Indian Journal of Cancer Medknow Publications on behalf of Indian Cancer Society ISSN: 0019-509X EISSN: 1998-4774 Vol. 48, Num. 1, 2011, pp. 123-124

Indian Journal of Cancer, Vol. 48, No. 1, January-March, 2011, pp. 123-124

Letter to Editor

Role of adjuvant radiation therapy in unusually rare primary malignant osteoclast-like giant cell tumor of the kidney

MS Tiwana¹, S Kakkar¹, N Shirazi², P Upadhya¹, H Nautiyal³

¹ Department of Radiation Oncology, Cancer Research Institute, Himalayan Institute Hospital Trust, Swami Rama Nagar, P.O. Doiwala, Dehradun 248 140, Uttarakhand, India
² Department of Pathology, Cancer Research Institute, Himalayan Institute Hospital Trust, Swami Rama Nagar, P.O. Doiwala, Dehradun 248 140, Uttarakhand, India
³ Department of Surgery, Cancer Research Institute, Himalayan Institute Hospital Trust, Swami Rama Nagar, P.O. Doiwala, Dehradun 248 140, Uttarakhand, India

Correspondence Address:
M S Tiwana
Department of Radiation Oncology, Cancer Research Institute, Himalayan Institute Hospital Trust, Swami Rama Nagar, P.O. Doiwala, Dehradun 248 140, Uttarakhand
India
tiwanams@yahoo.co.in

Code Number: cn11027

Sir,

Osteoclast-like giant cell tumors usually arise in bone or as tumors of tendon sheath and rarely have been reported in extraosseous epithelial sites like kidney, lungs, larynx, and pancreas. ^{[1],[2],[3],[4]} We report the case of a 28-year old premenopausal female who presented with a 3-month history of unrelenting left-sided abdominal pain attributed to a bulky mass arising from the left kidney. Contrast-enhanced computed tomography (CECT) scan confirmed a moderately enhancing 8.19 × 6.57 cm left renal mass, in association with central non-enhancing necrotic cystic areas. [Figure - 1] With an interim diagnosis of renal cell carcinoma, the patient underwent a left radical nephrectomy. Grossly, a soft and cystic mass in the enlarged lower pole of the dissected kidney was seen. Microscopically, a tumor comprising of multinucleated osteoclast-like giant cells and mononuclear stromal cells was visualized. [Figure - 2] Extensive necrosis, hemorrhage, nuclear polymorphism, and atypical mitotic features were hallmark of this malignancy. Additionally, capsular infiltration was detected, however, the Gerota′s was intact. The adjacent renal vessels, IVC, and hilar lymph nodes were free of disease and thrombus formation. No evidence of associated renal cell carcinoma or urothelial tumor was appreciated. Immunohistochemical (IHC) staining with vimentin was positive in the multinucleated giant cells, cytokeratin staining, however, was negative. Postoperative, she received adjuvant radiation therapy - 50.40 Gy in 28 fractions to the left renal bed. She is on regular follow up, and her last clinicoradiological evaluation was done 5 months post-surgery (September 2009), which suggested a disease-free status.

The incidence of renal tumors with osteoclast-like giant cells is exceptionally rare, and is only reported in association with papillary, transitional renal cell carcinoma, or sarcomatoid carcinoma. ^[2],[5] This is a rare case of primary de novo malignant osteoclast-like giant cell tumor of the kidney, being first in the Indian subcontinent. ^[1],[2] The earlier reports detailed more on clinicopathological findings, but our report discusses the adjuvant therapy and outcome parameters of this rare entity. Wide surgical excision for extra-osseous giant cell tumors involving larynx, pancreas, lung, bladder, and kidney offers excellent long-term prognosis. ^[1],[4] Radiation therapy is reserved for unresectable disease. ^[4] The origin of these osteoclast-like giant cells is controversially debated as either epithelial or pluripotent mesenchymal stromal cell lineage. This theory of IHC defined cellular origin underlies a strong predictive significance. Carcinomas containing osteoclast-like giant cells show a rapid progression and metastatic potential, while those with histiocytic differentiation seem to have a better prognosis. ^[3] Vimentin staining classified our case to a histiocytic lineage. However, aggressive pathological features of excessive necrosis, nuclear polymorphism, and atypical mitotic figures with an associated capsular infiltration validated adjuvant radiation therapy in our patient. Indeed, a longer follow up and requirement for more number of subjects to understand the natural history of disease would always be an inherent limitation for any rare clinical entity.

In conclusion, primary malignant giant cell tumor of the kidney is exceptionally uncommon. Upfront surgical resection is the treatment of choice while adjuvant radiation therapy should be based on aggressive pathological features as assessed on microscopic, and a possible IHC evaluation.

References

Copyright 2011 - Indian Journal of Cancer

The following images related to this document are available:

Photo images