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  Table of Contents    
CASE REPORT  
Year : 2013  |  Volume : 56  |  Issue : 1  |  Page : 40-42
Metastatic renal cell carcinoma in the nasopharynx


1 Department of Otorhinolaryngology, Yenikent Government Hospital, Sakarya, Turkey
2 Okmeydani Training and Research Hospital, Istanbul, Turkey
3 Department of Pathology, Okmeydani Training and Research Hospital, Istanbul, Turkey

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Date of Web Publication6-Aug-2013
 

   Abstract 

Metastatic renal cell carcinoma of the nasopharynx, nasal cavity, and paranasal sinuses can be misdiagnosed as primary malignant or benign diseases. A 33-year-old male attended our outpatient clinic complaining of difficulty breathing through the nose, bloody nasal discharge, postnasal drop, snoring, and discharge of phlegm. Endoscopic nasopharyngeal examination showed a vascularized nasopharyngeal mass. Under general anesthesia, multiple punch biopsies were taken from the nasopharynx. Pathologically, the tumor cells had clear cytoplasm and were arranged in a trabecular pattern lined by a layer of endothelial cells. After the initial pathological examination, the pathologist requested more information about the patient's clinical status. A careful history revealed that the patient had undergone left a nephrectomy for a kidney mass diagnosed as renal cell carcinoma 3 years earlier. Subsequently, nasopharyngeal metastatic renal cell carcinoma was diagnosed by immunohistochemical staining with CD10 and vimentin. Radiotherapy was recommended for treatment.

Keywords: Metastasis, nasopharynx, renal cell carcinoma

How to cite this article:
Atar Y, Topaloglu I, Ozcan D. Metastatic renal cell carcinoma in the nasopharynx. Indian J Pathol Microbiol 2013;56:40-2

How to cite this URL:
Atar Y, Topaloglu I, Ozcan D. Metastatic renal cell carcinoma in the nasopharynx. Indian J Pathol Microbiol [serial online] 2013 [cited 2019 Aug 25];56:40-2. Available from: http://www.ijpmonline.org/text.asp?2013/56/1/40/116147



   Introduction Top


Metastatic tumors of the nasopharynx, nose, and paranasal sinuses are rare from infraclavicular neoplasm metastasizing to the head and the neck. [1],[2],[3] Breast and lung tumors are the most common such metastatic tumors, while renal cell carcinoma (RCC) is relatively rare. [1],[2],[3] Metastatic RCC of the nasopharynx, nasal cavity, or paranasal sinuses is often misdiagnosed as a malignant or benign lesion. Therefore, a careful history, pathological examination, and immunohistochemical methods are vital.

As metastatic RCC has a very rich vascular stroma, biopsy procedures can cause massive hemorrhage. [1],[2],[3] Surgical interventions performed to take a biopsy or perform curative procedures can cause morbidity and mortality with advanced-stage lesions due to the lack of a definitive diagnosis.


   Case Report Top


A 33-year-old male visited his family physician five times in 1 year complaining of difficulty breathing, bloody nasal discharge, postnasal secretions, and the discharge of phlegm. He was diagnosed with rhinosinusitis and treated with various antibiotics, nasal decongestants, and a nasal steroid inhaler. Dissatisfied with the treatment results, he visited our clinic. Nasal endoscopy revealed a multilobulated, vascularized mass covered by normal mucosa, extending from the posterior wall of the nasopharynx to the choana. Otherwise, the physical examination was unremarkable. Magnetic resonance imaging (MRI) revealed an approximately 2-cm mass originating from the posterior nasopharyngeal wall and extending to the choana [Figure 1]. Endoscopy and multiple punch biopsies of the mass were performed under general anesthesia. Anterior tamponade was applied after the bleeding was controlled. The histopathological examination revealed tumor infiltration consisting of oval atypical cells with clear cytoplasm in the subepithelial area [Figure 2].
Figure 1: Cranial MRI of the tumor in the nasopharynx in a sagitt al view

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Figure 2: Hematoxylin and eosin-stained tumor specimen. Oval atypical cells with clear cytoplasm are visible in the subepithelial area

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The pathologist reported a malignancy and asked for detailed clinical information. A careful history revealed that the patient had undergone a left nephrectomy for a kidney mass 3 years earlier. The mass was reported to be 7.5 cm in diameter and located on the upper pole of the left kidney, not extending to the adrenal gland (T2N0Mx). The patient stated that he went to the first follow-up visit 6 months postoperatively, but did not attend subsequent examinations because he felt well. These details had not been included in the patient's initial history. This clinical information led our pathologist to perform immunohistochemical studies in which the atypical infiltration stained positively for CD10 [Figure 3] and vimentin [Figure 4]. Consequently, the mass was diagnosed as metastatic clear-cell RCC. The metastatic nasopharyngeal mass was treated with radiotherapy, and there has been no evidence of recurrence or metastasis for 3 years.
Figure 3: Immunohistochemical staining shows that the atypical clear cells were strongly positi ve for CD10

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Figure 4: The atypical clear cells stained positi vely for vimentin

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   Discussion Top


RCC constitutes only 3% of malignancies in adults and is generally seen in patients 30-60 years old. [2],[4] The frequency of metastasis is 30-40%, and the most frequent sites are the lung (76%), regional lymph nodes (66%), bone (42%), and liver (41%). Metastasis to the head and neck region, excluding intracranial metastasis, occurs in 15% of cases. [2],[4] The thyroid, parotids, tonsils, tongue, sinonasal region, mandible, and scalp are frequent sites of metastasis to the head and neck. [2],[3],[4] Common symptoms observed in metastatic RCC of the nasopharynx, nasal cavity, and paranasal sinuses are recurrent epistaxis, nasal obstruction, oronasal mass, anosmia, facial pain, induration, diplopia, and edema. [2],[5],[6] Since the same symptoms are seen in all nasopharyngeal lesions, the differential diagnosis includes primary nasopharyngeal squamous cell carcinoma (SCC), sarcoma, angiofibroma, minor salivary gland tumor, plasmacytoma, melanoma, teratoma, and germ cell tumors. [1],[7]

Computed tomography (CT) will show metastatic RCC involvement in the head and neck, but does not help with the differential diagnosis. Contrast-enhanced CT will show the destruction and calcification associated with metastatic RCC. Angiography may show the vascular structure and whether the nodule can be removed by excision; it can also be used for embolization in order to decrease vascularization. MRI is also useful for demonstrating intracranial extension and any residual disease after radiotherapy. [2]

Surgical interventions other than biopsies are limited because of the risk of residual disease. It is essential that the surgeon be aware of the dense vascular structure of the tumor and the possibility of severe bleeding; consequently, any biopsy must be obtained with maximum care. [3] The diagnosis of metastatic tumor might be difficult due to massive bleeding during excision and necrotic tissues in the samples. The most frequent histological variant of RCC is the clear-cell type, as in our case. [2] Non-keratinizing SCC of the nasopharynx, hyalinizing clear-cell carcinoma, and malignant melanoma (MM) should be included in the differential diagnosis and can be confused with RCC. [8],[9],[10],[11],[12] Immunohistochemical staining is required for a complete histological examination and diagnosis. Vimentin, cytokeratin 7 (CK7), cytokeratin 20 (CK20), epithelial membrane antigen (EMA), and CD10 are used to diagnose RCC, [9],[12] while MM is positive for S-100, HMV45, and melan-A and SCC for cytokeratin 5/6. [10],[11] CD10 and vimentin were examined in our case.

Sabo et al. [5] reported a case of metastatic RCC in the nasopharynx that regressed completely following radiotherapy and brachytherapy. Regardless of the interval between diagnosis of the metastatic lesion and nephrectomy, the survival rate after excising the metastatic RCC lesion is 41% at 2 years and 13% at 5 years. [2] In metastatic RCC, the curative treatment of the nasal cavity and paranasal sinuses includes surgical treatment to remove any residual tumor after radiotherapy. [3]

Radiotherapy, chemotherapy and immunotherapy are generally used to treat metastatic RCC. Although RCC is traditionally considered a radioresistant tumor, metastatic RCC will respond to radiotherapy. Interferon therapy can be used to decrease the tumor size for palliation. [2],[5],[6] Using interleukin-2 and interferon-α, a partial response is seen in 5-20% of patients, with a full response in less than 5%. [2]

In conclusion, metastatic nasopharyngeal lesions should be considered in the differential diagnosis of a patient with recurrent epistaxis, difficulty breathing, and postnasal discharge. The patients should be asked about a history of nephrectomy and kidney tumors. If a mass is detected in the nasopharynx at endoscopic examination or imaging, a biopsy is indicated. All precautions to deal with massive hemorrhage should be taken. The alternatives for curative treatment of RCC metastasis in the nasopharynx include radiotherapy, chemotherapy, immunotherapy and other current curative treatments.

 
   References Top

1.Lee HM, Kang HJ, Lee SH. Metastatic renal cell carcinoma presenting as epistaxis. Eur Arch Otorhinolaryngol 2005;262:69-71.  Back to cited text no. 1
    
2.Pritchyk KM, Schiff BA, Newkirk KA, Krowiak E, Deeb ZE. Metastatic renal cell carcinoma to the head and neck. Laryngoscope 2002;112:1598-602.  Back to cited text no. 2
    
3.Simo R, Sykes AJ, Hargreaves SP, Axon PR, Birzgalis AR, Slevin NJ, et al. Metastatic renal cell carcinoma to the nose and paranasal sinuses. Head Neck 2000;22:722-7.  Back to cited text no. 3
    
4.Sgouras ND, Gamatsi IE, Porfyris EA, Lekka JA, Harkiolakis GC, Nikolopoulou SM, et al. An unusual presentation of a metastatic hypernefroma to frontonasal region. Ann Plast Surg 1995;34:653-6.  Back to cited text no. 4
    
5.Sabo R, Sela M, Sabo G, Herskovitz P, Feinmesser R. Metastatic hypernephroma to the head and neck: Unusual case reports and review of the literature. J Otolaryngol 2001;30:140-4.  Back to cited text no. 5
    
6.Koscielny S. The paranasal sinuses as metastatic site of renal cell carcinoma. Laryngorhinootologie1999;78:441-4.  Back to cited text no. 6
    
7.Shanmugaratnam K, Sobin HL. The World Health Organization histological classification of tumours of the upper respiratory tract and ear. Cancer 1993;71:2689-97.  Back to cited text no. 7
    
8.O'Sullivan-Mejia ED, Massey HD, Faquin WC, Powers CN. Hyalinizing clear cell carcinoma: Report of eight cases and a review of literature. Head Neck Pathol 2009;3:179-85.  Back to cited text no. 8
    
9.Gilani SM, Tashjian R, Qu H. Clear cell papillary renal cell carcinoma with characteristic morphology and immunohistochemical staining pattern. Pathologica 2012;104:101-4.  Back to cited text no. 9
    
10.De-Andrade BA, Toral-Rizo VH, León JE, Contreras E, Carlos R, Delgado-Azañero W, et al. Primary oral melanoma: A histopathological and immunohistochemical study of 22 cases of Latin America. Med Oral Patol Oral Cir Bucal 2012;17:383-8.  Back to cited text no. 10
    
11.Grenier J, Soria JC, Mathieu MC, Andre F, Abdelmoula S, Velasco V, et al. Differential immunohistochemical and biological profile of squamous cell carcinoma of the breast. Anticancer Res 2007;27:547-55.  Back to cited text no. 11
    
12.Storck K, Hadi UM, Simpson R, Ramer M, Brandwein-Gensler M. Sinonasal renal cell-like adenocarcinoma: A report on four patients. Head Neck Pathol 2008;2:75-80.  Back to cited text no. 12
    

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Correspondence Address:
Yavuz Atar
Cayici Mh. Ayca Sk. no: 15 Osmanli Konaklari villa no: 19, Sapanca, Sakarya
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.116147

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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