A case of kidney metastasis in vulvar squamous cell carcinoma: A case report and review of literature

doi:10.4236/crcm.2013.25082

Paper Menu >>

Journal Menu >>

Vol.2, No.5, 306-309 (2013) Case Reports in Clinical Medicine

http://dx.doi.org/10.4236/crcm.2013.25082

A case of kidney metastasis in vulvar squamous cell

carcinoma: A case report and review of literature

Anit a Agrawal1*, Kimberly A. Wood2, Christopher K. Giede3, Rajni Chibbar4

1Department of Obstetrics and Gynecology, University of Saskatchewan, Saskatoon, Canada;

*Corresponding Author: [email protected]

2College of Medicine, University of Saskatchewan, Saskatoon, Canada

3Department of Obstetrics and Gynecology, Royal University Hospital, Saskatoon, Canada

4Department of Pathology, Royal University Hospital, Saskatoon, Canada

Received 17 December 2012; revised 25 January 2013; accepted 10 February 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Vulvar cancer is an uncommon tumor and re-

presents 3% - 5% of all female genital tract ma-

lignancies. Squamous cell carcinoma (SCC) is

the most common carcinoma of the vulva. Dis-

t ant met astasis of recurrent vulvar squamous cell

carcinoma is rare and occurs late in the disease

process. We report the first case of kidney me-

tastasis from a vulvar squamous cell carcinoma

in a 68-year-old Caucasi an female. On initial pre-

sentation she was treated with radical vulvec-

tomy, upper urethrectomy w ith bilateral inguinal

and deep femoral lymph node dissection. She

was staged as FIGO stage IVA and also received

adjuvant chemo-radiation. She remained in re-

mission for 24 months. Subsequently she was

found to have a k idney tumor and underwent ne-

phrectomy and was diagnosed with metastatic

squamous cell carcinoma from the vulva to the

kidney. In ca ses of recur rent v ulvar carci noma dis -

t ant metastasis to the bo nes, breast, and brain is

only rarely reported. Metastasis to kidneys from

vulvar carcinoma is exceptionally rare with no

reported cases in the literature. Renal meta stas is

should be considered in the differential diagno-

sis of kidney tumor in this group of women.

Keyw ords: Vulva; Squamous Cell Carcinoma;

Kidney Metastasis

1. INTRODUCTION

Squamous cell carcinoma is the most common carci-

noma of the vulva. Squamous cell carcinoma (SCC) of

the vulva can spread via direct extension into adjacent

structures, lymphatic embolization and hematogenous

spread to distant sites [1]. Distant metastases in patients

with primary SCC of the vulva are relatively rare and

usually occur late in the disease process. In cases of re-

current vulvar carcinoma distant metastasis to bones,

breast, and brain is rarely reported. Metastasis to k idneys

from vulvar carcinoma is exceptionally rare with no re-

ported cases in the literature. Here we present the first

case of vulvar SCC with metastatic spread to the kidney.

2. CASE PRESENTATION

A 66-year-old postmenopausal woman with one year

history of lichen sclerosus et atrophicus presented in

2008 with bilateral lesions on the labia majora and mi-

nora, with ulceration present on the left labia lesion

(Figure 1). A palpable inguinal lymph node was noted on

the right side. A punch biopsy revealed moderately dif-

ferentiated keratinizin g SCC (Figure 2). Staging wo rk up

showed a single peripheral 5 mm nodule in the middle

lobe of right lung unlikely to be metastasis. Patient un-

derwent radical vulvectomy and upper urethrectomy with

bilateral inguinal and deep femoral lymph node dissec-

tion. Histopathology was consistent with an invasive

keratinizing SCC with a 5 mm depth of invasion. Ure-

thral and deep vagina margins were focally positive with

carcinoma. One out of six and 1 out of 5 inguinal lymph

nodes were positive for metastatic spread on the left and

right side respectively. Deep femoral lymph nodes on the

left side were positive (2/2). She was staged as FIGO

stage IVA (pT3 pN3 M0 G2). The patient underwent con-

current chemo-radiation therapy consisting of cisplatin

and external beam radiotherapy of a 4500 cGy in 25

fractions o ve r 3 6 day s.

Patient remained in remission for 24 months and in

2010 experienced sudden onset of severe left flank pain

and microscopic hematuria. CT scan of the abdomen

A. Agrawal et al. / Case Reports in Clinical Medicine 2 (2013) 306-309 307

Figure 1. Vulvar tumor on initial presentation.

Figure 2. High power H & E stain vulvar tumor showing high

grade squamous cell carcinoma.

reported a 5.5 × 4.5 × 4.5 cm infiltrative, ill defined,

solid heterogeneous exophytic mass present within the

left kidney appearance suggestive of renal cell carcinoma

(Figure 3). Low density adenopathy was present subjacent

to renal vein, measuring 2.2 cm. A left radical nephrec-

tomy and para-aortic lymph dissection was performed.

Gross examination of the left kidney revealed two

masses, one extended through the capsule to the perirenal

fat and into the renal sinus and measured 5.5 × 4.5 × 4.5

cm and the other was present in the upper pole of the

perirenal fat and measured 1.0 × 0.8 × 0.9 cm. Micro-

scopic examination revealed moderately differentiated

keratinizing SCC with lympho-vascular invasion consis-

tent with metastatic vulvar carcinoma (Figure 4). Me-

tastatic disease was also noted in the para-aortic lymph

nodes (Figure 5) and small foci within the renal paren-

chyma and perirenal fat.

The patient’s health progressively declined and was

transferred to palliative care unit and passed away 2

weeks later in 2010.

Figure 3. CT scan showing a 5.5 cm left renal tumor and en-

larged para-aortic lymph nodes.

Figure 4. Low power H & E stain kidney showing metastatic

vulvar squamous cell carcinoma.

Figure 5. High power H & E stain lymph node showing me-

tastatic vulvar squamous cell carcinoma.

3. DISCUSSION

Carcinoma of the vulva represents 3% to 5% of all

female genital tract malignancies and 90% of the primary

A. Agrawal et al. / Case Reports in Clinical Medicine 2 (2013) 306-309

308

vulvar malignancies are diagnosed as SCC [1]. Vulvar

SCC can spread by three different routes, direct exten-

sion to adjacent structures, lymphatic embolization and

hematogenous spread to distant sites. Lymphatic spread

occurs early in the disease process and will commonly

spread to the ipsilateral inguinal, femoral and pelvic

lymph nodes, in a sequential manner. Spread to the in-

guinal and femoral lymph nodes occurs in about 30% of

the patients and about 12% of patients will have spread

to the pelvic lymph nod es.

Hematogenous spread to distant sites varies and occurs

in about 8% - 1 2% of patients [2]. Distan t sites of spread

were reported in lung [3,4], skin [4-7], bone [4,8], intra-

abdominal [4], liver [4], heart [4], breast [9], muscle [2]

and central nervous system [4,10,11]. Our case is un ique

in that distant metastatic spread occurred to the kidney,

which has not been previously reported in literature.

Metastatic spread of cancer to the kidneys is not

common despite the fact that the kidneys receive 20% of

the cardiac output. Metastatic spread to the kidney usu-

ally occurs through a combination of venous and lym-

phatic routes. Autopsy findings showed that the most

common metastatic renal lesion is lymphoma [12] and

the top four carcinomas metastasizing to the kidneys are

lung, breast, stomach and opposite kidney [11,12] occur-

ring in 4.6% to 7.6% of patients [13].

Majority of patients presenting with metastatic spread

to the kidneys are asymptomatic and the presence of the

kidney metastasis are not known un til autopsy. However,

patients with renal metastases may present with albu-

minuria, microscopic hematuria, a renal mass or renal

failure [14]. In this case, the patient was diagnosed with

a kidney metastasis after presenting to the emergency

department with severe flank pain and microscopic he-

maturia. A CT scan confirmed the presence of a solid

mass in the left kidney and a radical nephrectomy was

performed.

4. CONCLUSION

Although renal metastasis is rare, and has never been

documented in a case of vulvar SCC, it should be con-

sidered in the differential diagnosis of flank pain and

microscopic hematuria in women with a past history of

vulvar carcinoma. To the best of our knowledge, this is

the first reported case of vulvar carcinoma which devel-

oped renal metastasis.

5. RESULTS

We report a case of 68-year-old women who were

treated in September 2008 with radical vulvectomy, dis-

tal uretherectomy, and bilateral inguinofemoral lympha-

denectomy for FIGO stage IVA (pT3 pN3, M0 G2) mod-

erately differentiated squamous cell vulvar carcinoma.

Due to a positive bilateral lymph node status, close

vaginal and urethral margin, she received adjuvant pelvic

and vulvar radiation (4500 cGy).

The patient remained clinically in remission until Oc-

tober 2010, when presented with flank pain. CT scan of

abdomen reported a 5.5/4.5/4.5 cm tumor in the left kid-

ney and appearance was suggestive of renal cell carci-

noma (Figure 1). A left radical nephrectomy including

paraaortic lymph node dissection was performed in No-

vember 2010. The histopathology and of resected renal

tumor and paraaortic lymph nodes gave evidence of a

metastasis of the known vulvar carcinoma.

REFERENCES

[1] Holschneider, C.H. and Berek, J.S. (2007) Vulvar cancer.

In: Berek, J.S., Ed., Berek’s & Novak’s Gynecology, 14th

Edition, Lippincott Williams & Wilkins, Philadephia, 1549-

1580.

[2] Steele, M., Hegstrand, L.R., Julian, T.M. and Storm, F.K.

(1990) An unuasual presentation of metastatic squamous

cell carcinoma of the vulva. Gynecologic Oncology, 39,

218-220. doi:10.1016/0090-8258(90)90436-O

[3] Barbetakis, N., Antoniadis, T., Kaplanis, K., Deligiannis,

D., Toliou, T. and Tsilikas, C. (2002) Metastatic squa-

mous cell vulvar carcinoma of the lung: A case report and

review of literature. European Journal of Gynaecological

Oncology, 23, 475-476.

[4] Podratz, K.C., Symmonds, R.E. and Taylor, W.F. (1982)

Carcinoma of the vulva: Analysis of treatment failures.

American Journal of Obstetrics & Gynecology, 143, 340-

351.

[5] Ghaemmaghami, F., Modares, M., Behtash, N. and Moo-

savi, A.Z. (2004) Multiple, disseminated cutaneous me-

tastases of vulvar squamous cell carcinoma. International

Journal of Gynecological Cancer, 14, 384-387.

d oi: 10. 1111 /j .1048-891x.2004.014227.x

[6] Dudley, C., Kircik, L.H., Bullen, R., Snow, S., Landeck,

A. and Buchler, D. (1998) Vulvar squamous cell carci-

noma metastatic to the skin. Dermatologic Surgery, 24,

889-892. d oi: 10.1111/ j .1524-4725.1998.tb04268.x

[7] Kulkarni, R. and Bradford, W.P. (1995) Squamous cell

carcinoma of the vulva metastasizing to the skin. Acta

Obstetricia et Gynecologica Scandinavica, 74, 571-572.

doi:10.3109/00016349509024393

[8] Fischer, F., Kuhl, M., Feek, U., Romingers, M., Schipper,

M.L., Hadji, P., Wagner, U. and Jackisch, C. (2005) Bone

metastases in vulvar cancer: A rare metastatic pattern. In-

ternational Journal of Gynecological Cancer, 15, 1173-

1176. doi:10.1111/j.1525-1438.2005.00175.x

[9] Vicus, D., Korach, J., Friedman, E., Rizel, S. and Ben-

Baruch, G. (2006) Vulvar cancer metastic to the breast.

Gynecologic Oncology, 103, 1144-1146.

doi:10.1016/j.ygyno.2006.07.037

[10] Vázquez, J.P., Cobo, S.L.T., Antón, F.M., Asado, A.C.,

Vidart, J.A., Coronado, P. and Díaz-Rubio, E. (20 07) Brain

metastasis and carcinomatous meningitis from vulvar

A. Agrawal et al. / Case Reports in Clinical Medicine 2 (2013) 306-309

309

squamous cell carcinoma: Case report. European Journal

of Gynaecological Oncology, 28, 152-154.

[11] Dursun, P., Ayhan, A., Tarhan, N.C., Coban, G. and Kuscu,

E. (2009) Cerebellar metastasis in squamous cell vulvar

carcinoma. Archives of Gynecology and Obstetrics, 279,

69-71. doi:10.1007/s00404-008-0635-2

[12] Wagle, D.G., Moore, R.H. and Murphy, G.P. (1975) Sec-

ondary carcinomas of the kidney. Journal of Urology, 114 ,

30-32.

[13] Stoughton, W.B. and Milam, D.F. (1975) Metastatic tu-

mors to the kidney. West Virginia Medical Journal, 71,

199-201.

[14] Bennington, J.L. and Beckwith, J.B. (1975) Tumors of

the kidney, renal pelvis, and ureter. In Atlas of Tumor

Pathology, 2nd Series, Fascicle 12, Armed Forces Insti-

ture of Pathology, Washington DC, 162-163.