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Year : 2019  |  Volume : 15  |  Issue : 8  |  Page : 170-172

Hypercalcemia associated with squamous cell carcinoma of renal pelvis: A case and review of the literature

Department of Medical Oncology, Akdeniz University School of Medicine, Antalya, Turkey

Date of Web Publication22-Mar-2019

Correspondence Address:
Dr. Fatma Yalcin Musri
Department of Medical Oncology, Akdeniz University School of Medicine, Konyaalti, Antalya 07070
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-1482.187236

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 > Abstract 

Renal pelvis squamous cell carcinoma (RSCC) is a rare tumor. It starts with nonspecific symptoms and it is usually at an advanced stage with a poor prognosis at the time of diagnosis. SCC-associated hypercalcemia is a well-known paraneoplastic syndrome; however RSCC-associated hypercalcemia is a rare condition. Our patient is a 57-year-old-male patient with no bone metastases. Based on the literature screening on PubMed Database for paraneoplastic malignant hypercalcemia-associated RSCC, we found a few cases.

Keywords: Hypercalcemia, kidney pelvis, squamous cell carcinoma

How to cite this article:
Musri FY, Mutlu H, Eryilmaz MK, Salim DK, Tazegul G, Coşkun H&. Hypercalcemia associated with squamous cell carcinoma of renal pelvis: A case and review of the literature. J Can Res Ther 2019;15, Suppl S1:170-2

How to cite this URL:
Musri FY, Mutlu H, Eryilmaz MK, Salim DK, Tazegul G, Coşkun H&. Hypercalcemia associated with squamous cell carcinoma of renal pelvis: A case and review of the literature. J Can Res Ther [serial online] 2019 [cited 2021 Sep 19];15:170-2. Available from: https://www.cancerjournal.net/text.asp?2019/15/8/170/187236

 > Introduction Top

Most of the renal collective system tumors are transitional cell carcinomas. Renal pelvis squamous cell carcinoma (RSCC) is a very rare tumor; it occurs among all renal tumors at a rate of 0.5–8%.[1] RSCC development may be associated with factors causing chronic inflammation including calculi, infections, chemical exposure, vitamin deficiency, hormonal imbalance, and radiotherapy. It may also occur without any underlying factors.[2]

Hypercalcemia is a paraneoplastic syndrome mostly observed in SCCs. RSCC is reported rarely. Our case is a male patient with nephrolithiasis history, presented with a right kidney mass, diagnosed with RSCC after nephrectomy, and had paraneoplastic hypercalcemia.

 > Case Report Top

Our case is a 57-year-old male patient with a history of bilateral nephrolithiasis; he has not received any therapy. He has no other diseases. He does not smoke. He had no complaints other than nausea, starting 9 months ago and becoming progressively severe in 2 months. Physical examination revealed normal findings only sensitivity in the right lumbar region with no palpable masses was noted. His blood count was normal, biochemistry were as follows: creatinine 1.83 mg/dL, calcium 11.7 mg/dL, albumin 4.1 g/dL, intact parathyroid hormone (PTH) 6 pg/mL. PTH-rP was not measured; it is not available in our hospital. Other values were normal. Renal ultrasonography showed right kidney extension along with renal parenchymal thinning with Grade 3 hydronephrosis; left kidney was normal. Diethylenetriaminepentaacetic acid scintigraphy showed a nonfunctional right kidney and a normally functioning left kidney. A heterogeneous mass was detected on the right kidney on abdominal tomography; he underwent right nephrectomy in August 2015. Macroscopic and histopathologic assessment diagnosed mass as well-differentiated SCC that resulted in distortion of the renal pelvis and extended beyond renal capsule. Positron emission tomography-computed tomography (PET-CT) performed for staging detected mediastinal multiple lymphadenopathies and liver metastases while no bone metastases were observed. The patient was normocalcemic for a short while after operation; however, 2 months postoperatively calcium, phosphorus, albumin, 25-OH Vitamin D, and intact-PTH values were 13.98 mg/dL, 2.52 mg/dL, 4 g/dL, 36 ng/mL, and 6 pg/mL. He was started on 2.5 mg/month zoledronic acid and carboplatin + gemcitabine (5 AUC D1, 1000 mg/m2 D1-8, 21 days cycles) as palliative chemotherapy. At the 3rd month of treatment, PET-CT showed a partial response. He remained normocalcemic after that, and palliative chemotherapy and monthly bisphosphonate treatment were continued.

 > Discussion Top

SCC development in renal pelvis is commonly associated with chronic irritation. Metaplasia develops followed by dysplasia and carcinoma. RSCC occurs at a similar incidence in males and females between 50 and 70 years of age.[3] The incidence of renal calculus is higher among males, and it is reported at a higher rate among males.

SCC of the upper urinary tract may also manifest with paraneoplastic syndromes such as hypercalcemia, thrombocytosis, and leukocytosis. The main cause of malignant hypercalcemia is PTH. PTH is most commonly produced in malignancies of head-neck, esophagus, cervix, and lungs, breast and ovarian adenocarcinoma, and renal cell carcinoma.

A few cases of RSCC-related malignant hypercalcemia have been reported in the literature, and there are seven reports and eight case reports, in addition to ours.[4],[5],[6],[7],[8],[9],[10] In-line with the fact that the incidence of RSCC is progressively increasing in males, five cases were males and the age of diagnosis was consistent with the literature. Only two cases were 74 and 78 years old.[8],[9] In addition to our case, there were three cases with a history of nephrolithiasis.[6],[7],[8] While two patients with a calcium level >14 mg/dL and a patient with a calcium level of 11.7 mg/dL[5] were diagnosed following presentation with change in consciousness, one of the patients was diagnosed based on the chest pain in relation metastasis site.[7] There were two cases diagnosed based on flank pain and hematuria,[6],[10] our patient was another one, who presented with the constitutional symptoms. There were two cases, who had metastasis at the time of diagnosis in addition to ours. One had local lymphadenopathy and anterior mediastinal lesion,[7] other had multiple liver and perirenal lymphadenopathies. This case was reported not as an RSCC but as a renal parenchymal SCC.[10] Reviewing the laboratory findings of all reports, calcium was high, PTH was low, 25-OH Vitamin D levels were low or normal. In one report, PTH was normal (28 pg/mL).[6] While a portion of the patients was diagnosed by biopsy, all patients received nephrectomy. Most patients received palliative chemotherapy. There were also cases receiving radiotherapy.[7] A case, who had metastasis at diagnosis, had well-differentiated tumor, similar to our case. This patient survived the longest (17 months), had locally advanced disease at diagnosis and developed local recurrence following adjuvant chemotherapy.[7] Our patient was metastatic at diagnosis; he is currently of Eastern Cooperative Oncology Group performance status 1–2 and still under follow-up at the 4th month following surgery; he has been receiving palliative chemotherapy and bisphosphonate treatment with no active complaints.

In case of RSCC, it is difficult to diagnose with findings such as a nonspecific onset, presence of solid mass, as commonly detected on radiography, hydronephrosis, and calcification without making histopathologic assessments. Radical nephrectomy is the primary and curative treatment in case of local invasive SCC. However, RSCC is generally at a stage ≥pT3 at the time of diagnosis.[3],[4],[5],[6],[7],[8],[9],[10] Staging and prognosis are similar to that in transitional cell carcinoma. Therefore, surgery is rarely curative, and adjuvant chemotherapy is inadequate (chemoradiotherapy) at advanced stage. A relevant study reported the median survival as 7 months and the 5-year survival as 7.7%.[3] In the metastatic stage, nephrectomy has no benefit on survival; it should be considered only for causes such as diagnosis and symptom control.

We presented a case of RSCC with paraneoplastic hypercalcemia, which is very rare but has an aggressive course and poor prognosis. Based on our case report and literature analysis, physicians should keep in mind RSCC in a radiologically detected renal mass and hypercalcemia, and nephrectomy does not prolong survival in renal cell carcinoma even if it is metastatic and that surgical resection is not an absolute therapeutic method except selected cases.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Jain A, Mittal D, Jindal A, Solanki R, Khatri S, Parikh A, et al. Incidentally detected squamous cell carcinoma of renal pelvis in patients with staghorn calculi: Case series with review of the literature. ISRN Oncol 2011;2011:620574.  Back to cited text no. 1
Tanriverdi O, Mesrur SS, Guler H, Miroglu C. Squamous cell carcinoma of left kidney presenting with splenic hematoma. Int J Nephrol Urol 2009;1:65-8.  Back to cited text no. 2
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.  Back to cited text no. 3
Diaz González R, Barrientos A, Larrodera L, Ruilope LM, Leiva O, Borobia V. Squamous cell carcinoma of the renal pelvis associated with hypercalcemia and the presence of parathyroid hormone-like substances in the tumor. J Urol 1985;133:1029-30.  Back to cited text no. 4
Cadeddu JA, Jarrett TW. Hypercalcemia associated with squamous cell carcinoma of the renal pelvis. J Urol 1998;160:1798.  Back to cited text no. 5
Er O, Coskun HS, Altinbas M, Akgün H, Cetin M, Eser B, et al. Rapidly relapsing squamous cell carcinoma of the renal pelvis associated with paraneoplastic syndromes of leukocytosis, thrombocytosis and hypercalcemia. Urol Int 2001;67:175-7.  Back to cited text no. 6
Washino S, Terauchi F, Matsuzaki A, Kobayashi Y. Two cases of squamous cell carcinoma of upper urinary tract with hypercalcemia. Nihon Hinyokika Gakkai Zasshi 2008;99:703-8.  Back to cited text no. 7
Sakamoto W, Kishimoto T, Nakatani T, Kouno M, Maekawa M, Kawamura M. A case of renal pelvic squamous cell carcinoma accompanied with humoral hypercalcemia of malignancy. Nihon Hinyokika Gakkai Zasshi 1991;82:1305-8.  Back to cited text no. 8
Furukawa M, Tohbu S, Matsuo T, Hayashida Y, Takehara K, Tsuda S, et al. Acase of renal pelvic squamous cell carcinoma accompanied with humoral hypercalcemia of malignancy (HHM). Hinyokika Kiyo 2005;51:265-8.  Back to cited text no. 9
Açikgöz Y, Sendur MA, Aksoy S, Özdemir NY, Zengin N. Metastatic parenchymal renal squamous cell carcinoma with hypercalcemia. Med Oncol 2014;31:169.  Back to cited text no. 10


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