Case report. Metastatic renal cell carcinoma to the left maxillary sinus

Epistaxis presenting as sentinel feature of metastatic renal cell carcinoma: A case report and review of literature

About 30% of all newly diagnosed renal cell carcinoma (RCC) patients present with synchronous metastatic disease. Usual organs of involvement are lung (75%), soft tissues (36%), bone (20%), liver (18%), cutaneous sites (8%), and central nervous system (8%). Metastases to the paranasal sinuses (PNS) are relatively common and may be a part of synchronous multiorgan involvement or present in follow-up after radical nephrectomy (metachronous); but primary presentation as isolated paranasal mass before the diagnosis of RCC is extremely rare. Here, we report a case of 74-year-old female presented with epistaxis and nasal obstruction. On evaluation by magnetic resonance imaging (MRI), a heterogeneously enhancing mass was found involving left PNS. Biopsy from mass revealed clear cell RCC. Later on, contrast-enhanced computed tomography (CECT) of chest, abdomen, and pelvis showed enhancing mass from the upper pole of the left kidney with no evidence of metastasis elsewhere. The patient was started on pazopanib 800 mg once a day. At 6 months follow-up scan, there was a partial response at both primary as well as metastatic site.

The Specific Magnetic Resonance Imaging Indicators in Predicting Clear-Cell Renal Cell Carcinoma Metastatic to the Sinonasal Region

PURPOSE

The aim of this study was to determine the valuable magnetic resonance imaging (MRI) features of sinonasal metastatic clear-cell renal cell carcinoma (cc-RCC), especially focusing on its dynamic-enhanced characteristics.

METHODS

The conventional and dynamic-enhanced MRI findings of 8 patients with histopathologically confirmed sinonasal metastatic cc-RCC were reviewed by 2 radiologists. The control group of 8 patients with capillary hemangioma underwent the same MRI protocol.

RESULTS

Metastatic cc-RCCs arose from the nasoethmoid region, maxillary sinus, posterior ethmoid and sphenoid sinus, and nasal cavity in 2 patients in each. These lesions were well circumscribed and the mean maximum dimension was 42 mm. The signal intensity of these lesions was isointense to brain stem on both MR T1- and T2-weighted images. All metastatic tumors showed vivid enhancement on enhanced T1-weighted image. Multiple flow voids within these metastatic lesions were identified in 6 patients. Peripheral cyst was detected around the metastatic tumor in 4 patients. Metastatic cc-RCCs exhibited a characteristic type 4 time intensity curve (TIC) similar to that of the internal carotid artery, whereas capillary hemangiomas showed a type 3 TIC on dynamic-enhanced MRI.

CONCLUSIONS

A hypervascular mass with the characteristic type 4 TIC in the sinonasal region is highly suggestive of a metastatic cc-RCC.

Renal cell carcinoma metastatic to the sinonasal cavity: A review and report of 8 cases

Renal cell carcinoma (RCC) metastatic in the sinonasal cavity is rare. In many cases, it represents the initial presentation of RCC. We conducted a retrospective chart review to report the clinical presentation, imaging, and treatment of RCC metastases in the sinonasal cavity at two tertiary care referral centers. Our population was made up of 8 patients-6 men and 2 women, aged 55 to 86 years (mean: 66.9; median: 63.5)-who had been diagnosed with cancer in the sinonasal cavity. The most common complaints were epistaxis, nasal obstruction, and diplopia. Cancers were located in the ethmoid sinus (n = 3), nasal cavity (n = 2), sphenoid sinus (n = 2), and maxillary sinus (n = 1). Local treatment involved resection and adjuvant radiotherapy in 4 patients, surgery alone in 2 patients, and radiotherapy alone in the other 2. The lesion was embolized before surgery in 4 cases. We also performed a critical review of similar published cases. Our literature review covered 53 cases of RCC metastatic to the sinonasal cavity, including ours. Metastases were the first presentation of RCC in 24 of these cases (45.3%); in our series, the metastases led to the diagnosis of the primary RCC in 3 cases (37.5%). In the 53 reported cases, metastatic resection was performed on 35 patients (66.0%). Survival data were available for 22 of these operated patients, and 17 of them achieved a complete local response. Adjunctive radiotherapy was not associated with a better local response. Overall survival was significantly better in patients who had an isolated metastasis rather than multiple metastases (p = 0.013). There was no difference in overall survival between patients whose metastasis represented the initial presentation of RCC and those whose metastasis did not (p = 0.95). We recommend that sinonasal metastasis be suspected in the event of unilateral nasal bleeding or nasal obstruction in patients diagnosed with RCC. Embolization may prevent abundant bleeding during removal. Surgery may improve the quality of life of these patients while decreasing nasal obstruction and bleeding.

Metastatic Renal Cell Carcinoma Presenting as a Paranasal Sinus Mass: The Importance of Differential Diagnosis

Metastases in the paranasal sinuses are rare; renal cell carcinoma is the most common cancer that metastasizes to this region. We present the case of a patient with a 4-month history of a rapidly growing mass of the nasal pyramid following a nasal trauma, associated with spontaneous epistaxis and multiple episodes of hematuria. Cranial CT scan and MRI showed an ethmoid mass extending to the choanal region, the right orbit, and the right frontal sinus with an initial intracranial extension. Patient underwent surgery with a trans-sinusal frontal approach using a bicoronal incision combined with an anterior midfacial degloving; histological exam was compatible with a metastasis of clear cell renal cell carcinoma. Following histological findings, a total body CT scan showed a solitary 6 cm mass in the upper posterior pole of the left kidney identified as the primary tumor. Although rare, metastatic renal cell carcinoma should always be suspected in patients with nasal or paranasal masses, especially if associated with symptoms suggestive of a systemic involvement such as hematuria. A correct early-stage diagnosis of metastatic RCC can considerably improve survival rate in these patients; preoperative differential diagnosis with contrast-enhanced imaging is fundamental for the correct treatment and follow-up strategy.

Metastases to nasal cavity and paranasal sinuses

The sinonasal cavities are rare locations for metastases. Metastases to these locations are usually solitary and produce similar symptoms to those of a primary sinonasal tumor. Nasal obstruction and epistaxis are the most frequent symptoms. The maxillary sinus is most frequently involved. The most common primary tumor sites to spread to this region originate in the kidney, breast, thyroid, and prostate, although any malignancy could potentially lead to a metastasis to the paranasal sinuses. The patient's prognosis is usually poor because of the fact that the sinonasal metastasis is usually associated with widespread disseminated disease. In the majority of patients, palliative therapy is the only possible treatment option. Nevertheless, whenever possible, surgical excision either alone or combined with radiotherapy may be useful for palliation of symptoms and, rarely, to achieve prolonged survival. This review considers the most interesting cases reported in the literature that presents metastases to the sinonasal cavities. © 2016 Wiley Periodicals, Inc. Head Neck 38: 1847-1854, 2016.

Primary renal sinus tumor: Three case reports with a review of the literature

The aim of the present study was to investigate the clinical characteristics and management of primary renal sinus tumors. We retrospectively analyzed three cases of primary renal sinus tumors. The first patient was a 33-year-old man who presented with right flank pain for 6 months. Based on the imaging results, the patient was diagnosed with renal sinus tumor. The second case was a 34-year-old woman who presented with sudden lumbago in the right flank for 3 days. The imaging results confirmed the diagnosis of right renal angiomyolipoma. The third case was a 55-year-old woman with flank pain, which had persisted for 1 year. The imaging tests revealed lipoma of the left renal sinus. All three cases underwent surgical procedures. The first case was diagnosed with benign angioleiomyoma following pathological analysis. During surgery, the tumor was ablated and the kidney was spared. The second case was scheduled for tumor enucleating, but a nephrectomy was performed due to serious hemorrhaging and a damaged renal pelvis. Pathological analysis identified angiomyolipoma. The third case was scheduled for lipoma enucleating; however, nephrectomy was performed as the tumor encapsulated the renal vascular pedicle. Pathological analysis revealed lipoma. In the three cases, no relapse over 3 years, 10 months and 4 years of follow-up, respectively, was observed. In addition, this review examined previous literature and concluded that the occurrence of tumors in the renal sinus is rare and the majority of such tumors are benign. Furthermore, cases are easily misdiagnosed as renal pelvic tumors. Computed tomography, magnetic resonance imaging and intravenous urography are the best imaging examination methods for differential diagnosis. In conclusion, surgery is the usual approach for the treatment of renal sinus tumors and radical nephrectomy should be performed for malignant tumors.