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Oral Oncology EXTRA (2004) 40 50–53

http://intl.elsevierhealth.com/journal/ooex

CASE REPORT

Metastatic renal cell carcinoma presenting as


a clear cell tumour in the head and neck region
P.R. Jayasooriyaa, I.A.N.S. Gunarathnaa, A.M. Attygallab,
W.M. Tilakaratnea,*

a
Department of Oral Pathology, Faculty of Dental Sciences, University of Peradeniya,
Peradeniya, Sri Lanka
b
Department of Oral Surgery, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Received 15 December 2003; accepted 22 December 2003

KEYWORDS Summary Renal cell carcinoma (RCC) is the most frequent urological malignancy in
adults and has a male preponderance. It accounts for approximately 3% of adult
Renal cell carcinoma; malignancies and 90–95% of neoplasms arising from the kidney. RCC usually
Metastasis; metastasizes to lungs, bone and regional lymph nodes but very rarely to the head
Clear cell tumours and neck region. The following report is based on a female patient with a previously
undiagnosed RCC, which metastasized and presented as a clear cell tumour in the
head and neck region. A histopathological differential diagnosis for clear cell
tumours together with the contributing factors that led to the diagnosis of
metastatic RCC will be discussed.
c 2004 Published by Elsevier Ltd.

Case report compressing the naso-pharynx on the left side


(Fig. 2). However, no metastases were observed in
A 57 year old female presented with painful the brain. Thereafter, exploratory biopsy was
swellings on the left side of the face, which performed to arrive at a definitive diagnosis under
developed over a period of three weeks. Her face general anesthesia. H&E stained sections of the
was asymmetrical due to the swellings on the left lesion showed unencapsulated tumour containing
parotid and temporal regions (Fig. 1). Intra orally, abundant clear cells with moderate degree of
00
3 · 3 oval shaped, hard swelling was observed on cytological atypia. PAS/DPAS (periodic acid Schiff/
the left buccal mucosa. A computed tomography diastase resistant periodic acid Schiff) stained
(CT scan) revealed a large mass of mixed density sections showed the presence of glycogen, but
measuring 10 · 9 · 6 cm involving left mandible and there was no evidence of mucin in the clear cells.
maxilla. Moreover, the tumour was seen extending Moreover, the tumour was markedly vascular (Fig.
in to the temporal fossa and retropharyngeal space 3). These histopathological features were sugges-
tive of a metastatic RCC. Thereafter, the patient
* Corresponding author. Tel.: +94-81-2387500; fax: +94-81-
was referred to a radiologist for imaging studies
238-8948. and the ultra sound scan of the abdomen revealed a
E-mail address: wmtilak@pdn.ac.lk (W.M. Tilakaratne). large (7.4 · 9.8 cm) upper polar mass in the left


1741-9409/$ - see front matter c 2004 Published by Elsevier Ltd.
doi:10.1016/j.ooe.2003.12.005
Metastatic renal cell carcinoma 51

attempt to stop bleeding; ligature of the carotid


artery was attempted. However, it was not suc-
cessful and resulted in patients’ death and pa-
tients’ family turned down subsequent request for
an autopsy.

Discussion

Renal cell carcinoma occurs most frequently in


the 5th and the 6th decade of life and has a male
preponderance.1 Approximately, three fourth (3/4)
of all RCC detected are clear cell RCCs. The classic
triad of presenting symptoms of RCC is hematauria,
back pain and mass in the flank.1 However, our
patient did not have any of the above symptoms
and instead the lesions on the oral-maxillofacial
region were the first indication of the undiscovered
RCC. An overview on meatstatic tumours to the
head and neck region indicated 30% of the meta-
static tumours to be of previously undiscovered
distant primaries.2;3
Figure 1 Clinical photograph to show the extra oral Metastases to the oral-maxillofacial region are
presentation of the lesions. uncommon and account for approximately 1% of all
malignant tumours in the region. However, autop-
sies of patients with carcinoma reveal higher level
kidney with no further secondaries in the lower of metastatic deposits in the facial bones, which do
abdomen. However, a metastatic deposit was ob- not manifest clinically.3 The common sites of oral
served in the left humerus. soft tissues for metastases are attached gingiva
Two weeks after referring the patient to an followed by the tongue while in the jaws mandible
oncologist for palliative treatment, uncontrolled is more commonly affected compared to the max-
bleeding occurred from the oral lesion. Initially, illa.2–10 However, as our patient had extensive
adrenalin packs, tranexamic acid and vitamin K lesions involving both soft tissue and bone the
were used to control bleeding. However, as this original site of the tumour could not be deter-
treatment failed, secondly, blood was transfused mined. The most common primary sources of
with prior medication of hydrocortisone and metastases to the oral soft tissues are lung, kidney
promethezine. Despite pre-medication the patient and skin in decreasing order when considering
developed a transfusion reaction. Then as a third both genders. However, a difference exists

Figure 2 CT scan to show the extent of the lesion.


52 P.R. Jayasooriya et al.

Figure 3 Photomicrograph to show the histopathological presentation of the metastatic renal cell carcinoma (·40).
Note: Abundant clear cells and vascularity of the lesion.

between genders as in females, tumour metastases diagnosis.13 Seventy percent of these involve a
from breast, genital organs, lung and bones are solitary organ while 30% may involve multiple or-
more common compared to kidney.2 gans. Surgical excision, radiotherapy, chemother-
Clear cells are a feature of majority of salivary apy or hormonal therapy can be used to treat
gland tumours such as mucoepidermoid carci- metastases. However, due to overall poor progno-
noma, acinic cell carcinoma, epithelial myoepi- sis only palliative treatment was given to our pa-
thelial carcinoma, sebaceous carcinoma, tient. Moreover, our patient died three months
sebaceous adenoma, oncocytoma;11 odontogenic after the discovery of the tumour and supports the
tumours namely clear cell odontogenic carcinoma, previous reports that indicate a relatively poor
calcifying epithelial odontogenic tumour and survival rate of only 6–9 months for patients with
metastatic lesions such as renal and thyroid metastatic RCC.13
primaries and in melanomas. In addition, alveolar
soft part sarcoma and paraganglioma that occur in
the head and neck region also contain clear References
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Metastatic renal cell carcinoma 53

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