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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2013  |  Volume : 24  |  Issue : 4  |  Page : 789-792
Renal cell carcinoma presenting as mandibular metastasis


1 Urology Department, Ghaem Medical Center, Mashhad University of Medical Sciences, Mashhad, Iran
2 Dental Department, Ghaem Medical Center, Mashhad University of Medical Sciences, Mashhad, Iran

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Date of Web Publication24-Jun-2013
 

   Abstract 

Renal clear cell carcinoma (RCC) has different manifestations, including uncommon metastasis and paraneoplastic syndromes. Here we report a rare case of RCC presenting as metastasis to the mandible. A 57-year-old patient with mandibular swelling was referred to the dentist. After necessary evaluations, an incisional biopsy of mandible showed metastatic RCC. The patient was referred to the urologist. The patient underwent right radical nephrectomy. Pathological examination showed clear renal cell carcinoma. Every abnormal bone lesion in the oral cavity should be evaluated carefully and the possibility of a malignant lesion should always be considered.

How to cite this article:
Ahmadnia H, Amirmajdi NM, Mansourian E. Renal cell carcinoma presenting as mandibular metastasis. Saudi J Kidney Dis Transpl 2013;24:789-92

How to cite this URL:
Ahmadnia H, Amirmajdi NM, Mansourian E. Renal cell carcinoma presenting as mandibular metastasis. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Jun 27];24:789-92. Available from: http://www.sjkdt.org/text.asp?2013/24/4/789/113889

   Introduction Top


Renal clear cell carcinoma (RCC) accounts for about 3% of adult malignancies and about 90% of neoplasms of the kidney. [1] RCC has different manifestations, including metastasis in uncommon sites and paraneoplastic syndromes. [2] About one-third of the patients with RCC have hematogenous metastasis at the time of diagnosis and, in 25% of the patients, metastasis occurs after radical nephrectomy. The most frequent sites of metastasis include the lung (50-75%), bone (30-40%), liver (30- 40%), brain and thyroid (25%). [1],[2]

We report here a rare case of RCC with metastasis to mandible.


   Case Report Top


A 57-year-old man was referred to a dentist with the chief complaint of right mandibular swelling for two weeks. Examination revealed a soft mass (2 cm × 3 cm) in the right molar region. In addition, he had trismus and mobility of the second and third molar teeth. In the panoramic radiography, there was an ill-defined radiolucent lesion in the right molar and ramous region.

An incisional biopsy was performed. The pathology report was metastatic renal clear cell carcinoma. Histologic evaluation revealed the presence of a solid nest of epithelial cells with clear cytoplasm and small, round hyperchromatic nuclei [Figure 1] and [Figure 2]. A rich vascular network was also noted. Immunoperoxidase specific antigen and desmin was positive and further supporting the diagnosis, tests were positive for cytokeratin and vimentin but was negative for S-100, HMB-45. The patient was therefore referred to the urologist.
Figure 1: Clear cell carcinoma. The tumor is composed of a solid nest of epithelial cells with clear cytoplasm (40×).

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Figure 2: Tumor cells near the bony structure (10×).

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There was no history of gross hematuria, but the patient complained of mild right flank pain. Routine laboratory tests demonstrated anemia, microscopic hematuria, increased erythrocyte sedimentation rate (ESR) and alkaline phosphatase (ALP). Ultrasonography revealed a solid mass in the right kidney. Abdominal computed tomography (CT) scan with and without IV contrast showed a heterogeneous solid mass (5 cm × 7 cm) in the lateral side of the right kidney, which was enhanced with IV contrast [Figure 3]. There was no visceral metastatic lesion. Pre-aortic lymphadenopathy was present. Color Doppler ultrasonography showed no venous involvement. Chest X-ray was normal. In the whole body bone scan, a metastatic lesion in the right mandible was present but no other bony metastatic lesion was reported.
Figure 3: Abdominal CT scan with IV contrast showed a heterogeneous solid mass in the lateral side of right kidney.

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Right radical nephrectomy was performed. The pathology report was clear cell carcinoma (conventional RCC) with Fuhrman grade 3. Histopathology exam confirmed that the resected lymph nodes were metastatic. The mandibular mass was subsequently resected with a safe margin of about 2 cm. The patient was referred to a medical oncologist for further therapeutic options.


   Discussion Top


RCC is a challenging diagnosis because of its various signs and symptoms. Spread in RCC is lymphatic, hematogenous or by direct invasion. Uncommon metastasis is characteristic of RCC, which may occur in any site of the body, such as the brain, contralateral kidney, adrenals, pancreas, peritoneum and bowel. Other areas of metastasis are endobronchial, skeletal muscle, laryngeal, dermal and spermatic cord. [2] Bone metastasis from renal carcinoma is purely lytic and expansile and is usually found in the axial skeleton, particularly from T12 through L5. Metastasis is more likely on the same side as the primary tumor. Although metastasis to bone from RCC is common, mandibular metastasis has rarely been reported. [3] Renal tumor is the primary origin in 16% of the metastatic jaw lesions. [4] In 20% of the cases, the first presentations of neoplasm are oral symptoms like pain, swelling, tooth mobility, bleeding and trismus. [4] Metastatic spread to the bone is hematogenous because the bone does not contain lymphatic vessels. This hematogenous spread passes via the vertebral venous plexus, which has no valves, and therefore the tumor emboli can reach the cranial areas without passing through the pulmonary circulation. [4]

Numerous tumors with clear cell features may present in the mandible. These neoplasms can be divided into primary tumors (odontogenic and non-odontogenic tumors) and metastatic tumors. The odontogenic clear cell lesions include odontogenic cysts, clear cell variants of calcifying epithelial odontogenic tumor, clear cell ameloblastoma and clear cell odontogenic carcinoma. [5],[6],[7],[8] Non-odontogenic clear cell tumors include acinic cell carcinoma, mucoepidermoid carcinoma, squamous cell carcinoma with clear cell features, clear cell oncocytoma, glycogen-rich salivary tumors, hyalinizing clear cell carcinoma, sebaceous tumors, epithelial-myoepithelial carcinoma and clear cell variants of adenocarcinoma of Salivary gland origin. [5],[6],[7],[8] Metastatic tumors from other organs that may present in the mandible with clear cell features include the breast (33%), lung (18%), kidney (16%), thyroid (6%), prostate (6%) and colon (6%). [5],[6],[7],[8] Of these, clear cell carcinoma of the kidney most closely resembles clear cell odontogenic carcinoma histologically. Histologically, differentiating among clear cell tumors with conventional light microscopy can be challenging. Immunohistochemical staining helps in differentiating RCC from others, because RCC metastasis exhibits focal cytokeratin positivity and a strong reaction for vimentin. [6],[7]

Most patients die within one year after detection of head and neck metastasis. Therefore, palliative therapies to maximize comfort and minimize morbidity should be the mainstay of the treatment considering the poor long-term prognosis. [7] Excision of RCC metastasis to the mandible was performed to relieve pain and allow the patient to swallow and prevent bleeding and infection.

Although RCC is traditionally known as a radio-resistant tumor, local radiotherapy can relieve local symptom for perhaps a few months. [1],[7] The use of systemic therapy in the metastatic RCC is disappointing. [7] Immuno-logic therapy following radical nephrectomy in metastatic disease may improve survival time in properly selected patients. In patients with synchronous metastatic disease, cytoreductive nephrectomy and systemic immunotherapy may have a survival advantage over those treated with immunotherapy alone. [7] Unfortunately, responses with systemic therapy are incomeplete and not durable and the use of immunologic agents are limited by their significant toxicity. However, newer agents targeting the vascular endothelial growth factor, such as bevacizumab and sorafenib, may provide hope for patients with metastatic RCC. Early trials demonstrated that the use of these targeted molecular therapies may improve the overall survival. [7]

This report emphasizes the importance of the consideration of unusual presentations in any organ such as the maxillofacial region as it may be a sign of either a primary or a metastatic tumor. When metastatic lesion is suspected, a search for the primary site should be immediately initiated and a biopsy for definitive tissue diagnosis should be obtained. In addition, appearance of a new oral or neck lesion in a patient with a history of RCC should include metastatic RCC as part of the differential diagnosis. If metastatic RCC is diagnosed, additional therapeutic options, including radio-therapy immunotherapy and participation in a clinical trial, should be discussed with the patient despite the poor overall prognosis.

 
   References Top

1.Flanigan RC, Campbell SC, Clark JI, Picken MM. Metastatic renal cell carcinoma. Curr Treat Options Oncol 2003;4:385-90.  Back to cited text no. 1
    
2.Ahmadnia H, Molaei M, Mansourian E. An uncommon manifestation of renal cell carcinoma: Contralateral spermatic cord metastasis. Central Euro J Urol 2009;62:40-1.  Back to cited text no. 2
    
3.Shetty SC, Gupta S, Nagsubramanium S, Hasan S, Cherry G. Mandibular metastasis from renal cell carcinoma. A case report. Indian J Dent Res 2001;12:77-80.  Back to cited text no. 3
[PUBMED]    
4.Sastre J, Naval L, Muñoz M, Gamallo C, Diaz FJ. Metastatic renal cell carcinoma to the mandible. Otolaryngol Head Neck Surg 2005; 132:663-4.  Back to cited text no. 4
    
5.Eversole LR. On the differential diagnosis of clear cell tumors of the head and neck. Oral Oncol Eur J Cancer 1993;29B:173-9.  Back to cited text no. 5
    
6.Maiorano E, Altini M, Favia G. Clear cell tumors of the salivary glands, jaws, and oral mucosa. Semin Diagn Pathol 1997;14:203-12.  Back to cited text no. 6
    
7.Will TA, Agarwal N, Petruzzelli GJ. Oral cavity metastasis of renal cell carcinoma: A case report. J Med Case Rep 2008,2:313.  Back to cited text no. 7
    
8.Ebert CS Jr, Dubin MG, Hart CF, Chalian AA, Shockley WW. Clear cell odontogenic carcinoma: A comprehensive analysis of treatment strategies. Head Neck 2005;27:536-42.  Back to cited text no. 8
    

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Correspondence Address:
Ehsan Mansourian
Department of Urology, Mashhad University of Medical Sciences, Mashhad
Iran
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DOI: 10.4103/1319-2442.113889

PMID: 23816732

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    Abstract
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