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Verrucous carcinoma of the renal pelvis
CASE REPORT
VERRUCOUS CARCINOMA OF THE RENAL PELVIS NEIL S. KANSAL, GENE ROSENBERG, MIN HAN,
AND
FRANK RICHTER
ABSTRACT We report a case of a verrucous carcinoma of the renal pelvis after a long history of a renal pelvis stone. Only 1 case of verrucous carcinoma of the renal pelvis has been previously reported, and ours is the first case not associated with a horseshoe kidney. UROLOGY 58: 105xvi–105xvii, 2001. © 2001, Elsevier Science Inc.
T
he verrucous variant of squamous cell carcinoma is a rare tumor that has been described in the bladder in association with schistosomiasis.1,2 We report a case of verrucous carcinoma of the renal pelvis. To our knowledge, only 1 case of verrucous carcinoma of the renal pelvis has been previously reported, and ours is the first case not associated with a horseshoe kidney.2 CASE REPORT A 64-year-old woman was admitted to the hospital with right flank pain and microhematuria in 1998. The abdominal computed tomography scan revealed moderate right hydronephrosis and an enhancing mass lesion at the mid-portion of the right kidney. The serum blood urea nitrogen and creatinine level was 20 mg/dL and 0.9 mg/dL, respectively. The patient had a long history of a right renal calculus for which she underwent right nephrolithotomy in 1994. Under the assumption of a renal tumor, she underwent radical nephrectomy through a right 12th rib transcostal approach. The kidney, including the tumor, was completely resected without evidence of extracapsular invasion. The local lymph nodes were not involved. The surgical specimen measured 15 ⫻ 10 ⫻ 6 cm and weighed 202 g. The lower half of the mucosa of the renal pelvis, From the Departments of Urology and Laboratory Medicine and Pathology, University of Medicine and Dentistry New Jersey-New Jersey Medical School and Hackensack University Medical Center, Newark, New Jersey Address for correspondence: Frank Richter, M.D., Division of Urology, Department of Surgery, University of Medicine and Dentistry New Jersey, MSB-G536, 185 South Orange Avenue, Newark, NJ 07103 Submitted: December 19, 2000, accepted (with revisions): March 14, 2001
105xvi
© 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
extending into the ureteropelvic junction, showed a gray plaque-like tumor measuring 5.5 cm in its largest diameter (Fig. 1). The histologic findings of the surgical specimen revealed an extensive keratinizing squamous metaplasia with an area of verrucous acanthosis. The hyperplastic, papillomatous, wart-like architecture had infiltrated into the underlying stroma consistent with a verrucous carcinoma of the renal pelvis (Fig. 2). The carcinoma was limited in its extent and did not invade the lamina propria. The immunohistochemistry results for human papillomavirus were negative. The postoperative course was uneventful, and the patient was discharged home on the third postoperative day. Additional surveillance with cystoscopy/urine cytologic analyses and selective ureteral cytologic analyses remained without evidence of recurrence during 2 years of follow-up.
FIGURE 1. Bisected nephrectomy specimen demonstrating extent of renal pelvis tumor. 0090-4295/01/$20.00 PII S0090-4295(01)01133-5
COMMENT The term verrucous carcinoma is used for a specific histologic appearance of a well-differentiated squamous cell carcinoma that infiltrates locally with little tendency to metastasize to regional lymph nodes or distant sites. Additional histologic features are extensive keratinization with exophytic or papillomatous extension into the stroma and a lack of significant cellular anaplasia. Cases of verrucous carcinomas have been described within the bladder, mostly in areas endemic for Schistosoma hematobium.1 The only case report that describes this uncommon tumor was published by Sheaff et al.2 in 1996. A 41-year-old man presented with gross hematuria and recurrent pyelonephritis caused by staghorn calculi within a horseshoe kidney. The investigators found extensive keratinization of the tumor and squamous metaplasia. The local lymph nodes were not involved. Immunohistochemistry and polymerase chain reaction did not reveal any evidence of infection with human papillomavirus. The investigators concluded that the tumor arose from a background of chronic inflammation caused and maintained by the renal calculi. Interestingly, our patient underwent surgery in 1994 for a staghorn calculus within the right renal pelvis. Without evidence of papillomavirus involvement, we assume that chronic inflammation of the renal pelvis caused by a long history of stone disease could have contributed to the carcinogenesis of the verrucous carcinoma.
FIGURE 2. (A) Low magnification view showing verrucous carcinoma with papillomatous growth into the underlying stroma. (B) High magnification view showing papilloma with relatively uniformly shaped cells without significant mitoses.
UROLOGY 58 (1), 2001
REFERENCES 1. Mahran MR, and El-Baz M: Verrucous carcinoma of the bilharzial bladder: impact of invasiveness on survival. Scand J Urol Nephrol 27: 189 –192, 1993. 2. Sheaff M, Fociani P, Badenoch D, et al: Verrucous carcinoma of the renal pelvis: case presentation and review of the literature. Virchows Arch 428: 375–379, 1996.
105xvii
VERRUCOUS CARCINOMA OF THE RENAL PELVIS NEIL S. KANSAL, GENE ROSENBERG, MIN HAN,
AND
FRANK RICHTER
ABSTRACT We report a case of a verrucous carcinoma of the renal pelvis after a long history of a renal pelvis stone. Only 1 case of verrucous carcinoma of the renal pelvis has been previously reported, and ours is the first case not associated with a horseshoe kidney. UROLOGY 58: 105xvi–105xvii, 2001. © 2001, Elsevier Science Inc.
T
he verrucous variant of squamous cell carcinoma is a rare tumor that has been described in the bladder in association with schistosomiasis.1,2 We report a case of verrucous carcinoma of the renal pelvis. To our knowledge, only 1 case of verrucous carcinoma of the renal pelvis has been previously reported, and ours is the first case not associated with a horseshoe kidney.2 CASE REPORT A 64-year-old woman was admitted to the hospital with right flank pain and microhematuria in 1998. The abdominal computed tomography scan revealed moderate right hydronephrosis and an enhancing mass lesion at the mid-portion of the right kidney. The serum blood urea nitrogen and creatinine level was 20 mg/dL and 0.9 mg/dL, respectively. The patient had a long history of a right renal calculus for which she underwent right nephrolithotomy in 1994. Under the assumption of a renal tumor, she underwent radical nephrectomy through a right 12th rib transcostal approach. The kidney, including the tumor, was completely resected without evidence of extracapsular invasion. The local lymph nodes were not involved. The surgical specimen measured 15 ⫻ 10 ⫻ 6 cm and weighed 202 g. The lower half of the mucosa of the renal pelvis, From the Departments of Urology and Laboratory Medicine and Pathology, University of Medicine and Dentistry New Jersey-New Jersey Medical School and Hackensack University Medical Center, Newark, New Jersey Address for correspondence: Frank Richter, M.D., Division of Urology, Department of Surgery, University of Medicine and Dentistry New Jersey, MSB-G536, 185 South Orange Avenue, Newark, NJ 07103 Submitted: December 19, 2000, accepted (with revisions): March 14, 2001
105xvi
© 2001, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
extending into the ureteropelvic junction, showed a gray plaque-like tumor measuring 5.5 cm in its largest diameter (Fig. 1). The histologic findings of the surgical specimen revealed an extensive keratinizing squamous metaplasia with an area of verrucous acanthosis. The hyperplastic, papillomatous, wart-like architecture had infiltrated into the underlying stroma consistent with a verrucous carcinoma of the renal pelvis (Fig. 2). The carcinoma was limited in its extent and did not invade the lamina propria. The immunohistochemistry results for human papillomavirus were negative. The postoperative course was uneventful, and the patient was discharged home on the third postoperative day. Additional surveillance with cystoscopy/urine cytologic analyses and selective ureteral cytologic analyses remained without evidence of recurrence during 2 years of follow-up.
FIGURE 1. Bisected nephrectomy specimen demonstrating extent of renal pelvis tumor. 0090-4295/01/$20.00 PII S0090-4295(01)01133-5
COMMENT The term verrucous carcinoma is used for a specific histologic appearance of a well-differentiated squamous cell carcinoma that infiltrates locally with little tendency to metastasize to regional lymph nodes or distant sites. Additional histologic features are extensive keratinization with exophytic or papillomatous extension into the stroma and a lack of significant cellular anaplasia. Cases of verrucous carcinomas have been described within the bladder, mostly in areas endemic for Schistosoma hematobium.1 The only case report that describes this uncommon tumor was published by Sheaff et al.2 in 1996. A 41-year-old man presented with gross hematuria and recurrent pyelonephritis caused by staghorn calculi within a horseshoe kidney. The investigators found extensive keratinization of the tumor and squamous metaplasia. The local lymph nodes were not involved. Immunohistochemistry and polymerase chain reaction did not reveal any evidence of infection with human papillomavirus. The investigators concluded that the tumor arose from a background of chronic inflammation caused and maintained by the renal calculi. Interestingly, our patient underwent surgery in 1994 for a staghorn calculus within the right renal pelvis. Without evidence of papillomavirus involvement, we assume that chronic inflammation of the renal pelvis caused by a long history of stone disease could have contributed to the carcinogenesis of the verrucous carcinoma.
FIGURE 2. (A) Low magnification view showing verrucous carcinoma with papillomatous growth into the underlying stroma. (B) High magnification view showing papilloma with relatively uniformly shaped cells without significant mitoses.
UROLOGY 58 (1), 2001
REFERENCES 1. Mahran MR, and El-Baz M: Verrucous carcinoma of the bilharzial bladder: impact of invasiveness on survival. Scand J Urol Nephrol 27: 189 –192, 1993. 2. Sheaff M, Fociani P, Badenoch D, et al: Verrucous carcinoma of the renal pelvis: case presentation and review of the literature. Virchows Arch 428: 375–379, 1996.
105xvii