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Uterine Cervical Cancer and Chronic Kidney Disease An association that

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MARIA DANIELA TANASESCU1,2, ANDRA ELENA BALCANGIU STROESCU3,4*, LAURA RADUCU5,6, ALEXANDRA MARIA LIMBAU7,
ALEXANDRU CRISTIAN DIACONESCU3, DANIELA GABRIELA BALAN4, DORIN IONESCU1,2
1
Carol Davila University of Medicine and Pharmacy,Faculty of Medicine, Department of Medical Semiology, Discipline of Internal
Medicine I and Nephrology, 8 Eroii Sanitari Blvd., 050474, Bucharest, Romania
2
Department of Nephrology, Emergency University Hospital Bucharest, 169 Splaiul Independenei, 050098,Bucharest, Romania
3
Department of Dialysis,Emergency University Hospital Bucharest, 169 Splaiul Independenei, 050098, Bucharest, Romania
4
Carol Davila University of Medicine and Pharmacy,Faculty of Dental Medicine, Discipline of Physiology, 8 Eroii Sanitari Blvd.,
050474, Bucharest, Romania
5
Carol Davila University of Medicine and Pharmacy, Faculty of Medicine, Department of Plastic and Reconstructive Microsurgery,
8 Eroii Sanitari, 050474, Bucharest, Romania
6
Department of Plastic and Reconstructive Surgery, Prof. Dr. Agrippa Ionescu Clinical Emergency Hospital, 7 Ion Mincu Str.,
011356, Bucharest, Romania
7
Department of Dermatology, Clinical Hospital Curtea de Arges, 6-8 Cuza Voda Str., 115300, Curtea de Arges, Romania

We present the case of a 65 year old female patient with a history of bilateral hydronephrosis (known for
about 3 years) diagnosed with keratinizing squamous carcinoma and chronic kidney disease. The low
adherence of the patient to the uterine cervical cancer screening program led to the diagnosis of tumor in an
advanced stage. In this patient, specific urological treatment (bilateral percutaneous nephrostomy) was not
associated with significant improvement in renal function, and therefore she was deemed ESRD, dialysis
dependent.
Keywords: cervical cancer, nephrostomy, squamous carcinoma, chronic kidney disease

Systemic factors such as hypertension, diabetes are patient with a decrease in survival rate [11-13]. To improve
often incriminated in renal function decline, [1]. However, the quality of life of these patients, specialty studies support
in many studies the association between renal injury and the association of surgical treatment of obstruction to
urinary obstruction is well documented. In a patient with specific oncological treatment [14]. In this regard, in
pre-existing renal impairment - CKD (eg, elderly patients patients with neoplasms in the genital sphere, in the
with multiple comorbidities), the occurrence of an urinary treatment of extrinsic ureteral obstruction we mention the
obstruction leads to Acute Kidney Injury-AKI [2,3]. As for utility of percutaneous nephrostomy in the improvement
the etiology of urinary obstruction, both benign causes of renal function [14,15]. However, in the case of prolonged
(congenital malformations, benign prostatic hyperplasia, obstruction, the restoration of diuresis by relieving of the
urinary calculi) and malignant causes are incriminated [4]. obstruction does not always result in reversibility of renal
The renal involvement secondary to the presence of a impairment [7,14].
pelvic tumor is a common clinical entity. Bladder, prostate The purpose of presenting this case is to highlight the
and uterine malignancies can lead to an secondary intrinsic indisputable association between advanced stage genital
or extrinsic obstruction of the urinary tract [5]. Bladder neoplasia and renal impairment. It is also desirable to
bilateral obstruction due to neoplasms in the genital sphere highlight the importance of tumor size and the duration of
occurs in advanced stages of illness usually result in poor ureteral obstruction în the likelihood of restoring renal
prognosis [6-8]. In female patients, the occurrence of function in patients with advanced cervical cancer.
genital neoplasm is commonly associated with the
occurrence of renal injury through obstructive mechanisms Experimental part
[7]. Among these, uterine cervical cancer is a common A 65-year-old female patient with a history of about 3
cause of obstructive uropathy [9,10]. Tumor extension and years of bilateral hydronephrosis grade I-II comes in our
secondary ureteral obstruction assume the involvement clinic for fatigue and loss of appetite. The symptoms started
of broad ligaments and the parametrium. The localization 2-3 weeks prior without any identified triggering factor.
of the distal portion of the ureter at the level of the Also for about 1 week, the patient had associated nausea
connective tissue which forms the tumor parametrium and and vomiting. Physical examination revealed elevated
extension at this level explains the renal involvement in blood pressure (BP 190 / 85mm Hg), tachycardia (HR-94 /
uterine cervical cancers. By these modifications, the min, regular), pale skin and sclerae. At that time lab results
affected distal portion of the ureter determines the revealed serum creatinine of 11.7 mg/dL, urea 168.65 mg/
appearance of the ureteral obstruction. However, in uterine dL, serum hemoglobin (Hb) 6.3 g/dL, normal MCV 96.4 fl,
cervical cancer patients, lymphatic invasion and the Na 133.7 mmol / L, K 6.2 mmol / L, pH 7.36, bicarbonate 23
occurrence of metastatic nodules at this level may also mmol/L .Upon admission, the patient also had significant
lead to compression at the higher ureteral levels [7]. Given inflammator y syndrome (ESR 57mm/1h, fibrinogen
that the obstructive kidney disease is encountered in 431.59mg/dL, CRP 2mg/dL) and urine samples without
advanced stages of cervical cancer, the occurrence of significant changes. The abdominal ultrasound showed
hydronephrosis suggests a poor long-term prognosis of the hydronephrosisgr. IV on right side and gr. III on the left;

*email: stroescu_andra@yahoo.ro All authors contributed equally to the present work and thus are main authors
2524 http://www.revistadechimie.ro REV.CHIM.(Bucharest) ♦ 69♦ No.9♦ 2018
Bladder with transsonic content, walls of normal size. In periodic cytology. At the same time, the nonspecific
the context of persistent symptoms, lab changes resistant presenting symptoms (fatigue, GI symptoms) correlate
to conservative treatment (increasing nitrogen retention), with advanced stages of illness [24,25].
as well as the persistence of high blood pressure, we At the time of admission, lab data-elevated BUN, Cr as
decided to initiate hemodialysis (using right femoral vein well as significant anemia, lead to the diagnosis to renal
vascular catheter ) with good tolerance by the patient and impairment.In this regard, it is interesting to note that in
without any incidents during the procedure. In the context this patient, despite the fact that important kidney damage
of suspicion of an extrinsic ureteral obstruction, we decided is identified, the acid-base balance is within normal limits.
to do a non-contrast abdominal-pelvic CT scan to elucidate This is contrary to specialist studies that show a close
de etiology of obstruction. CT findings: Cervical uterine association between decline in renal function and the
necrosis expansive tissue with interior, air bubbles in 39 / occurrence of metabolic acidosis [26]. However, at this
35mm, transaxial with irregular contours, spiculated, with stage of the investigation, renal impairment may explain
no limits to the posterior wall of the bladder, bilateral the important inflammatory status identified in this patient
involvement of inferior ureteral meatus holes, oncology- [27]. To complete the diagnosis, performing renal
free lymph nodes and bilateral hydronephrosis gr. II.Due to ultrasound revealed the presence of significant
the changes in the uterine cervix, gynecological evaluation hydronephrosis. High suspicion of an extrinsic ureteral
was requested for cervical biopsy. obstruction due to lack of nephrolithiasis history, absence
of colicky pain and lack of ultrasound findings suggestive
Results and discussions of calculus was the basis for completing the imaging with
The histopathological exam revealed the presence of a a CT. Diagnosis of keratinized squamous carcinoma was
classical invasive keratinizing squamous cell carcinoma: made by performing a cervical biopsy.
invasive tumor proliferation consisting of islets and We mention that literature studies describe renal co-
polygonal epithelial cell walls , with the formation of involvement in the case of extensive cervical cancers at
frequent keratosis pearls, accentuated nuclear the parametrium level [7]. In the case presented, the
pleomorphism.Focal prominent nucleoli, rare monstrous existence of the tumor at the genital level explains the
nuclei and increased mitotic activity, with the presence of presence of bilateral hydronephrosis secondary to extrinsic
frequent atypical mitosis. ureteral obstruction. The anatomopathological description
During the admission, the extrarenal clearing is of the tumor supports the association of oncological
maintained with a net improvement in symptomatology pathology with the patient’s renal impairment.
and a slight decrease in BUN retention. Given a slight improvement in renal function with
A urological evaluation advocated for bilateraldouble-J initiation of hemodialysis sessions, it was necessary to
stent. After this procedure the diuresis increased from 2000- perform specific urological treatment in order to improve
3000mL / day at the time of admission, to 4000-4500mL / the patient’s evolution [7,11-13]. In this regard, the basis
day. After bilateralureteral double-J stent, the nitrate for the decision to perform a bilateral nephrostomy was
retention products remained elevated- urea-87mg / dL, the description in the literature of certain benefits of this
creatinine -7.72mg / dL, thus the decision was made to procedure in order to improve the quality of life and restore
maintain the patient in a chronic hemodialysis program. the renal function of patients with cervical cancer [14].
The oncological evaluation recommends combined Despite the nephrostomy mounting, the lack of
therapy - radiotherapy and chemotherapy with subsequent improvement in BUN, Cr lead to the decision to maintain
evaluation for surgical treatment of the tumor. the patient in a chronic hemodialysis program.
Uterine cervical cancer is a major global health problem, In this particular patient, a number of factors may
representing the second or third neoplasia in women and contribute to the deterioration of renal function. Thus,
with an increasing incidence of 0.6% per year [15]. There patient’s age (65 years) suggests underlying functional
are large discrepancies between developed countries and and structural changes that define the concept of aged
those with fewer resources in terms of incidence and kidney. Taking these into account and the addition by various
mortality. The essential factor is the existence of effective mechanisms of a new injury can cause acceleration of
screening programs and the presence of an adequate renal decline [28]. Furthermore, prior histor y of
infrastructure for the management of precancerous hydronephrosis does not exclude the possibility of chronic
lesions. In Romania, the incidence of cervical cancer is renal involvement due to a preexisting obstructive
the highest in Europe, many cases being diagnosed in nephropathy. The presence of a paraneoplastic glomerular
advanced stages of the disease [16]. disease in patients with genital neoplasm is well described
Squamous carcinoma is the most common histological in the literature. In the development of this paraneoplastic
type of uterine cervical cancer (80% of cases) and is syndrome, the membranous nephropathy is the most
subdivided into several histological subtypes, one of them commonly found glomerular change [29]. Particularly for
being keratinizing squamous carcinoma [17-20]. cervical cancer, the possibility of an associated
Squamous carcinoma can affect also the vulva, most membranous nephropathy is supported by many
commonly the patients being diagnosticated after the researchers [30]. In the present case, in the absence of a
menopause with the keratinizing type [21]. renal biopsy (contraindicated at the time of admission due
The identification of cytological changes by Pap smear to the stage of CKD), it is not possible to establish a definite
, as well as the presence of clinical manifestations such as etiological diagnosis of renal impairment. Due to the
abnormal vaginal bleeding (metrorrhagia after sexual increased risk of bleeding in this patient, the procedure
intercourse or in menopausal women), the presence of could complicate associated anemia [31]. At the same
vaginal discomfort or lumbar pain may raise suspicion of time, we note that, in order to improve the patient’s
cervical cancer. Early diagnosis has a positive impact on prognosis, it was considered appropriate to carry out
patient survival and is dependent on the recognition of the surgical dissection and initiation of the oncology therapy.
first symptoms of the disease [22,23]. Regardless of the patient’s underlying disease, the addition
In the presented case, the absence of specific cervical of secondary obstructive component to the presence of
cancer manifestations delayed the diagnosis. An additional extensive neoplastic cervical neoplasia led to decreased
factor in this case was the absence of screening through renal function to the point where extra-renal treatment
REV.CHIM.(Bucharest) ♦ 69 ♦ No.9♦ 2018 http://www.revistadechimie.ro 2525
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