Winning Abstracts from the 2009 Medical Student Abstract Competition: Metastatic Renal Cell Carcinoma In A 19-Year-Old Male Treated With Interleukein-2
Authors: Ian Amber, Priyanka Handa, Michael Shiman, Paul Mendez, MD FACP
A 19-year-old Haitian male presented to the hospital after receiving a positive PPD test and an abnormal chest X-ray from immigration authorities. The patient was asymptomatic, denying shortness of breath, cough, or hemoptysis. His oxygen saturation was normal. Upon admission, a chest CT scan revealed bilateral pulmonary nodules consistent with metastatic disease. Additionally, partially visualized hypodensities with peripheral calcifications were seen appearing to originate from the right kidney. Given the patient's age, a germ cell tumor was suspected. However, beta-hCG, alpha-fetoprotein, and lactate dehydrogenase levels were within normal limits. Furthermore, an ultrasound of the scrotum indicated no evidence of disease. Additional imaging was performed. A brain CT was normal. A CT of the abdomen and pelvis confirmed a 3.8 x 3.7 cm exophytic lesion, with ring-like calcifications, in the mid portion of the right kidney. Biopsies of the lung lesions were performed using video-assisted thoracoscopic surgery (VATS). The lesions were consistent with juvenile renal cell carcinoma. Immunostaining was negative for thyroid transcription factor-1 (TTF-1), thyroglobulin, CK-7, and amylase. However, stains were positive for CD10 and strongly positive for carbonic anhydrase IX (CAIX).
Tumors with an over-expression of CAIX typically correlate with a poor prognosis, due to aggressive metastasis. However, CAIX positivity makes him a candidate for interleukin-2 treatment. CAIX is an important prognostic indicator of interleukin-2 treatment, because while response rates vary at approximately 15-20%, only patients who are positive for CAIX are capable of achieving a complete remission.
Because interleukin-2 therapy produces potentially fatal systemic toxicities, it is relatively contraindicated in older patients. Typically, vascular endothelial growth factor inhibitors, such as sunitinib and sorafenib, are used as a less toxic, though palliative, option. While it is rare to diagnose renal cell carcinoma in a young patient, it is important to note how age affects the treatment paradigm. Specifically, in a young patient such as this case, the opportunity to achieve complete remission with interleukin-2 therapy outweighs the risks associated with this treatment modality.
Though clinically he appeared to present with a classic case of a germ cell tumor, this case supports the need for biopsy before any treatment decisions are made. In addition, it highlights the importance of seeking immunomodulatory therapy in young patients with a potentially curable illness.
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