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Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank

A case report

Kim, Jung Ryul MDa; Jeong, Young Beom MDb; Lee, Nae Ho MDc,d; Wang, Sung Il MDa,∗

Section Editor(s): NA.,

doi: 10.1097/MD.0000000000017049
Research Article: Clinical Case Report
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Rationale: Although chronic pyelonephritis and urolithiasis are established risk factors for squamous cell carcinoma (SCC), only a minority of patients with chronic urolithiasis eventually develop SCC. It is believed that the chronic irritation leads to squamous cell metaplasia that may subsequently develop into SCC. Although studies show that SSC generally spreads locally with associated symptoms of lymphadenopathy, metastasis to the lungs and liver have also been reported. However, cases spreading to the flank have yet to be reported. Therefore, the use of reconstructive techniques for the repair of extensive soft tissue defects in the flank region after extended retroperitoneal resection, is unknown.

Patient concerns: We report a 54-year-old man who presented with a 1-month history of an enlarged skin mass on the right flank.

Diagnoses: The patient was subsequently diagnosed with metastatic SCC involving the patient's integumentary system near the flank region proximal to the right kidney following percutaneous nephrostomy.

Interventions: The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin including radial nephrectomy. The soft tissue defect after resection was reconstructed using a unilateral gluteus maximus myocutaneous V-Y advancement flap.

Outcomes: No recurrence of the SSC was found on follow-up CT performed 12 months postoperatively.

Lessons: In patients with long-standing nephrolithiasis complicated by staghorn stone-related infections, biopsies from suspicious lesions detected during percutaneous nephrolithotomy may facilitate early diagnosis. The modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft-tissue defects involving the flank region.

aChonbuk National University, Biomedical Research Institute of Chonbuk National University Hospital, Research Institute of Clinical Medicine of Chonbuk National University, Department of Orthopedic Surgery

bDepartment of Urology, Chonbuk National University Medical School, Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital

cDepartment of Plastic and Reconstructive Surgery, Chonbuk National University Hospital, Chonbuk National University College of Medicine

dResearch Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Republic of Korea.

∗Correspondence: Sung Il Wang, Department of Orthopedic Surgery, Chonbuk National University Medical School, Research Institute for Endocrine Sciences and Research Institute of Clinical Medicine of Chonbuk National University–Biomedical Research Institute of Chonbuk National University Hospital, 567 Baekje-ro, Dukjin-gu, Jeonju 561-756, Republic of Korea (e-mail: wsi1205@naver.com).

Abbreviations: CT = computed tomography, SCC = squamous cell carcinoma.

How to cite this article: Kim JR, Jeong YB, Lee NH, Wang SI. Squamous cell carcinoma of the renal pelvis presenting as an integumentary neoplasm of the flank. Medicine 2019;98:36(e17049).

The authors have no funding and conflicts of interest to disclose.

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc/4.0

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1 Introduction

Squamous cell carcinoma (SCC) of the renal collecting system is rare, accounting only for 0.5% to 0.8% of malignant renal tumors.[1] The risk factors for the development of SCC of the renal pelvis include renal calculi, infections, endogenous and exogenous chemicals, radiation therapy and prior percutaneous nephrolithotomy (PCNL).[2–4] Although studies show that SSC generally spreads locally with associated symptoms of regional lymphadenopathy, metastasis to the lungs, liver, and bone have also been reported.[5] To date, no cases have been reported indicating metastatic spread to the integumentary system near the flank region. Therefore, the role of reconstructive technique in the repair of extensive soft tissue defects of flank region after extended retroperitoneal resection is unknown. Here, we report a case of SCC involving the renal pelvis spreading along the remnant percutaneous nephrostomy track to the skin on the flank region proximal to the right kidney in a 54-year-old-man. We suggest that the modified gluteus maximus V-Y advancement flap may be a useful technique for the reconstruction of extensive soft tissue defects involving the flank region.

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2 Consent

The patient signed informed consent for publication of this case report and any accompanying image. The ethical approval of this study was waived by the ethics committee of Chonbuk National University Hospital, because this study was case report and the number of patients was less than 3.

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3 Case report

In February 2018, a 54-year-old man presented with a 1-month history of progressively enlarged integumentary mass located on his right flank. The patient reported that he was treated for staghorn calculi involving both kidneys via percutaneous nephrolithotomy (PCNL) 13 years ago. Three months prior to the clinical presentation, the patient was treated for pyelonephritis and subjected to PCNL of the right kidney in the urology department. Physical examination revealed an erythematous nodular ulcerative skin mass measuring approximately 4.0 × 5.0 cm in size and located near the previous PCNL site on the right flank (Fig. 1). The laboratory results indicated an abnormally high erythrocyte sedimentation rate of 41 mm/h and a high sensitivity C-reactive protein level of 18.2 mg/L. The other laboratory results were within the normal range. The patient's urinalysis revealed microscopic hematuria and pyuria.

Figure 1

Figure 1

Radiographs of the kidney, ureter and bladder (KUB) obtained 3 months previously indicated nephrolithiasis with staghorn renal calculi within the right kidney (Fig. 2). Compared with previous radiographs contrast computed tomography (CT) of the abdomino-pelvic region revealed increasingly fragmented staghorn calculus. Multiple cysts measuring less than 2 cm were also identified in the right kidney (Fig. 3). Abdominal magnetic resonance imaging (MRI) with enhancement revealed a 4.0 × 5.0 cm well-defined mass of the integumentary system on the right flank. In addition, increased signaling was detected around the dermis and the muscles connected to the right kidney. A lesion with a parenchymal invasion measuring approximately 3.0 cm in diameter at the lower pole of the right kidney was observed (Fig. 4). However, no significant lymphadenopathy was identified. Chest CT and bone scan did not reveal any metastasis. A histopathological examination of the skin mass based on incisional biopsy confirmed the diagnosis of a well-differentiated SCC.

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin and radial nephrectomy was performed (Fig. 5a). The extensive soft tissue defect after resection was reconstructed using a V-Y unilateral gluteus maximus myocutaneous advancement flap (Fig. 5b). The final pathology report showed invasive, well-differentiated SCC of the right kidney. The tumor extended to the integumentary system near the right flank along the previous percutaneous nephrostomy track (Fig. 6). All surgical margins of the tumor were negative without any indication of regional lymphatic or adrenal invasion of the tumor (stage T3N0M0). The patient had an uneventful postoperative course and was discharged on postoperative day 17 with a well-healed flap wound (Fig. 5c). No recurrence of the SSC was noted on a follow-up CT scan performed 12 months postoperatively.

Figure 5

Figure 5

Figure 6

Figure 6

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4 Discussion

Although chronic pyelonephritis and nephrolithiasis are established risk factors for SCC, only a minority of patients suffering from these conditions develop SCC. Other etiologic factors such as tuberculosis, immunosuppression with azathioprine, radiation therapy, chronic rejection of a transplanted kidney and prior percutaneous nephrolithotomy have been associated with SCC.[4–6] Chronic irritation leads to squamous metaplasia, which may subsequently develop into SCC.[7] Early diagnosis of SCC in patients with nephrolithiasis is difficult and often impossible due to the existing stones and the inflammatory response of the kidney. Li et al[1] reported that the average duration of symptomatic nephrolithiasis in their patients with SCC was 8 years. The major symptoms of carcinoma of the renal pelvis include hematuria, lumbar pain, renal mass, and loin sinus formation,[8,9] although the first 3 symptoms may be confused with the recurrence of nephrolithiasis. Although cases of renal SCC are associated with renal stones, no specific imaging features are available to establish a definitive diagnosis. Renal SCC presents as a diffuse enlargement of the nonfunctional kidney with renal calculi, hydronephrosis, perirenal infiltration, and low density or echogenicity of the renal parenchyma.[7] SCC may also present as an infiltrative soft tissue in the renal pelvis without evidence of a distinct mass.[8] More specific findings detected via imaging include an enhanced extra-luminal or exophytic mass.[10] These varying imaging characteristics often contribute to diagnostic delays until histopathologic examination of the surgical specimen is performed.

The prognosis of patients with SCC of the renal pelvis is often poor due to delayed diagnosis and the biological behavior of the cancer. Since early diagnosis may be the only option for increased survival, Katz et al[4] suggested that biopsies from suspicious lesions during the PCNL may facilitate early diagnosis. In the present case, multiple cysts in the right kidney reflected inflammatory response to chronic calculi and a biopsy was not performed with the initial PCNL. Subsequently, 3 month later, SCC of the renal pelvis presented as an integumentary neoplasm near the flank along the previous percutaneous nephrostomy track. Thus, in the absence of clinical or radiological evidence of SCC, the possibility of SCC should always be considered while operating on a patient with a chronic history of nephrolithiasis or pyelonephritis. A biopsy is indicated for suspected lesions during the PCNL to prevent potential spread to surrounding tissues via the percutaneous nephrostomy track.

The skin mass and the surrounding muscle tissue of the right flank were excised with a wide resection margin and radial nephrectomy was performed. The extensive soft tissue defects of the flank region were reconstructed using the modified gluteus maximus V-Y advancement flap. The gluteus maximus V-Y advancement flap was originally used to treat decubitus ulcers in the sacral and ischial regions, or in the region of the greater trochanter. This myocutaneous flap has a copious blood supply, is safe, and facilitates the reconstruction of extensive skin defects after excision of a decubitus ulcer.[11,12] We reconstructed the flank region using the modified gluteus maximus V-Y advancement flap.[13] The original V-Y advancement is horizontal, lateral-to-medial, whereas the modified V-Y advancement employs a craniocaudal sliding technique. An additional 90 minutes of operation time was required for the flap; however, no severe postoperative pain was reported by the patients. The patient was able to perform normal daily activities without any complications. Thus, the modified gluteus maximus V-Y advancement flap is indicated for patients with metastatic renal cancer of the flank region requiring extensive tumor resection, and is associated with limited complications and a relatively rapid postoperative recovery.

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Author contributions

Conceptualization: Jung Ryul Kim, Young Beom Jeong, Sung Il Wang.

Data curation: Nae Ho Lee, Sung Il Wang.

Investigation: Jung Ryul Kim.

Resources: Young Beom Jeong, Nae Ho Lee.

Supervision: Jung Ryul Kim.

Writing – original draft: Jung Ryul Kim.

Writing – review & editing: Jung Ryul Kim, Sung Il Wang.

Sung Il Wang orcid: 0000-0002-3890-6516.

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References

[1]. Li MK, Cheung WL. Squamous cell carcinoma of the renal pelvis. J Urol 1987;138:269–71.
[2]. Schena S, Bogetti D, Setty S, et al. Squamous cell carcinoma in a chronically rejected renal allograft. Am J Transplant 2004;4:1208–11.
[3]. Papadopoulos I, Wirth B, Weichert-Jacobsen K, et al. Primary squamous cell carcinoma of the ureter and squamous adenocarcinoma of the renal pelvis: 2 case reports. J Urol 1996;155:288–9.
[4]. Katz R, Gofrit ON, Golijanin D, et al. Urothelial cancer of the renal pelvis in percutaneous nephrolithotomy patients. Urol Int 2005;75:17–20.
[5]. Hameed ZB, Pillai SB, Hegde P, et al. Squamous cell carcinoma of the renal pelvis presenting as sacral bone metastasis. BMJ Case Rep 2014;2014. pii: bcr2013201719.
[6]. Lee TY, Ko SF, Wan YL, et al. Renal squamous cell carcinoma: CT findings and clinical significance. Abdom Imaging 1998;23:203–8.
[7]. Holmäng S, Lele SM, Johansson SL. Squamous cell carcinoma of the renal pelvis and ureter: incidence, symptoms, treatment and outcome. J Urol 2007;178:51–6.
[8]. Blacher EJ, Johnson DE, Abdul-Karim FW, et al. Squamous cell carcinoma of the renal pelvis. Urology 1985;15:124–6.
[9]. Leong CH, Lim TK, Womg KK, et al. Carcinoma of the renal pelvis: An analysis of the diagnostic problems in 23 cases. Br J Surg 1976;63:102–6.
[10]. Kalayci OT, Bozdag Z, Sonmezgoz F, et al. Squamous cell carcinoma of the renal pelvis associated with kidney stones: radiologic imaging features with gross and histopathological correlation. J Clin Imaging Sci 2013;3:14.
[11]. Scheflan M, Nahai F, Bostwick J 3rd. Gluteus maximus island musculocutaneous flap for closure of sacral and ischial ulcers. Plast Reconstr Surg 1981;68:533–8.
[12]. Ramirez OM. The distal gluteus maximus advancement musculocutaneous flap for coverage of trochanteric pressure sores. Ann Plast Surg 1987;18:295–302.
[13]. Parry SW, Mathes SJ. Bilateral gluteus maximus myocutaneous advancement flaps: sacral coverage for ambulatory patients. Ann Plast Surg 1982;8:443–5.
Keywords:

gluteus maximus myocutaneous flap; kidney; percutaneous nephrolithotomy; squamous cell carcinoma

Copyright © 2019 the Author(s). Published by Wolters Kluwer Health, Inc.