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E-JCRT CORRESPONDENCE
Year : 2015  |  Volume : 11  |  Issue : 4  |  Page : 1039

Clear cell renal cell carcinoma with osseous metaplasia: Rare case report


1 Department of Pathology, Maulana Azad Medical College, New Delhi, India
2 Department of Surgery, Maulana Azad Medical College, New Delhi, India

Date of Web Publication15-Feb-2016

Correspondence Address:
Swapnil Agarwal
Department of Pathology, Maulana Azad Medical College, Room No. 62, Pathology Block, Bahadur Shah Zafar Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.146109

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 > Abstract 

Osseous metaplasia with clear cell renal cell carcinoma (RCC) is exceedingly rare. There are less than 20 reported cases of osseous metaplasia in association with RCC. We present a case of 39-year-old male patient presented to outpatient department with complaints of pain in the left lumbar region since 4 years. Computed tomography scan revealed a heterogeneous enhanced mass lesion having areas of necrosis and specks of calcification involving the left kidney. Clinicoradiological diagnosis of RCC was made and left radical nephrectomy was performed. Histological sections from the growth revealed features of clear cell carcinoma Fuhrman grade-2 with a focal area of metaplastic bone formation. The prognostic implications of calcification per se are not very clearly mentioned in the literature. Patients with osseous metaplasia generally present with early stage disease and a favorable prognosis. However, few of them were of high grade and poorer prognosis.

Keywords: Bone, cancer, kidney


How to cite this article:
Agarwal S, Bohara S, Jha R, Khurana N, Agarwal P N. Clear cell renal cell carcinoma with osseous metaplasia: Rare case report. J Can Res Ther 2015;11:1039

How to cite this URL:
Agarwal S, Bohara S, Jha R, Khurana N, Agarwal P N. Clear cell renal cell carcinoma with osseous metaplasia: Rare case report. J Can Res Ther [serial online] 2015 [cited 2020 Aug 3];11:1039. Available from: http://www.cancerjournal.net/text.asp?2015/11/4/1039/146109




 > Introduction Top


Calcifications are seen in a variety of renal lesions. First case of calcified renal cell carcinoma (RCC) was reported by Albrecht in 1905.[1] Since then renal calcifications have been reported in many vascular, infectious, cystic lesions as well as many benign and malignant tumors of the kidney such as oncocytomas, metanephric adenoma, wilms, neuroblastoma and sarcomas. However, there are very few cases osseous metaplasia in RCC.

We hereby present a case of 39-year-old male patient who presented with complaints of pain in the left lumbar region since 4 years. Computed tomography (CT) scan revealed a heterogeneous enhancing mass lesion having areas of necrosis and specks of calcification involving the lower pole of the left kidney. Radical nephrectomy was done, and cut section through the kidney showed a grey-white growth in the lower pole. Histological sections from the growth revealed features of clear cell carcinoma Fuhrman grade-2 with a focal area of metaplastic bone formation.


 > Case Report Top


A 39-year-old male patient presented to outpatient department with the complaints of pain in the left lumbar region since 4 years. The pain was dull and present throughout the day and was not relieved by analgesics. There was no history of fever, dysuria, urgency or hematuria. There was no history of renal calculus disease, tuberculosis, or diabetes. On examination, patient was thin built. Per abdomen was soft and revealed tenderness in the left renal angle, but no mass was palpable. No abnormality was detected in any other organ system. Renal function and liver function tests were normal. Urine analysis was negative without any hematuria. X-ray of kidney, ureter and bladder showed stippled calcification in the left renal region. CT scan revealed a heterogeneous enhancing mass lesion measuring 12 cm × 8.5 cm, having areas of necrosis and specks of calcification involving the lower pole of the left kidney with a simple cyst in bilateral kidneys [Figure 1]. The tumor was confined to Gerota's fascia. No lymph nodal enlargement was seen in the hilar region. Clinicoradiological diagnosis of RCC was made and left radical nephrectomy was performed. On gross examination, the radical left nephrectomy specimen measured 12.5 cm × 6.7 cm × 4 cm. Cut section through the kidney showed a well-circumscribed, heterogeneous, firm, variegated grey-white growth in the lower pole measuring 3 cm × 3 cm × 1.5 cm. Single unilocular cyst was identified at the lower pole adjacent to the tumor measuring 4 cm × 2 cm × 0.1 cm. The tumor did not appear to infiltrate the surrounding normal kidney and was free from the renal sinus and the pelvis. The renal vein and ureter were unremarkable. Histological sections from the growth revealed features of clear cell carcinoma Fuhrman grade-2 with a focal area of metaplastic bone formation [Figure 2] and [Figure 3].
Figure 1: Computed tomography scan showing a heterogeneous enhancing mass lesion measuring 12 cm × 8.5 cm, having areas of necrosis and specks of calcification involving the lower pole of the left kidney with simple cyst in bilateral kidneys

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Figure 2: Histological sections from the growth revealed features of clear cell carcinoma Fuhrman grade-2 (H and E, ×100)

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Figure 3: Renal cell carcinoma with a focal area of metaplastic bone formation (H and E, ×40)

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The tumor focally involved the renal capsule. However, there was no infiltration into perinephric fat. The tumor cells were positive for vimentin, and cytokeratin.


 > Discussion Top


Calcifications are present in a variety of renal lesions. First case of calcified RCC was reported by Albrecht in 1905.[1] Since then renal calcifications have been reported in many vascular, infectious, cystic lesions as well as many benign and malignant tumors of kidney such as oncocytomas, metanephric adenoma, wilms, neuroblastoma and sarcomas.

In the 10 year study at mayo clinic by Daniel et al. 111 cases out of 2709 renal masses were calcified with an incidence of 4.1%.[2] Most calcified renal parenchymal tumors were relatively large but tended to be localized and histologically well-differentiated. These tumors had a slow growth and were associated with a predicted 5-year survival rate of 77 per cent.[3]

Renal cell carcinoma with osseous metaplasia has rarely been reported. There are 14 reported cases of osseous metaplasia in association with RCC. However, osseous metaplasia with clear cell RCC is exceedingly rare. After a thorough search of the literature, we could find only five such cases.[4],[5],[6],[7],[8] Two of these case reports were in a cystic RCC and two in a solid RCC without a cystic component. Our case was without any cystic component similar to last two cases.

The exact mechanism of bone formation in RCC is not known. Several hypotheses have been put forward for ossification in RCC. One hypothesis suggests simple production of bone by tumor cells secondary to ischemia, necrosis, inflammation or there might be ossification in preexisting focus of calcification.

Recently, Yamasaki et al. reported involvement of bone morphogenic protein 2, an inducer of osteoblastic differentiation of pluripotential cells, in ossification of RCC.[9]

The prognostic implications of calcification perse are not very clearly mentioned in the literature. Patients with osseous metaplasia generally present with early stage disease and a favorable prognosis.[10] However, few of them were of high grade and poorer prognosis. Our case support a favorable prognosis as it was of Furham grade 2 and had no evidence of metastatic disease at presentation. The above mentioned patient is doing well at follow-up.

 
 > References Top

1.
Albrecht P. Und pathologischen anatomie der malignen hypernephrome. Arch F Klin Chir 1905;77:1072.  Back to cited text no. 1
    
2.
Daniel WW Jr, Hartman GW, Witten DM, Farrow GM, Kelalis PP. Calcified renal masses. A review of ten years experience at the Mayo Clinic. Radiology 1972;103:503-8.  Back to cited text no. 2
[PUBMED]    
3.
Krieger JN, Sniderman KW, Seligson GR, Sos TA. Calcified renal cell carcinoma: A clinical, radiographic and pathologic study. J Urol 1979;121:575-80.  Back to cited text no. 3
[PUBMED]    
4.
Bloom TL, Gray Sears CL, Williams TR, Linfesty RL, Amling CL. Multilocular cystic renal cell carcinoma with osseous metaplasia in a 25-year-old woman. Urology 2003;61:462.  Back to cited text no. 4
    
5.
Puppa G, Gervasio A, Yorukoglu K, Colombari R, De Marchi F, Canzonieri V. Huge renal cyst with parietal renal cell carcinoma, osseous metaplasia and a papillary adenoma: A case report with unique clinicopathological features and literature review. Virchows Arch 2008;452:325-30.  Back to cited text no. 5
    
6.
Singh V, Sinha RJ, Sankhwar SN, Dalela D. Heterotopic bone formation in renal cell carcinoma: A diagnostic challenge. Indian J Cancer 2008;45:126-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Fukuoka T, Honda M, Namiki M, Tada Y, Matsuda M, Sonoda T. Renal cell carcinoma with heterotopic bone formation. Case report and review of the Japanese literature. Urol Int 1987;42:458-60.  Back to cited text no. 7
    
8.
Hartman RJ, Helfand BT, Dalton DP. Clear cell renal cell carcinoma with osseous metaplasia: A case report. Can J Urol 2011;18:5564-7.  Back to cited text no. 8
    
9.
Yamasaki M, Nomura T, Mimata H, Nomura Y. Involvement of bone morphogenetic protein 2 in ossification of renal cell carcinoma. J Urol 2004;172:475-6.  Back to cited text no. 9
    
10.
Sostre G, Johnson JF 3rd, Cho M. Ossifying renal cell carcinoma. Pediatr Radiol 1998;28:458-60.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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