|Year : 2021 | Volume
| Issue : 1 | Page : 30-32
Carcinoma cervix with ectopic kidney, its treatment and outcome
Mridul Anand, Ankita Parikh, Sonal Patel Shah
Department of Radiation Oncology, Gujarat Cancer Research Institute, Ahmedabad, Gujarat, India
|Date of Submission||04-May-2019|
|Date of Decision||25-Aug-2020|
|Date of Acceptance||01-Jan-2021|
|Date of Web Publication||14-Apr-2021|
6-C Fruit Garden, NIT, Faridabad - 121 001, Haryana
Source of Support: None, Conflict of Interest: None
The occurrence of pelvic malignancies along with an ectopic kidney is a rare finding. In the patients of early stage carcinoma of cervix presenting with pelvic kidney, surgery is preferred to radiation to avoid irradiating the kidney. However, advanced stage carcinoma of cervix in such scenario poses a therapeutic dilemma and conformal radiotherapy in the form of intensity-modulated radiotherapy (IMRT) is preferred option. This helps to achieve the desired dose to the target while reducing the dose to the surrounding organs at risk particularly to the pelvic kidney. Herein, we present a case of International Federation of Gynecology and Obstetrics Stage IIB carcinoma of cervix having ectopic right pelvic kidney in a 40-year-old female, and the patient was successfully treated with chemoradiotherapy in IMRT technique. The patient is disease free with normal renal function at 2-year follow-up. The previously reported cases of pelvic malignancies with ectopic kidney in the literature are discussed here briefly.
Keywords: Carcinoma of cervix, ectopic kidney, intensity-modulated radiotherapy
|How to cite this article:|
Anand M, Parikh A, Shah SP. Carcinoma cervix with ectopic kidney, its treatment and outcome. Oncol J India 2021;5:30-2
| Introduction|| |
The incidence of pelvic kidney varies worldwide with an approximation of between 1 in 2200 and 1 in 3000 births. The presence of pelvic malignancy along with the ectopic pelvic kidney is rare. Depending on the risk factors and stage of the pelvic malignancy, radiotherapy may be required in terms of adjuvant setting or radical intent. However, accurate delivery of planned radiation dose schedule through conventional technique is impossible in the presence of pelvic kidney to maintain dose to the pelvic kidney within tolerance limit. Intensity-modulated radiotherapy (IMRT) is a good valid technique to keep the dose to the functional pelvic kidney under normal constraints in locally advanced pelvic malignancies. The function of the ectopic kidney should be evaluated with renal function tests and isotopic nephrograms before the start of treatment. Technetium-99m dimercaptosuccinic acid (99mTc) or technetium-99m diethylenetriaminepentaacetic acid (99mTc-DTPA) renal scintigraphic study shows the amount of radio-labeled marker, which is excreted by the kidney and have correlated well with the functional status of the kidney.
Here, we report a case of locally advanced carcinoma of cervix along with pelvic kidney where IMRT plan was successfully made and executed preserving function of the pelvic ectopic kidney.
| Case Report|| |
A 40-year-old female presented to our department with the complaints of lower abdominal pain and intermenstrual bleeding per vaginum for 7 months. On contrast-enhanced computed tomography scan of abdomen and pelvis imaging, right kidney was not seen in the right renal fossa but seen in the lower abdomen and malrotated. After complete workup, the patient was diagnosed as a case of carcinoma of cervix International Federation of Gynecology and Obstetrics (FIGO) Stage IIB. An isotopic nephrogram was done to see the function of the ectopic kidney and uptake was found to be 15% for the right ectopic kidney and 85% for the left kidney. After discussion in multidisciplinary team, the patient was planned for radical external beam radiotherapy (EBRT) along with concurrent chemotherapy, followed by brachytherapy. The EBRT was planned with IMRT technique by nine coplanar beams for a total dose of 40 gray in twenty fractions at 2 gray per fraction along with concurrent chemotherapy of weekly injection carboplatin AUC 1–2. The comparatively lower dose of external radiotherapy has been given as a part of institutional protocol for Stage II carcinoma of cervix. Radiotherapy was planned on Elekta synergy machine and MONACO planning system. Contouring was done as follows. For primary lesion, gross tumor volume to clinical target volume (CTV) margin was taken to be 1 cm, and CTV to planning target volume (PTV) margin was taken to be 0.5 cm. CTV-nodal was drawn by giving 7 mm margins around the vessels, and PTV-nodal was made by giving 0.5 cm margin around the CTV-nodal. Another PTV, i.e., PTV 2 was made by excluding 0.5 cm of the ectopic right kidney from PTV.
After segmentation, 9-beam IMRT plan was made for a dose of 40 Gy in twenty fractions. The dose volume statistics with tables of various organs and dose volume histogram had been presented in [Figure 1] and [Figure 2], respectively. 95% of PTV received 94.6% of planned target dose, i.e., 40 Gy and the mean right kidney dose was 20.28 Gy [Figure 3]. The slight underdosage (94.6%) was seen in the area of nodal planning tumor volume near the right kidney but was accepted to limit the kidney dose.
The planned concurrent chemotherapy was stopped after receiving two cycles of it along with EBRT due to deteriorating renal function and EBRT alone was continued up to planned schedule. This was followed by assessment for feasibility of brachytherapy after 1 week of completion of EBRT. Since patient could be taken up for intracavitary brachytherapy, three fractions of 7.5 gray each were planned and delivered 1 week apart. The renal function tests during and after the treatment continue to be normal. A posttreatment 99mTc-DTPA renal scintigraphy scan of the patient done at 6 months was suggestive of prolonged but unobstructed tracer excretion in the ectopic kidney. Imaging and clinical examination done at regular intervals continue to be normal at the end of 2 years of follow-up.
| Discussion|| |
The simultaneous occurrence of the ectopic kidney and locally advanced carcinoma of cervix is a challenging scenario with no definitive guidelines. The concern in treating the patient lies in sacrificing the function of the ectopic pelvic kidney which lies in the radiation portal. This is due to limited radiation tolerance of kidney which depends on the irradiated volume. The tolerance dose of radiation to the whole kidney is 20 Gy, and radiation-induced damage to kidney can be reduced if dose delivery to the whole kidney is <20 Gy. The use of IMRT is a valid technique which can keep the pelvic kidney dose under acceptable dose volume constraints without comprising the target volume dose schedule. According to Emami et al., the dose constraint is 50 Gy for 5% complications at 5 years if one-third of the kidney is irradiated, 30 Gy for two–third, and 23 Gy for the whole kidney. This increases to 50% complication rate if two-third of the kidney is irradiated to 40 Gy or whole kidney to a dose is of 28 Gy. The constraints for kidney given by Quantitative Analyses of Normal Tissue Effects in the Clinic are V12 <55% and V20 <32%, and mean dose is 18 Gy. In our case, one-third of the kidney received 28 Gy and two-third of the kidney received 12 Gy. The mean dose received by the ectopic kidney was 18 Gy, V12 was 52%, but the V20 constraint, which was 42 Gy should rather be 32% could not be achieved. The slight underdosage (94.6%) in the area of nodal planning tumor volume near the right kidney was accepted to keep the dosage to the right kidney to minimum.
Review of published literatures suggested different options to preserve the ectopic normal pelvic kidney for start of treatment of malignancies either by nephrectomy or translocation of the ectopic normal kidney into upper abdomen, allograft autotransplantation for an already grafted kidney, or blocking the kidney to reduce effect of radiation.,, Castilho et al. in 2006 have reported the first time treatment of adjuvant IMRT for an endometrial cancer patient with a centrally located pelvic kidney at the level of the sacroiliac joints. Seven coplanar fields were used in their IMRT technique which covered 95% of the whole pelvis and lymphatics to 45 Gy. Two-thirds of the ectopic kidney received 21 Gy, and one-third received 31 Gy. The patient suffered no recurrence of the disease, and renal function evaluation was normal at 18-month follow-up. Lataifeh et al. reported a case of carcinoma cervix FIGO Stage IIB patient having pelvic kidney treated with chemoradiation and found disease free at 2-year follow-up with normal renal function tests. Bakri et al. in a letter to editor discussed the difficulties in treating a case of carcinoma cervix IIB complicated by pelvic kidney.
The present case reported a disease-free survival of 2 years with normal clinical examination, renal function tests, and imaging.
| Conclusion|| |
Management of pelvic malignancies presenting with ectopic kidney poses a great challenge in advanced cases, and conformal radiotherapy IMRT is a valid technique to reduce the dose to ectopic normal pelvic kidney and other critical organs, without compromising the target dose.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cinman NM, Okeke Z, Smith AD. Pelvic kidney: Associated diseases and treatment. J Endourol 2007;21:836-42.
Mohiuddin MM, Mahmood U, Hall AA, Rosenshein N. Adjuvant pelvic irradiation for cervical cancer in the setting of a transplanted pelvic kidney. J Cancer Res Ther 2012;8:427-9.
Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, et al.
Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys 1991;21:109-22.
Dewit L, Anninga JK, Hoefnagel CA, Nooijen WJ. Radiation injury in the human kidney: A prospective analysis using specific scintigraphic and biochemical endpoints. Int J Radiat Oncol Biol Phys 1990;19:977-83.
Ramamurthy R, Muthusamy V, Hussain SA. Approach to carcinoma cervix with pelvic kidney. Indian J Surg Oncol 2010;1:323-7.
Abouna GM, Micaily B, Lee DJ, Kumar MS, Jahshan AE, Lyons P. Salvage of a kidney graft in a patient with advanced carcinoma of the cervix by reimplantation of the graft from the pelvis to the upper abdomen in preparation for radiation therapy. Transplantation 1994;58:520-2.
Rosenshein NB, Lichter AS, Walsh PC. Cervical cancer complicated by a pelvic kidney. J Urol 1980;123:766-7.
Castilho MS, Jacinto AA, Viani GA, Campana A, Carvalho J, Ferrigno R, et al.
Intensity modulated radiotherapy (IMRT) in the postoperative treatment of an adenocarcinoma of the endometrium complicated by a pelvic kidney. Radiat Oncol 2006;1:44.
Lataifeh I, Amarin Z, Jaradat I. Stage IIB carcinoma cervix that is associated with a pelvic kidney a therapeutic dilemma. Am J Obstet Gynecol 2007;197:e8-10.
Bakri YN, Mansi M, Sundin T. Stage IIB carcinoma of the cervix complicated by an ectopic pelvic kidney. Int J Gynaecol Obstet 1993;42:174-6.
[Figure 1], [Figure 2], [Figure 3]