Renal Cell Carcinoma Presenting in the Skin

Skin manifestations associated with kidney cancer

Kidney cancer is a heterogenous disease encompassing several distinct clinicopathologic entities with different underlying molecular aberrations and clinical outcomes. Renal cell carcinoma (RCC) has been shown to evoke immunologic responses that can impact the natural history of disease and clinical presentation. It is important to recognize atypical presentations of disease, including cutaneous manifestations. The incidence of skin metastases from RCC is low, yet needs to be appreciated in the appropriate setting; clinical presentation for these lesions is reviewed briefly. There are several hereditary syndromes that present with well characterized cutaneous lesions and are associated with an increased risk for RCC, including Von Hippel-Lindau and Birt-Hogg-Dubé syndromes. Given that these skin lesions may be the first presenting sign for RCC, timely recognition is of essence and both are discussed in some detail. Several therapeutic options based on immunomodulation are approved for the treatment of advanced RCC. Dermatologic toxicities observed with these agents are also briefly discussed.

The use of immunohistochemistry in the diagnosis of metastatic clear cell renal cell carcinoma: a review of PAX-8, PAX-2, hKIM-1, RCCma, and CD10

The diagnosis of metastatic clear cell renal cell carcinoma may be difficult in some cases, particularly in the small image-guided biopsies that are becoming more common. As targeted therapies for renal cell carcinoma are now standard treatment, the recognition and diagnosis of renal cell carcinoma has become even more critical. Many adjunctive immunohistochemical markers of renal epithelial lineage such as CD10 and RCCma have been proposed as aids in the diagnosis of metastatic renal cell carcinoma, but low specificities often limit their utility. More recently described markers (PAX-2, PAX-8, human kidney injury molecule-1, hepatocyte nuclear factor-1-β, and carbonic anhydrase-IX) offer the potential for greater sensitivity and specificity in this diagnostic setting; however, knowledge of their expected staining in other neoplasms and tissues is critical for appropriate use. In this review, we discuss the most widely used immunohistochemical markers of renal lineage with an emphasis on their sensitivity and specificity for metastatic clear cell renal cell carcinoma. Subsequently, we present a variety of organ-specific differential diagnostic scenarios in which metastatic clear cell renal cell carcinoma might be considered and we propose immunopanels for use in each situation.

A Case of Metastatic Renal Cell Carcinoma Mimicking Granuloma Pyogenicum

Renal cell carcinoma (RCC) is well known for its frequent metastasis and particularly to the lungs, liver, bones and brain, but metastasis to the skin is rare. We report here on a case of metastatic RCC in a 73-year-old man who presented with a 1.5 cm sized, moist, beefy-red and exophytic nodule on the scalp. The lesion had grown rapidly for 2 months and it clinically mimicked granuloma pyogenicum. A skin biopsy revealed a solid mass composed of clear cells with clear cytoplasm and oval hyperchromatic nuclei, and they were arranged in an alveolar pattern. As skin metastasis from renal cell carcinoma signals widespread systemic metastasis and a poor prognosis, clinicians should conduct a careful inspection of the skin of a patient with RCC and they should also have a high index of suspicion for finding a primary internal organ malignancy in the RCC patients who present with a skin lesion.

CD10 Expression in Cutaneous Adnexal Neoplasms and a Potential Role for Differentiating Cutaneous Metastatic Renal Cell Carcinoma

Context.—Recent investigations have demonstrated the utility of CD10 as a marker for renal cell carcinoma (RCC). Cutaneous metastases occur in up to 11% of patients with RCC and may be the presenting sign of widespread disease. The differential diagnosis in histopathologic evaluation of these cases includes cutaneous adnexal neoplasms, and describing the expression of CD10 in these tumors may be helpful in delineating the differential diagnosis.

Objective.—To determine CD10 expression in a variety of adnexal lesions and to determine the diagnostic utility of CD10 in an immunohistochemical panel differentiating metastatic cutaneous renal cell carcinoma from cutaneous adnexal neoplasms.

Design.—We studied 57 primary adnexal neoplasms of eccrine (n = 31), apocrine (n = 16), and sebaceous (n = 10) differentiation as well as normal skin (n = 3) and RCC metastatic to the skin (n = 4). A CD10 monoclonal antibody was applied to formalin-fixed, paraffin-embedded tissue. Specimens were randomized and categorized as immunopositive or immunonegative by a pathologist with expertise in immunohistochemistry who was blinded to the diagnoses.

Results.—Two (6.5%) of 31 eccrine, 1 (6%) of 16 apocrine, and 4 (40%) of 10 sebaceous neoplasms demonstrated CD10 immunopositivity. Four (100%) of 4 RCC were CD10 immunopositive. CD10 expression was significant for eccrine and apocrine neoplasms (P < .001) compared to metastatic RCC, but not for sebaceous neoplasms (P = .08).

Conclusion.—Based on these results, CD10 is a useful additional immunostain for the discrimination of RCC metastatic to the skin and cutaneous adnexal neoplasms with eccrine and apocrine differentiation, but not with sebaceous differentiation.

Renal cell carcinoma metastatic to the scalp: case report and review of the literature

BACKGROUND

Renal cell carcinoma metastatic to the skin is rare.

OBJECTIVE

To illustrate by a case report the clinical presentation and management of the disease.

METHODS

We present a case of renal carcinoma metastatic to the skin of the scalp that occurred 6 years after removal of her kidney. The tumor was diagnosed using frozen tissue and paraffin sections.

RESULTS

Cutaneous metastasis treated by excision.

CONCLUSION

Renal cell carcinoma may metastasize to the skin of the scalp. Our case illustrated an interesting ipsilateral metastasis that occurred 6 years after treatment of her primary tumor. Physicians, dermatologists, pathologists, and Mohs surgeons should be aware of this entity.

Renal cell carcinoma: diagnosis based on metastatic manifestations

Renal cell carcinomas are notorious for their tendency to metastasize early, often before the primary tumor has become apparent. Frequently, the initial complaint is referable to a distant metastatic lesion. Metastatic lesions have been found in almost every organ or tissue of the body. When a patient with a clinically asymptomatic renal cell carcinoma has signs and symptoms referable to a localized lesion, the final diagnosis depends on histologic and cytologic evaluation of a biopsy specimen. In this article, we describe a patient who had a pulsating transcalvarial occipital-suboccipital mass as the initial manifestation of an occult renal cell carcinoma. Initial manifestations by site of metastasis described in the literature are reviewed, and the differential diagnosis of primary clear cell tumor versus metastatic lesions from a renal cell carcinoma, according to their pathologic features, is discussed.

Cutaneous metastatic disease

The relative frequencies of cutaneous metastases are similar to those of the primary cancers; breast, colon, and melanoma are the most frequent in women and lung, colon, and melanoma are the most common in men. Cutaneous metastases represent an opportunity to detect a potentially treatable cancer before other evidence of it is present, to modify therapy as appropriate to the tumor stage, or possibly to use the cutaneous lesion as a source of easily accessible tumor cells for specific therapy. Cutaneous metastatic disease as the first sign of internal cancer is most commonly seen with cancer of the lung, kidney, and ovary.