case report. Med Oncol. 2011;28(Suppl 1):S392–4. 5. Kulshreshtha P, Kannan N, Bhardwaj R, Batra S. Primary squamous cell carcinoma of the renal parenchyma. Indian J Pathol Microbiol. 2012;55:370–1. 6. Kose F, Bal N, Ozyilkan O. Squamous cell carcinoma of the renal pelvis. Med Oncol. 2009;26(1):103–4. 7. Sendur MA, Aksoy S, Arık Z, Yaman S, Ozdemir NY, Uncu D, Zengin N. Small cell carcinoma of the urinary bladder with hypercalcemia. Med Oncol. 2012;29(2):827–8. 8. Cadeddu JA, Jarrett TW. Hypercalcemia associated with squamous cell carcinoma of the renal pelvis. J Urol. 1998;160(5):1798.
