Histopathological findings in parotid gland metastases from renal cell carcinoma

Use of Immune Checkpoint Inhibitors in Elderly Patients With Chronic Kidney Disease and Renal Cell Carcinoma Metastasis of the Parotid Gland: Case Report and Review of the Literature

Renal cell carcinoma metastasis of the parotid gland is extremely rare, and the present literature review found only 23 cases reported in the last two decades. We present a case of a 75-year-old woman with a colon cancer history who had parotid gland metastasis as the first manifestation of second primary kidney cancer. The presence of multiple comorbidities affected medical decision-making. Therefore the patient was treated primarily with immunotherapy. After four cycles of dual immune checkpoint blockade, this advanced patient still benefited and was changed to nivolumab monotherapy as maintenance therapy.

Differential Diagnosis between Oral Metastasis of Renal Cell Carcinoma and Salivary Gland Cancer

Renal cell carcinoma, which has clear cells in 70% of cases, has a high frequency of hematogenous distant metastases to lung, bone, liver, and other areas. Metastatic cancer accounts for 1 to 3% of malignant tumors in the stomatognathic region, and the metastasis of renal cell carcinoma to the oral mucosal tissue, though extremely rare, does occur. In addition, clear cells have been observed in some salivary gland cancers in the oral cavity. Therefore, the differential diagnosis of metastatic renal cell carcinoma and salivary gland cancer is important. This review discusses the differential diagnosis between metastatic renal cell carcinoma and malignant tumors of the salivary gland.

Metastatic disease in head & neck oncology

The head and neck district represents one of the most frequent sites of cancer, and the percentage of metastases is very high in both loco-regional and distant areas. Prognosis refers to several factors: a) stage of disease; b) loco-regional relapses; c) distant metastasis. At diagnosis, distant metastases of head and neck cancers are present in about 10% of cases with an additional 20-30% developing metastases during the course of their disease. Diagnosis of distant metastases is associated with unfavorable prognosis, with a median survival of about 10 months. The aim of the present review is to provide an update on distant metastasis in head and neck oncology. Recent achievements in molecular profiling, interaction between neoplastic tissue and the tumor microenvironment, oligometastatic disease concepts, and the role of immunotherapy have all deeply changed the therapeutic approach and disease control. Firstly, we approach topics such as natural history, epidemiology of distant metastases and relevant pathological and radiological aspects. Focus is then placed on the most relevant clinical aspects; particular attention is reserved to tumours with distant metastasis and positive for EBV and HPV, and the oligometastatic concept. A substantial part of the review is dedicated to different therapeutic approaches. We highlight the role of immunotherapy and the potential effects of innovative technologies. Lastly, we present ethical and clinical perspectives related to frailty in oncological patients and emerging difficulties in sustainable socio-economical governance.

The rising incidence of parotid metastases: our experience from four decades of parotid gland surgery

Secondary neoplasia in the parotid gland is increasingly frequent. We examined outcomes from 40 years of parotid surgery to analyse patterns for metastasis, review the staging procedure and discuss management. We retrospectively examined 772 consecutive cases of parotid surgery in a university hospital between 1975 and 2015 and assessed changes in incidence and management over four decades. In all, 71% percent of patients were male and 29% were female, with a mean age of 68 years, aged between 23 and 93 years. We diagnosed 683 parotid tumours of which 15.8% (n = 108) were malignant; 44% (n = 48) of all malignant lesions were metastases. The incidence of malignant tumours rose from 8% in the first decade, 14% in the second, 17% in the third to 21% in the fourth. The incidence increased even further from 10% in the first to 57% in the final decade. Most frequent tumours were metastases of squamous cell carcinoma (79%), and the majority of these lesions (87%) arose from above the clavicle, with 30 primary tumours in the skin. In most cases, the skin tumour had been excised between 6 and 24 months prior to parotid metastasis. Management consisted of surgery with neck dissection. 48 patients (67%) received adjuvant therapy, but despite aggressive multimodal treatment, disease progressed in the majority of cases, in 57% squamous cell carcinoma of the skin primaries, 67% of mucosal primaries above the clavicle and 83% of infraclavicular primaries. Parotid malignant tumours are increasing in incidence, mostly due to a rise in metastatic malignant tumours within the parotid gland, most of which are metastases of skin tumours, commonly squamous cell carcinoma. Despite multimodal therapy, their recurrence and progression rate remains high. We propose inclusion in head and neck follow-up in all cases of head and neck skin cancers.

Diagnostic relevance of metastatic renal cell carcinoma in the head and neck: An evaluation of 22 cases in 671 patients

Purpose

Renal cell carcinoma (RCC) is a malignant tumor that metastasizes early, and patients often present with metastatic disease at the time of diagnosis. The aim of our evaluation was to assess the diagnostic and differential diagnostic relevance of metastatic renal cell carcinoma (RCC) with particular emphasis on head and neck manifestations in a large patient series.

Patients and methods

We retrospectively evaluated 671 consecutive patients with RCC who were treated in our urology practice between 2000 and 2013.

Results

Twenty-four months after diagnosis, 200/671 (30%) of RCC had metastasized. Distant metastases were found in 172 cases, with 22 metastases (3.3%) in the head and neck. Cervical and cranial metastases were located in the lymph nodes (n=13) and in the parotid and the thyroid gland, tongue, the forehead skin, skull, and paranasal sinuses (n=9). All head and neck metastases were treated by surgical excision, with 14 patients receiving adjuvant radiotherapy and 9 patients receiving chemotherapy or targeted therapy at some point during the course of the disease. Five patients (23%) survived. The mean time of survival from diagnosis of a head and neck metastasis was 38 months, the shortest period of observation being 12 months and the longest 83 months.

Discussion and conclusion

Our findings show that while RCC metastases are rarely found in the neck, their proportion among distantly metastasized RCC amounts to 13%. Therefore, the neck should be included in staging investigations for RCC with distant metastases, and surgical management of neck disease considered in case of resectable metastatic disease. Similarly, in patients presenting with a neck mass with no corresponding tumor of the head and neck, a primary tumor below the clavicle should be considered and the appropriate staging investigations initiated.

Histological reclassification of parotid gland carcinomas: importance for clinicians

Reassessment of histological specimens of salivary gland carcinomas is associated with a change of primary diagnosis in a significant number of patients. The authors evaluated the relation between reclassification/verification of histological diagnosis and the clinical course of parotid gland carcinomas. Histological and immunohistochemical examinations of 111 specimens of parotid gland carcinomas operated on during the years 1992-2010 were revised and in some cases supplemented with cytogenetic tests (FISH), to verify the diagnosis and potentially reclassify the tumours. Analysis of the clinical documentation and follow-up data of patients whose diagnosis was changed was then carried out. The prognostic factors taken into account in the evaluation of the clinical course included the T and N stage, the tumour grade and the extent of resection. The primary diagnosis was changed on review in 28 patients (25.2 %). In 16 patients, the change involved a different histological type of cancer. In six cases, what was thought to be a primary salivary gland cancer was reclassified as a secondary tumour. In four other cases, the change was made from a malignant to a benign tumour and in one case to a non-neoplastic lesion (necrotizing sialometaplasia). Additionally, in two patients with carcinoma ex pleomorphic adenoma, the malignant component was found to be of in situ type. A potentially atypical clinical course was observed in 4 out of 28 patients whose diagnosis was changed. In the case of 2 patients, the course of disease was more aggressive (dissemination, death) than predicted and less aggressive in rest of the patients. Histological reclassification/verification of parotid gland carcinomas can explain the cause of an atypical clinical course in some patients and sometimes enables doctors to implement a change in therapy.

Parotid gland metastases of distant primary tumours: A diagnostic challenge

OBJECTIVE

Metastatic disease is common among parotid malignancies. The majority of primary tumours are located in the head and neck, but primary tumours below the clavicle must also be considered, especially in histological types not usually found in primary parotid or skin tumours.

METHODS

We performed 644 consecutive parotidectomies between 1980 and 2012. Benign tumours were found in 555 patients (86%) and malignant tumours in 89 patients (14%).

RESULTS

Of 89 malignant tumours, 39 were metastases (44%). In 5 cases, the primary tumour was located below the clavicle (6% of malignant tumours). A carcinoma of the bronchus was subsequently diagnosed in three patients: one patient had breast carcinoma and one renal cell carcinoma.

CONCLUSION

The majority of metastases in the parotid gland arise from primary tumours of the head and neck. In 10-20% of metastases, the primary tumour arises below the clavicle. Parotid metastases can be the first clinical manifestation of a malignant tumour, and can also occur years after curative intent treatment. Histopathology and immunohistochemistry will offer clues to a possible metastatic process and to primary tumour location. Parotidectomy with complete excision of the tumour can be a curative measure or form an essential part of symptom control and should be considered in all but the most moribund patients.

Renal clear cell carcinoma with thyroid and parotid metastases: A case report

The present study reports a rare case of a renal clear cell carcinoma with thyroid and parotid metastases. A 56-year-old female, with a painless, right preauricular mass present for 6 months was referred to Renji Hospital (Shanghai, China). Physical examination revealed a mass of 3×3 cm, which was smooth, firm, immobile and non-tender. There was no accompanying facial weakness. Parotid ultrasonography revealed a hypoechoic mass within the right parotid gland, which was potentially a parotid mixed tumor. In July 2011, the patient underwent a superficial parotidectomy with preservation of the facial nerve. Pathology confirmed as right parotid clear cell carcinoma (metastasis). The patient's relevant medical history included a right radical nephrectomy for renal clear cell carcinoma (clinical stage III) in 2004. Additionally, in 2009, the patient underwent a resection of thyroid metastatic renal cell carcinoma. To the best of our knowledge, no similar case has previously been reported in English-language literature. The present study discusses a case report, and investigates the clinical features and treatment strategy.

Rapidly growing and ulcerating metastatic renal cell carcinoma of the lower lip: A case report and review of the literature

Renal cell carcinomas (RCCs) have a tendency to metastasize at an early stage, therefore, the patients frequently exhibit metastatic disease at the time of diagnosis. Common locations for the metastases are adjacent organs and abdominal lymph nodes; however, occasionally metastasis to the peripheral organs may be the initial clinical symptom. The 71-year-old male patient in the current case suffered from radioresistant and aggressively behaving RCC metastasis in the mandible and lower lip, which was successfully managed by surgical resection. RCC metastasis to the facial area is considered to be uncommon based on a review of the existing literature. RCC are somewhat radioresistant and therefore, palliative surgery must be considered when treating patients with this metastatic disease.

Renal cell carcinoma metastasis to the parathyroid gland: A very rare occurrence

INTRODUCTION

Metastases to the parathyroid gland are very uncommon. Although renal cell carcinoma metastasis to the head and neck region is well recognised, with a predilection for unpredictable metastasis to unusual sites such as the thyroid gland, nose, paranasal sinuses, and cranial bones, there are no reports of parathyroid gland involvement.

PRESENTATION OF CASE

We describe an unusual case of renal cell carcinoma metastasis to a parathyroid gland in a 69-year-old male who had been treated 8 years previously for a pT3b N0 M1 clear cell carcinoma of the right kidney with a right nephrectomy, and interferon immunotherapy for 18 months. The patient had originally presented to the plastic surgeons with a rapidly enlarging 3 cm superficial lesion on the ventral aspect of the left forearm, which was excised with histology revealing metastatic renal (clear) cell carcinoma.

DISCUSSION

Renal cell carcinoma has a reputation for unpredictable patterns of metastasis, and our case highlights this, with the first description in the literature of parathyroid gland metastasis. Despite the poor prognosis associated with metastatic renal cell carcinoma, our patient is still alive 10 years following original presentation, despite having metastasis to two different extra-renal sites and a shortened course of initial adjuvant systemic therapy.

CONCLUSION

In parathyroid gland metastasis, metastectomy can offer excellent local long term local control.

Metastatic renal cell carcinoma, clear cell type, of the parotid gland: a case report, review of literature, and proposed algorithmic approach to salivary gland clear cell neoplasms in fine-needle aspiration biopsies

Renal cell carcinoma (RCC), clear cell type, is a commonly encountered metastatic tumor that can present at unusual anatomic sites many years after the primary tumor resection. Noncutaneous metastasis to the parotid gland is unusual; however, a number of cases of parotid RCC metastasis have been reported. Fine-needle aspiration biopsy (FNAB) is regularly utilized during the evaluation of salivary gland lesions, where it has a high sensitivity, specificity, and accuracy; however, the identification and definitive diagnosis of primary and metastatic clear cell neoplasms is a potential diagnostic pitfall for salivary gland FNAB. Here, we describe a case of RCC, clear cell type, metastatic to the parotid gland that was diagnosed entirely from FNAB cell block material, which is the first such reported case to our knowledge. We review the literature for cases of parotid RCC metastasis and focus on the utility of FNAB for synchronous versus metachronous presentations. Finally, we evaluate the differential diagnosis of clear cell parotid lesions, including ancillary histologic studies, and propose an algorithmic approach to clear cell neoplasms of the salivary gland.

Rare case of renal cell carcinoma with mandibular swelling as primary presentation

Introduction. Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90–95% of neoplasms arising from the kidney. This disease is characterized by a lack of early warning signs, diverse clinical manifestations, and resistance to radiation and chemotherapy. Approximately one-third of patients with renal cell carcinoma have metastatic disease at initial presentation. Fifteen percent of patients with renal cell carcinoma are said to present with metastases in the head and neck region. Most of the metastases from RCC to the head and neck involve the thyroid gland. The head and neck are unusual sites for metastases, but skin, skeletal muscle, thyroid gland, nasal cavity and paranasal sinus metastases have been reported. Case Report. The following report describes a rare case where the patient presented with mandibular swelling of short duration as the primary complaint without any symptom or sign pertaining to urinary tract and was found to have renal cell carcinoma on further workup. Conclusion. Metastatic renal cell carcinoma is a diagnostic dilemma especially when there is no pointer historically towards renal cell carcinoma as was in our case. An unusual vascular osteolytic lesion in head and neck in a middle-aged person should be dealt with high index of suspicion with renal cell carcinoma at the back of the mind.

Metastatic renal cell carcinoma to the parotid gland in the setting of chronic lymphocytic leukemia

Renal cell carcinoma (RCC) is infamous for its unpredictable behavior and metastatic potential. We report a case of a patient with a complex history of multifocal renal cell carcinoma and chronic lymphocytic leukemia (CLL), who subsequently developed a parotid mass. Total parotidectomy revealed this mass to be an additional site of metastasis which had developed 19 years after his initial diagnosis of RCC.

Atypical presentations and rare metastatic sites of renal cell carcinoma: a review of case reports

Renal cell carcinoma is a potentially lethal cancer with aggressive behavior and a propensity for metastatic spread. Due to the fact that the patterns of metastases from renal cell carcinomas are not clearly defined, there have been several reports of cases of renal cell carcinoma associated with rare metastatic sites and atypical presenting symptoms. The present review focuses on these atypical rare clinical presentations of renal cell carcinomas both at the time of diagnosis of the primary tumor but also in the years after radical nephrectomy.

Renal cell carcinoma presenting with cutaneous metastasis: a case report

Renal cell carcinoma is the most common kidney tumor in adults. Cutaneous metastasis is a rare first symptom of the disease. This paper describes the diagnosis of a renal cell carcinoma that was indicated by cutaneous metastasis in the head and neck region, and considers the etiopathogenesis of such cases. A careful skin examination is important to detect cutaneous metastasis associated with renal cell carcinomas. Metastatic skin lesions in the head and neck region must be taken into consideration during a differential diagnosis.