
==== Front
Urol Case Rep
Urol Case Rep
Urology Case Reports
2214-4420
Elsevier

S2214-4420(24)00179-7
10.1016/j.eucr.2024.102825
102825
Oncology
Simultaneous lung and renal squamous cell carcinoma: A diagnostic and treatment challenge
Zhang Feng a
Sun Wei-Cheng a
Sun Jia-Ning b
Tang Gong-Lin c
Chen Xin c
Zhao Hong-Wei 15153578806@126.com
c⁎
a Second Clinical Medical College, Binzhou Medical University, Yantai, China
b Shandong Second Medical University Clinical Medical College, Weifang, China
c Qingdao University Affiliated Yantai Yuhuangding Hospital, Yantai, China
⁎ Corresponding author. 15153578806@126.com
18 8 2024
9 2024
18 8 2024
56 10282517 6 2024
5 8 2024
11 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
This article discusses a case study of a 68-year-old male patient with lung squamous cell carcinoma (LUSC) who developed solitary renal metastasis. The importance of routine imaging for detecting asymptomatic renal metastasis is highlighted. The efficacy of various treatment options, including nephrectomy, stereotactic body radiation therapy, and cryoablation, is explored. The study underscores the need for a multidisciplinary team approach in managing LUSC with renal metastasis, due to the lack of clear treatment guidelines.
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pmc1 Background

Lung cancer is traditionally categorized into small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC), with NSCLC comprising approximately 80 % of all lung cancer cases.1 Within the NSCLC subset, LUSC accounts for roughly 40 % of cases.1 Although primary LUSC involving the solitary kidney is a rare occurrence, distant metastasis remains the leading cause of mortality.2 Diagnosing LUSC with renal metastasis presents a significant challenge, and the optimal treatment approach for solitary renal metastasis remains elusive. This study presents a case of LUSC with solitary unilateral renal metastasis, along with the subsequent nephrectomy performed on the patient.

2 Case presentation

A 68-year-old male patient presented to the hospital with coughing and underwent radiological evaluation, revealing a mass in the right lower lobe on chest X-ray and computed tomography (CT) scans (Fig. 1A and B). Bronchoscopy revealed a neoplasm obstructing the lumen at the opening of the right lower lobe bronchus. Subsequently, the patient underwent right lower lobectomy and mediastinal lymph node dissection. Postoperative pathology confirmed a poorly differentiated squamous cell carcinoma with multifocal involvement, but no evidence of metastasis (Fig. 1C). Immunohistochemical analysis demonstrated positive staining for CK5/6, P40, and partial weak positivity for CK7, with negative staining for NapsinA and a Ki-67 proliferation index of approximately 70 %. Following surgery, the patient received four cycles of adjuvant chemotherapy with cisplatin and vincristine.Fig. 1 Chest X-ray showing patchy high-density shadows in the right lower lung field, indicating a potential lung lesion (A). Computed tomography (CT) scan of the chest, highlighting a nodule in the right lung lobe, which was confirmed as squamous cell carcinoma postoperatively (B,C). Enhanced abdominal CT scan revealing a solitary mass in the right kidney, corresponding to the squamous cell carcinoma pathology of the surgically removed kidney tissue (D,E,F).

Fig. 1

Following completion of chemotherapy, the patient underwent regular check-ups and follow-up examinations every 4 months. Approximately 8 months after achieving a disease-free status, a contrast-enhanced abdominal CT scan revealed an irregular mass in the right kidney. Enhanced CT scans of the chest and brain MRI did not demonstrate any evidence of metastasis elsewhere (Fig. 1D). Consequently, the patient underwent a radical right nephrectomy, with no postoperative complications (Fig. 1E). The patient's renal function remained stable before and after nephrectomy, with creatinine levels rising from 1.2 mg/dL to 1.6 mg/dL and estimated glomerular filtration rate (eGFR) decreasing from 75 mL/min/1.73 m2 to 60 mL/min/1.73 m2, both remaining within the acceptable range for a single functioning kidney. Blood urea nitrogen (BUN) levels increased slightly from 12 mg/dL to 15 mg/dL, also within acceptable limits for a single kidney. The patient's urine output decreased from 1.5 L/24 hours to 1.2 L/24 hours, but this was still within the normal range. Pathological examination of the resected kidney tissue confirmed an infiltrating low-grade carcinoma, which was interpreted as renal metastasis from the LUSC (Fig. 1F). Immunohistochemical analysis revealed negative staining for GATA-3. The patient subsequently received systemic chemotherapy with gemcitabine and oxaliplatin. However, tragically, 19 months after the nephrectomy, the patient succumbed to tumor progression.

3 Discussion

Approximately 50 % of patients diagnosed with primary lung cancer exhibit distant metastasis at the time of initial presentation.3 The most common sites of metastasis for LUSC include the bones, brain, liver, and adrenal glands.4 A study conducted by Adamy et al. evaluated 3472 patients who underwent partial or total nephrectomy, revealing that only 13 patients underwent surgery due to isolated renal metastasis; among these, 5 patients had lung cancer as the primary tumor origin 5. Common symptoms associated with renal metastatic tumors include abdominal pain, hematuria, weight loss, sweating, and fever. However, the majority of renal metastases typically remain asymptomatic.5 Tomita et al. reported 64 cases of lung tumors with renal metastasis, and 50 % of these patients presented with hematuria.6 In the present case, the patient was asymptomatic, and the renal metastasis was discovered incidentally during a routine abdominal CT scan. This highlights the critical importance of routine radiological examinations following surgery for lung cancer patients.

The diagnosis of renal metastasis is often made through routine imaging examinations. Renal metastasis can typically be identified using abdominal ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI).7 Preoperative biopsy may influence the clinical management of renal masses and potentially improve the prognosis for patients diagnosed with renal cell carcinoma. However, the impact of renal biopsy results on the treatment of patients with large masses appears to be minimal, as these patients generally require radical or partial nephrectomy if surgery is deemed appropriate.8 Imaging examinations are generally effective in distinguishing between primary and secondary renal tumors. Honda et al. reported on the imaging characteristics of metastatic renal cancer, describing renal metastasis as typically small, multiple, bilateral, wedge-shaped, exophytic, and confined within the renal capsule.7 However, the present case exhibited a unilateral, large mass (5.0cm*5.1cm*4.2cm), which did not align with the typical characteristics of renal metastasis. Consequently, renal metastatic tumors caused by squamous cell lung cancer can be easily overlooked, and known primary suspicious renal lesions identified on imaging should be highly suspect and thoroughly investigated.9

Currently, there are no established guidelines for the treatment of patients with isolated kidney involvement due to LUSC. Treatment decisions are often informed by the prognosis observed in case reports and clinical studies, with medication choices frequently dictated by the histology of the primary tumor. Clinically, platinum-based combination chemotherapy has long been the standard first-line treatment for advanced LUSC. However, recent advancements in immunotherapy and targeted therapy have significantly improved survival rates for patients with non-small cell lung cancer (NSCLC).10 The KEYNOTE-407 trial (NCT02775435) demonstrated that the addition of pembrolizumab to chemotherapy significantly improved overall survival (OS) and progression-free survival (PFS) in patients with metastatic LUSC.11 Qin L et al. conducted a study examining the impact of chemotherapy, radiotherapy, and surgery on the long-term prognosis of organ metastatic LUSC. Their findings indicated that chemotherapy exerted a significant protective effect on both single-organ and multiple-organ metastatic LUSC.12

The role of nephrectomy in patients with LUSC and solitary renal metastasis remains undefined, although evidence suggests that survival rates may improve following nephrectomy. In non-randomized studies involving other cancer types, surgical resection of isolated metastases has been shown to enhance survival.13 Adamy et al. conducted a study involving 13 patients with solitary renal metastases, who underwent nephrectomy or partial nephrectomy. Among these patients, four died due to primary tumor progression, and one died of other causes after 50 months. The remaining eight patients had an average follow-up of 30 months, with four patients showing no evidence of metastasis and four patients developing tumor metastases. Considering this patient's treatment and outcomes, it appears that surgical resection may be a beneficial approach with the potential to positively impact survival in patients with solitary metastases.4 Tomita et al. reported two cases of NSCLC patients with solitary renal metastases who underwent radical nephrectomy, and no recurrence was observed in either case after 2.5 years and 1 year, respectively.6 For patients with NSCLC and solitary renal metastasis, surgical intervention may be a viable treatment option worth considering. Qin L et al. have confirmed that patients with single-organ and double-organ metastases in LUSC can benefit from surgery. However, the surgical benefit was not statistically significant for patients with triple-organ metastases.12

In addition to surgical resection, other treatment options for renal metastasis include stereotactic body radiation therapy (SBRT) and cryoablation. SBRT offers effective local control and symptom relief without significant adverse reactions, as proposed by Verma et al..14 Qin L's research found that patients with single-organ metastasis who received radiotherapy had improved overall survival (OS) compared to those who did not receive radiotherapy, although radiotherapy did not improve the long-term prognosis for patients with multiple-organ metastasis.12 Cryoablation is another viable option for treating isolated renal metastases, providing an alternative to invasive surgery and potentially reducing hospital stays and postoperative complications.15 The specific condition of the patient, physical constitution, postoperative care, and presence of underlying diseases can all influence surgical outcomes and survival.16 Currently, no randomized controlled trials have conclusively determined the superiority of one treatment over another. It is crucial to emphasize the importance of multidisciplinary team (MDT) meetings in selecting the optimal treatment strategy for patients. All lung cancer patients with renal metastases should undergo MDT meetings prior to treatment selection.15 Before deciding on surgical treatment, doctors must comprehensively assess the patient's overall condition and engage in thorough communication and discussion with the patient and their family members.

4 Conclusion

The case presented highlights the challenges and considerations associated with diagnosing and treating LUSC with solitary renal metastasis. While routine imaging is crucial for early detection, the rarity of this condition and its often asymptomatic nature can make diagnosis difficult. The treatment options for solitary renal metastasis are not well-established, but evidence suggests that nephrectomy may improve survival in some cases. Additional treatment modalities, such as SBRT and cryoablation, may also be considered based on patient-specific factors. The decision-making process should involve a multidisciplinary team approach to ensure the most appropriate and effective treatment strategy is chosen for each individual patient.

CRediT authorship contribution statement

Feng Zhang: Writing – original draft. Wei-Cheng Sun: Software. Jia-Ning Sun: Writing – review & editing. Gong-Lin Tang: Visualization. Xin Chen: Methodology. Hong-Wei Zhao: Writing – review & editing.
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