
==== Front
IJU Case Rep
IJU Case Rep
10.1002/(ISSN)2577-171X
IJU5
IJU Case Reports
2577-171X
John Wiley and Sons Inc. Hoboken

10.1002/iju5.12771
IJU512771
IJUCR-2024-0035.R1
Case Report
Case Report
Primary squamous cell carcinoma of the kidney with hepatic invasion
SCC of the kidney with hepatic invasion
M Takanashi et al.
Takanashi Masato https://orcid.org/0009-0001-0116-3624
1
Asaoka Miho 1
Imano Masashi 1
Fujioka Azumi 1
Oishi Yuka 2
Matsuda Goro 2
Chiba Sawako 3
Hirai Kotaro 1 kohirai2002@yahoo.co.jp

1 Department of Urology National Hospital Organization Yokohama Medical Center Yokohama Kanagawa Japan
2 Department of Surgery National Hospital Organization Yokohama Medical Center Yokohama Kanagawa Japan
3 Department of Diagnostic Pathology National Hospital Organization Yokohama Medical Center Yokohama Kanagawa Japan
* Correspondence: Kotaro Hirai M.D., Department of Urology, National Hospital Organization Yokohama Medical Center, 3‐60‐2, Harajuku, Totsuka, Yokohama, Kanagawa 245‐8575, Japan. Email: kohirai2002@yahoo.co.jp

13 8 2024
9 2024
7 5 10.1002/iju5.v7.5 408413
04 3 2024
04 8 2024
© 2024 The Author(s). IJU Case Reports published by John Wiley & Sons Australia, Ltd on behalf of Japanese Urological Association.
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Introduction

Primary squamous cell carcinoma of the kidney is rare, with only a few cases reported to date.

Case presentation

A right renal mass was detected in a 73‐year‐old asymptomatic man. Dynamic contrast‐enhanced computed tomography showed a hypodensity mass extending from the upper pole of the kidney to the right lobe of the liver. Renal biopsy revealed that this tumor was squamous cell carcinoma. One month later, computed tomography showed rapid tumor growth. Radical nephrectomy and partial hepatic resection were performed. Pathological analysis indicated that this tumor originated from the tubular epithelium, and the patient was diagnosed with primary squamous cell carcinoma of the kidney.

Following up without adjuvant therapy, he developed retroperitoneal recurrence and multiple lung metastases and expired.

Conclusion

In this case, squamous cell carcinoma of the kidney invaded the liver and progressed rapidly. Considering these observations, surgical resection should be promptly performed in suspected cases.

hepatectomy
kidney
liver
nephrectomy
squamous cell carcinoma
source-schema-version-number2.0
cover-dateSeptember 2024
details-of-publishers-convertorConverter:WILEY_ML3GV2_TO_JATSPMC version:6.4.8 mode:remove_FC converted:01.09.2024
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pmc Keynote message

Primary squamous cell carcinoma of the kidney is very rare. This disease may be invasive and progress rapidly. Considering its rapid progression, surgical resection should be performed as soon as possible in suspected cases.

Abbreviations & Acronyms

CRP C‐reactive protein

CT computed tomography

FDG‐PET fluorodeoxyglucose‐positron emission tomography

GATA3 GATA‐binding protein 3

HE hematoxylin and eosin

PAX8 paired box 8

SCC squamous cell carcinoma

Introduction

Primary SCC of the kidney is rare, with only a few cases reported to date. 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 This disease is often detected at an advanced stage with chronic inflammatory reactions like kidney stones and infections, and there are reports of invasion to adjacent organs. 8 It is difficult to diagnose only by imaging and blood test, and surgery is the primary treatment option, with chemotherapy and radiotherapy exhibiting limited efficacy. 7 , 9 We report a very rare case of a primary SCC of the kidney with liver invasion, characterized by rapid progression.

Case presentation

A 73‐year‐old asymptomatic man, without remarkable family/medical history, was referred to our hospital for further evaluation after an abdominal ultrasonography detected a right renal mass. Physical examination did not reveal abnormalities. Contrast‐enhanced CT showed a poorly marginated, inhomogeneous low‐density mass with capsular enhancement and internal calcification extending from the upper pole of the right kidney to the right lobe of the liver, measuring approximately 8.0 cm (Fig. 1). There were no distant or lymph node metastases, and no venous thrombosis (cT4N0M0). A CT scan performed 10 months earlier had revealed a renal cyst with internal calcification at the upper pole, but not a right renal mass (Bosniak classification: IIF) (Fig. 1). Blood testing showed elevated levels of CRP (7.57 mg/dL; normal ~0.30 mg/dL) and corrected calcium (12.0 mEq/L; normal 8.8–10.1 mEq/L), and normal liver enzymes.

Fig. 1 Contrast‐enhanced CT showed a hypodense mass with capsular enhancement effect extending from the upper pole of the right kidney to the right lobe of the liver (a–c). A CT scan performed 10 months earlier had revealed the presence of a renal cyst with internal calcification at the upper pole, but not a right renal mass (d–f).

A percutaneous kidney biopsy was performed to identify the origin of the tumor. Histopathological examination revealed SCC forming an infiltrative pavement‐like arrangement (Fig. 2). Immunohistochemistry showed positivity for high molecular‐weight cytokeratin, p63, almost negativity for GATA3, and negativity for PAX8 (Fig. 2). Nevertheless, this analysis could not determine the origin of this SCC (i.e., urothelial or renal cell).

Fig. 2 Histologic findings of the tumor biopsy (a–c) and resected specimen (d–f). (a) Tumor cells had a polygonal eosinophilic cytoplasm with well‐defined borders. HE staining: (a) 100×, (b) 200×. (b) GATA3‐almost negative (200×). (c) PAX8‐negative (200×). (d) The right kidney and part of the liver were removed as a single lump. (e) The cut surfaces of the right kidney and liver. The renal cystic lesion (arrow) showing pure SCC, including numerous renal stones with cavitation due to necrosis. (f) Tumor cells grew and migrated within the tubules and along the glomerular structures. HE staining: (e) 100×; (f) 200×.

Two weeks after the initial visit, the patient developed chronic fever and worsening general malaise. Repeated contrast‐enhanced CT at 1 month after initial presentation showed rapid tumor growth and progression to hepatic invasion. There were no distant or lymph node metastases observed (Fig. 3). FDG‐PET/CT confirmed the absence of metastasis (Fig. 3). Blood testing showed further elevation of CRP and corrected calcium levels (CRP: 9.64 mg/dL; calcium: 14.64 mg/dL).

Fig. 3 A CT scan and FDG‐PET/CT were performed 1 month after the CT shown in Figure 1. There was rapid growth of the right renal tumor and progression to hepatic invasion (a–d). FDG‐PET/CT did not reveal metastasis (e, f).

Radical nephrectomy and hepatic resection of the posterior segment by laparotomy were urgently performed. The right kidney and part of the liver were removed as a single lump with a reversed L‐shaped incision (Fig. 2). No lymph node enlargement or venous thrombosis was observed, but mild adhesions were noted. Total operative time was about 10 h, total blood loss was 1850 mL. Almost the entire upper pole of the kidney had been replaced by the tumor, and a calcified renal cyst had been filled with tumoral tissue, including numerous small black stones (>100) (Fig. 2). The tumor had invaded the Gerota's fascia, right adrenal gland, and liver. Histopathological analysis indicated negative resection margins and revealed a pure SCC arranged in a multilayered squamous‐like sheet, with focal or fenestrated structures and infiltrative growth (Fig. 2). Tumor cells were growing and migrating within the tubules and along the glomerular structures. Immunohistochemistry showed positivity for high molecular‐weight cytokeratin, p63, and negativity for GATA3 and PAX8. Although differentiation was not possible with immunostaining, the findings suggesting an origin from the cyst wall led to the determination that it derived from the renal tubules. These findings led us to conclude that the final diagnosis was primary SCC of the kidney (pT4N0, moderate‐to‐well differentiated).

The patient was discharged 12 days after surgery without major complications. He did not receive any adjuvant treatment. Two months after surgery, he developed right retroperitoneal recurrence and multiple lung metastases. The patient expired of multiple organ failure due to cancer progression 4 months after surgery.

Discussion

SCC of the urinary tract rarely originates from the kidney, and the etiology of renal SCC remains unclear. This is one of the few cases of renal primary SCC (Table 1). We present a case of invading the liver and exhibiting extremely rapid tumor growth.

Table 1 Characteristics of the published cases of primary SCC of the kidney

Reference number	Author	Sex	Age	Presentation	Location	Treatment	Tumor extent	Adjuvant treatment	Prognosis	
1	Terada (2010)	M	73 years	Hematuria and lumbago	Bladder, left ureter, and left kidney	Cystectomy and nephroureterectomy	Replace the entire kidney	Absent	Alive and disease free after at 3 months after surgery	
2	Kulshreshtha (2012)	F	60 years	Weight loss for 3 months	Mid and lower pole of the left kidney	Radical nephrectomy with lymph node dissection	6.5 × 5.5 cm

Gerota fascia invasion and para‐aortic lymph node metastasis (pT4N1)

	Absent	Alive and disease free after at 13 months after surgery	
3	Ghosh (2014)	M	51 years	Dull and intermittent flank pain for 5 months	Lower pole of the right kidney	Radical nephrectomy	5.8 × 5.5 cm (pT1bN0)	Absent	Alive and disease free after at 12 months after surgery	
4	Sahoo (2015)	F	50 years	Right abdomen pain for 6 months	Upper pole of the right kidney	Radical nephrectomy	8.0 × 6.0 cm (pT2aNx)	Absent	Alive and disease free after at 6 months after surgery	
5	Wang (2016)	M	61 years	Hematuria and lumbago for 2 months	Right kidney	Radical nephrectomy	Gerota fascia invasion (pT3aNx)	Absent	Alive and disease free after at 1 month after surgery	
6	Zhang (2020)	F	61 years	Intermittent flank pain for 2 months	Lower pole of the right kidney	Radical nephrectomy	Gerota fascia invasion (pT3aNx)	Absent	Alive and disease free after at 3 months after surgery	
7	Fotovat (2021)	F	41 years	Flank pain and dysuria for 3 months	Lower pole of the left kidney	Radical nephrectomy	Gerota fascia invasion and para‐aortic lymph node metastasis (pT3aN1)	Adjuvant chemotherapy with cisplatin and gemcitabine	Ovarian metastasis 8 months after surgery, then death	
8	Cheol (2022)	M	61 years	Flank pain and weight loss for 2 months	Lower pole of the right kidney	Radical nephrectomy with right hemicolectomy	9.0 × 8.0 cm

Ascending colon invasion (pT4N0)

	Absent	Alive and disease free after at 6 months after surgery	
9	Liang (2023)	M	52 years	1 week of renal cyst found in physical examination	Upper pole of the right kidney	Robot‐assisted partial nephrectomy	8.3 × 8.2 × 8.1 cm (pT2aNx)	Absent	Alive and disease free after at 6 months after surgery	
10	Present	M	73 years	Renal mass on echo	Upper pole of the right kidney	Radical nephrectomy with partial hepatectomy	9.0 × 9.0 cm

Adrenal and hepatic invasion (pT4)

	Absent	Retroperitoneal recurrence and multiple lung metastases appeared 2 months after surgery, then death	

SCC tends to invade surrounding organs, while urothelial carcinoma is associated with distant metastases. 10 Hepatic invasion is rare in renal cell carcinoma, and combined renal‐hepatic resection is recommended as curative treatment. 11 Invasion of the ascending colon by SCC of the kidney has been previously reported. 8 Nevertheless, invasion of other organs, including the liver, has rarely been reported thus far.

Most previous cases of SCC of the kidney developed following chronic stresses (e.g., kidney stones and hydronephrosis). 1 , 2 , 4 , 5 , 6 , 7 , 8 , 9 SCC in various organs is thought to be associated with chronic inflammation. 12 , 13 In this case, a calcified renal cyst was observed several years before the onset of this cancer, and calcified content might irritate the epithelium of the wall. Histopathology showed the cyst was filled with tumoral tissue and tumor cell grew within the tubules, and immunohistochemistry showed no diagnostic information of urothelial and renal cell carcinoma. Thus, we thought that the epithelium of the wall was most likely the origin of this cancer.

Unlike in this case, disease progression was not regularly monitored (e.g., on a monthly basis) in previous cases. According to our observations, SCC of the kidney could progress rapidly within weeks or months. Therefore, prompt surgical intervention for renal tumors that develop due to chronic stress could be an appropriate treatment option.

Platinum‐based chemotherapy has been used to treat SCC of the kidney, renal pelvis, and ureter. 7 , 14 Nonetheless, this treatment has demonstrated limited effectiveness, and including this case, recurrent cases often result in death. Chemotherapy with cisplatin, methotrexate, and vinblastine is effective in treating SCC of the urinary tract. 15 However, this option has not been established as standard treatment for SCC of the kidney. Despite the low responsiveness of SCC of the urinary bladder to standard chemotherapy regimens, the use of preoperative radiotherapy has been associated with improved patient survival. 10 Further research is required to evaluate the effectiveness of newly developed treatments (e.g., immune checkpoint inhibitors) as well as chemotherapy and radiotherapy strategies.

Conclusion

We reported the case of renal SCC with invasion of the liver, treated by combined renal‐hepatic resection. Renal SCC is very rare, could progress very rapidly, and should be suspected in cases where chronic stress has precipitated the renal malignancy. Furthermore, considering the risk of exceedingly rapid progression of this disease, surgery should be performed as soon as possible.

Author contributions

Masato Takanashi: Writing – original draft; writing – review and editing. Miho Asaoka: Validation. Masashi Imano: Validation. Azumi Fujioka: Validation. Yuka Oishi: Validation. Goro Matsuda: Validation. Sawako Chiba: Writing – review and editing. Kotaro Hirai: Supervision; writing – review and editing.

Conflict of interest

The authors declare no conflict of interest.

Approval of the research protocol by an Institutional Reviewer Board

Not applicable.

Informed consent

Written informed consent was provided by the patient for the publication of this case report and any accompanying images.

Registry and the Registration No. of the study/trial

Not applicable.
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