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GENITOURINARY RADIOLOGY Table of Contents   
Year : 2000  |  Volume : 10  |  Issue : 4  |  Page : 249-251
Case report: Renal cell carcinoma: Unusual metastases


Dept of Radiodiagnosis, Government Medical College, Amritsar, Iceland

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Keywords: Renal cell carcinoma, Metastases, Maxillary sinus

How to cite this article:
Jain V, Shergill G S, Gupta K, Bhandari R K. Case report: Renal cell carcinoma: Unusual metastases. Indian J Radiol Imaging 2000;10:249-51

How to cite this URL:
Jain V, Shergill G S, Gupta K, Bhandari R K. Case report: Renal cell carcinoma: Unusual metastases. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Jun 20];10:249-51. Available from: http://www.ijri.org/text.asp?2000/10/4/249/30607
Renal cell carcinoma is known to metastasize to the lungs, liver, bones, lymph nodes and the brain. Unusual metastases to other sites are rare but have been reported. We present an incidence of a woman with a histologically proven renal cell carcinoma (RCC), with metastases in the maxillary sinus extending to the oral cavity with mediastinal lymphadenopathy.


   Case Report Top


A thirty-years-old woman presented with complaints of swelling over the right maxilla which developed slowly over a period of three months. History of loss of weight, appetite, dry cough and epistaxis was present. There was no history of hematuria, abdominal pain, abdominal mass or hypertension.

On examination the patient was in good general condition except for anemia. On local examination of the maxillary mass, it was seen that the mass was solid, crossed the midline and extended to the oral and nasal cavities and cheek. Abdominal examination revealed a big bimanually palpable, ballotable mass in the right renal fossa. It was solid, non-tender and moved with respiration.

The patient was referred to us for imaging studies. A chest radiograph [Figure - 1] showed right paratracheal lymphadenopathy and partial collapse and consolidation of the right upper lobe. The right dome of the diaphragm was raised. No pleural effusion or any other evidence of metastases was seen in the lungs.

Ultrasound of the abdomen [Figure - 2] revealed a large heterogeneous mass with areas of calcification and necrosis measuring 8x9x10 cm in the right renal fossa completely replacing the renal tissue. The para-aortic end para-caval lymph nodes were enlarged. No thrombus was seen in the renal veins or IVC. No metastases were seen in the liver.

CT of the abdomen [Figure - 3] showed a large heterogeneous mass with irregular margins replacing the right kidney with mild to moderate enhancement. The mass showed perinephric extension but did not involve the adjacent organs. The paracaval and para-aortic lymph nodes were enlarged. No thrombus was seen in the renal vein or IVC.

CT of the maxillary sinus [Figure - 4] revealed a soft tissue heterogeneous mass (3.3 x 4.4 x 4.0 cm) with mild enhancement. Destruction of the anteromedial wall of the right maxilla was seen. The mass was centered on the anterior maxillary wall with extension to the cheek, nasal cavity and oral cavity.

FNAC of the renal mass revealed renal cell carcinoma. Local biopsy of the maxillary swelling proved to be adenocarcinoma. A final diagnosis of renal cell carcinoma Stage IV B with metastases to the maxillary sinus and mediastinal lymph nodes was made.


   Discussion Top


Renal cell carcinoma is the most frequent urological malignancy in adults. It occurs most frequently in the fifth and sixth decade of life. It is more common in men than in women. Metastases from RCC may spread to any part of the human body. Regional lymph nodes, lungs, bones and liver are the most common sites.

Fifteen percent of patients with RCC are said to present with metastases in the head and neck region [1],[2]. Renal cell carcinoma is the third most frequent primary infraclavicular tumor after lung and breast carcinoma to metastasize to the head and neck. Most of the metastases from RCC to the head and neck involve the thyroid gland [2]. However, it is the most frequent infraclavicular primary tumor to metastasize to the nasal cavity and paranasal sinuses (40-50%) [3]. These metastases occur through the vertebral plexus of veins that communicate with the great venous plexus of the head and in turn are related to the paranasal sinuses [2],[3]. Epistaxis is the chief presenting complaint in 70% of patients, because metastases from RCC are hypervascular [3]. Other presenting complaints of metastatic RCC to the sinonasal tract are nasal obstruction, swelling or facial asymmetry and pain, which are identical to the symptoms produced by primary sinus tumors [2]. There is nothing characteristic about these tumors clinically or radiologically that would aid the otolaryngologist in differentiating the neoplasm from primary malignant tumors of the sinus [3].

A metastatic lesion may be the initial manifestation of a silent hypernephroma. In eight of the sixteen cases reported by Boles [1], the renal primary was unsuspected until after the metastatic lesion in the head and neck was biopsied and read histologically as metastatic carcinoma from the kidney. Whenever the histopathology of a maxillary mass reveals adenocarcinoma, metastasis should be considered the first possibility because primary adenocarcinoma of the maxillary sinus is very rare. The most common primary tumor in such cases is renal cell carcinoma. However, secondaries in many such instances may also come from the breast, colon etc. Only after excluding the primary site, should a case of primary adenocarcinoma of the maxilla be diagnosed [4].

Mediastinal lymph node metastases from infra­diaphragmatic malignancies are reported to be a rare occurrence. The most common primary tumors are renal cell carcinomas, followed by other genitourinary and gastrointestinal carcinomas. The spread of infra­diaphragmatic malignancies to the mediastinum occurs primarily by extension from the retrocrural and para­aortic nodes into the thoracic duct and then by antegrade flow in the thoracic duct and its collaterals, with retrograde flow from these channels to the mediastinal nodes [6].

While RCC often metastasizes to chest cavity structures, it typically results in lesions of the pulmonary parenchyma with or without involvement of hilar and mediastinal lymph nodes. Rarely metastatic lesions from RCC may involve mediastinal lymph nodes without any metastatic lesions in the pulmonary parenchyma [7]. They may be the sole manifestation of metastatic RCC.

Thus renal cell carcinoma is characterized by its varied presentation and variable clinical course. It is the most unusual and unpredictable cancer. Like tuberculosis and syphilis, it is one of the great mimics in clinical medicine [2]. Recognizing the unusual presentation and natural history of an RCC can have a profound effect on patient management, and thus on morbidity and mortality.

 
   References Top

1.Boles R, Cerny J. Head and neck metastases from renal cell carcinoma. Michigan Medicine, 1971; 70: 616-18.  Back to cited text no. 1    
2.Miyamoto R, Helmus C. Hypernephroma metastatic to the head and neck. Laryngoscope, 1973; 83: 898-905.  Back to cited text no. 2    
3.Bernstein JM, Montgomery WW, Balogh K Jr. Metastatic tumors to the maxilla, nose and paranasal sinuses. Laryngoscope, 1966; 76: 621-50.  Back to cited text no. 3    
4.John RH, Charles FL, David JS, Elias AZ. Computed tomography and magnetic resonance imaging of the whole body. 3rd ed. St. Louis: Mosby, 1994; 485.  Back to cited text no. 4    
5.Kent SE, Majumdar B. Metastatic tumors in the maxillary sinus. A report of two cases and a review of the literature. J Laryngol Otol 1985; 99: 459-62.  Back to cited text no. 5    
6.Mahon TG, Libshitz HI. Mediastinal metastases of infradiaphragmatic malignancies. EurJ Radio[ 1992; 15: 130-4.  Back to cited text no. 6    
7.Mattana J, Kurtz B, Miah A, Singhal PC. Renal cell carcinoma presenting as a solitary anterior superior mediastinal mass. J Med 1996; 27: 205-10.  Back to cited text no. 7    

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Kamlesh Gupta
Mahajan Villa, Batala Road, Vijay Nagar, Amritsar
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4]

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