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Metastatic Renal Cell Carcinoma Presenting as a Skin Nodule: Case Report and Review of the Literature
0022-534 7/94/1526-2094$03. 00/0 THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL AssocIATION, INC.
Vol. 152, 2094-2095, December 1994
Printed in U.S.A.
METASTATIC RENAL CELL CARCINOMA PRESENTING AS A SKIN NODULE: CASE REPORT AND REVIEW OF THE LITERATURE J. CHANDLER WILLIAMS
AND
JOHN A. HEANEY*
From the Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
ABSTRACT
Cutaneous metastasis from renal cell carcinoma is unusual. A patient is described who presented with a solitary skin metastasis 6 months after unilateral radical nephrectomy for renal cell carcinoma. In most instances, once cutaneous involvement is manifest the disease is widespread and has a poor prognosis. The skin should be examined during tumor evaluation as part of the physical examination and skin lesions in patients with renal cell carcinoma should be evaluated aggressively to rule out cutaneous metastasis. KEY WORDS:
carcinoma, renal cell; kidney; skin; neoplasm metastasis
Renal cell carcinoma is known for its propensity for widespread metastases and poor survival rates. Options for treatment of disseminated disease are limited due to the poor response to chemotherapy and radiation therapy and, therefore, most patients with advanced stages die of the disease. The most common sites for metastases are the lungs, lymph nodes and bones. Skin metastases are unusual and have been reported infrequently. They typically herald coexistent disseminated disease and indicate a poor prognosis. A case of recurrent renal cell carcinoma presenting as a skin nodule is reported and the literature is reviewed. CASE REPORT
A 51-year-old white man presented with a 6-week history of an asymptomatic, rapidly enlarging nodule on the chin. He had undergone left radical nephrectomy 6 months previously for a poorly differentiated renal cell carcinoma (tumors, nodes and metastasis classification T3bNOMO, Robson stage Illa), which invaded the renal pelvis, ureter, renal capsule into perirenal fat and small renal veins. The surgical margins were free of tumor. Three months postoperatively physical examination and followup chest and abdominal computerized tomography were normal. Family history was significant since his mother died of renal cell carcinoma. On physical examination a single 1.5 X 1.5 cm. lesion was noted on the right lateral aspect of the chin (fig. 1). No other lesion, mass or adenopathy was detected. Biopsy resulted in prolonged bleeding at the surgical site. Microscopic evaluation demonstrated metastatic renal cell carcinoma (fig. 2). Chest computerized tomography showed a 5.0 X 3.0 cm. subcarinal mass, 3.0 X 3_5 cm. right paratracheal adenopathy and a 3.0 X 2.0 cm. right middle lobe lung mass. Laboratory studies were within normal limits. The patient declined further therapy. The disease progressed rapidly and he died of widely metastatic renal cell carcinoma 6 months after presenting with the cutaneous nodule. DISCUSSION
Renal cell carcinoma accounts for 2 to 3% of malignant tumors; it is usually a disease of adults and occurs in the fifth to seventh decades of life. 1 • 2 The incidence has increased since 1980 from 15,000 patients diagnosed annually in the United States 3 to 23,000 cases in 1992. 4 The 5-year survival rate after diagnosis has remained at 50%. 5 Between 10% and 45% of malignant renal tumors will have metastasized by the Accepted for publication February 25, 1994. * Requests for reprints: Section of Urology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, New Hampshire 03756-0001.
FIG. 1. Cutaneous lesion of chin
time of presentation. 6 Metastasis to the lungs, lymph nodes and bones occurs with the highest frequency. 7 The skin is a rare site for metastatic carcinoma compared to other organs such as lung and bone. In 1972 Brownstein and Helwig reviewed 742 cases of internal malignancy metastatic to the skin and found 30 cases of renal cell carcinoma (6.4%). 8 Brady et al studied 100 patients with internal neoplasms metastatic to the skin and noted that 6% resulted from the kidney. 9 In 1943 Hale and Burkland reported 54 cases of unrecognized renal cell carcinoma in 6,577 autopsies and indicated that the skin was the seventh most common site of metastatic renal cell carcinoma. 10 A predilection for the scalp has been described by many authors 11- 13 although skin lesions may appear in any anatomical area. 14• 15 Patients with facial, head or neck lesions present earlier for treatment due to the visibility of the lesions. Between 100 and 200 cases of renal cell carcinoma are diagnosed each year by presentation of cutaneous metastases. 16 In 2.8 to 6.8% of patients with renal cell carcinoma cutaneous metastases develop that, when discovered, usually indicate widespread disease. 17 Approximately 80% of cutaneous lesions are found after the primary renal neoplasm has been discovered and 10 to 20% of patients present with cutaneous lesions before the primary malignancy is documented. 17 Skin metastases may result from tumor cells passing unfiltered through the pulmonary venous vasculature, and may be disseminated to the head and neck through the paravertebral venous plexus. Patients with multiple metastases from renal cell carcinoma usually die of the disease. The prognosis of widespread or advanced stage renal cell carcinoma is poor with a median survival rate of less than 8 months independent of surgery7 and a 5-year survival
2094
2095
C1JTA.lfE01JS REN-,_<\L CELL Cl:..RCI1'-T01\!Il~,_
tomatic relief and cosmetic concerns. The renal tumor may be resected to TinwrmCs the quality of life decreasing pain, rnass effect the risk of bleeding as well as to provide substrate for tumor vaccines. Our case represents the ominous implications of cutaneous renal cell carcinoma metastasis. The patient presented with a single cutaneous nodule that after thorough evaluation heralded widely disseminated disease. Rapid death illustrates the typical end point of metastatic renal cell carcinoma. We encourage urologists to examine the skin during tumor evaluation as part of the physical examination and to evaluate aggressively skin lesions in patients with renal cell carcinoma to rule out cutaneous metastasis. REFERENCES
1. Wagle, D. G. and Seal, D.R.: Renal cell carcinoma-a review of
Fm. 2. Microscopic view of lesion shows dermis infiltrated by tumor, which is composed of epithelial cells with granular cytoplasm and small nucleoli arranged in glandular and organoid pattern consistent with metastatic renal cell carcinoma. Reduced from X 100.
rate of less than 20%. 1 s In 1993 Couillard and de Vere White noted that the 5-year survival rate for solitary metastasis after resection was 13 to 50% and the 5-year survival rate for multiple metastases was O to 8%. Renal cell carcinoma metastatic to the skin presents a therapeutic dilemma for urologists. Since cutaneous metastasis is generally regarded as a late manifestation of renal cell carcinoma, it is highly ~c,c,u,v,c_y that a skin metastasis is solitary. Brady et al reported that the average interval from the appearance of skin lesions to death was 12.7 months. 9 If a cutaneous renal cell carcinoma metastasis is discovered, exhaustive metastatic evaluation should be completed. Diffuse metastasis should be treated with appropriate systemic therapy while the focal cutaneous lesion is resected for symp-
256 cases. J. Surg. Oncol., 2: 23, 1970. 2. deKernion, J. B. and Belledegrun, A.: Renal tumors. In: Campbell's Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 2, chapt. 27, pp. 1053-1093, 1992. 3. Silverberg, E.: Cancer statistics. CA, 30: 23, 1980. 4. Boring, C. C., Squires, T. S. and Tong, T.: Cancer statistics, 1992. CA, 42: 19, 1992. 5. Swanson, D. A. and Johnson, D. E.: The management of renal cell carcinoma. Weekly Urology Update Series, vol. 1, lesson 36, 1978. 6. Ramon, C. V. and Taylor, H. B.: Hepatic dysfunction associated with renal carcinoma. Cancer, 29: 1287, 1972. 7. Couillard, D. R. and deVere VVhite, R. W.: Surgery of renal cell carcinoma. Urol. Clin. N. Amer., 20: 263, 1993. 8. Brownstein, M. H. and Helwig, E. B.: Metastatic tumors of the skin. Cancer, 29: 1298, 1972. 9. Brady, L. W., O'Neil, E. A. and Farber, S. H.: Unusual sites of metastases. Sem. Oncol., 4: 59, 1977. 10. Hale, N. G. and Burkland, C. E.: Unrecognized renal tumors: study of 54 cases in 6,577 autopsies and personal cases. J. Urol., 49: 426, 1943. 11. Connor, D. H., Taylor, H. B. and Helwig, E. B.: Cutaneous metastasis of renal cell carcinoma. Arch. Path., 76: 339, 1963. 12. Livingston, W. D., Jr., Becker, D. W., Jr. and Lentz, C. W., III: Solitary scalp metastasis as the presenting feature of a renal carcinoma. Brit. J. Plast. Surg., 30: 319, 1977. 13. Rosenthal, A. L. and Lever, W. F.: Involvement of the skin in renal carcinoma: report of two cases with review of the literature. Arch. Dermatol., 76: 96, 1957. 14. Vveigensberg, I. J.: Metastatic renal cell carcinoma: unusual and deceptive presenting features. South. Med. J., 65: 611, 1972. 15. Potter, G. K., Strauss, H. and Potter, R. C.: Delayed appearance of metastatic renal cell carcinoma subcutaneously in the left fifth toe after ipsilateral nephrectomy. J. Foot Surg., 30: 147, 1991. 16. Lumpkin, L. R. and Tschen, J. A.: Renal cell carcinoma metastatic to skin. Cutis, 34: 143, 1984. 17. Menter, A., Boyd, AS. and McCaffree, D. M.: Recurrent renal cell carcinoma presenting as skin nodules: two case reports and review of literature. Cutis, 44: 305, 1989. 18. deKernion, J. B. and Berry, D.: The diagnosis and treatment of renal cell carcinoma. Cancer, suppl., 45: 1947, 1980.
Vol. 152, 2094-2095, December 1994
Printed in U.S.A.
METASTATIC RENAL CELL CARCINOMA PRESENTING AS A SKIN NODULE: CASE REPORT AND REVIEW OF THE LITERATURE J. CHANDLER WILLIAMS
AND
JOHN A. HEANEY*
From the Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
ABSTRACT
Cutaneous metastasis from renal cell carcinoma is unusual. A patient is described who presented with a solitary skin metastasis 6 months after unilateral radical nephrectomy for renal cell carcinoma. In most instances, once cutaneous involvement is manifest the disease is widespread and has a poor prognosis. The skin should be examined during tumor evaluation as part of the physical examination and skin lesions in patients with renal cell carcinoma should be evaluated aggressively to rule out cutaneous metastasis. KEY WORDS:
carcinoma, renal cell; kidney; skin; neoplasm metastasis
Renal cell carcinoma is known for its propensity for widespread metastases and poor survival rates. Options for treatment of disseminated disease are limited due to the poor response to chemotherapy and radiation therapy and, therefore, most patients with advanced stages die of the disease. The most common sites for metastases are the lungs, lymph nodes and bones. Skin metastases are unusual and have been reported infrequently. They typically herald coexistent disseminated disease and indicate a poor prognosis. A case of recurrent renal cell carcinoma presenting as a skin nodule is reported and the literature is reviewed. CASE REPORT
A 51-year-old white man presented with a 6-week history of an asymptomatic, rapidly enlarging nodule on the chin. He had undergone left radical nephrectomy 6 months previously for a poorly differentiated renal cell carcinoma (tumors, nodes and metastasis classification T3bNOMO, Robson stage Illa), which invaded the renal pelvis, ureter, renal capsule into perirenal fat and small renal veins. The surgical margins were free of tumor. Three months postoperatively physical examination and followup chest and abdominal computerized tomography were normal. Family history was significant since his mother died of renal cell carcinoma. On physical examination a single 1.5 X 1.5 cm. lesion was noted on the right lateral aspect of the chin (fig. 1). No other lesion, mass or adenopathy was detected. Biopsy resulted in prolonged bleeding at the surgical site. Microscopic evaluation demonstrated metastatic renal cell carcinoma (fig. 2). Chest computerized tomography showed a 5.0 X 3.0 cm. subcarinal mass, 3.0 X 3_5 cm. right paratracheal adenopathy and a 3.0 X 2.0 cm. right middle lobe lung mass. Laboratory studies were within normal limits. The patient declined further therapy. The disease progressed rapidly and he died of widely metastatic renal cell carcinoma 6 months after presenting with the cutaneous nodule. DISCUSSION
Renal cell carcinoma accounts for 2 to 3% of malignant tumors; it is usually a disease of adults and occurs in the fifth to seventh decades of life. 1 • 2 The incidence has increased since 1980 from 15,000 patients diagnosed annually in the United States 3 to 23,000 cases in 1992. 4 The 5-year survival rate after diagnosis has remained at 50%. 5 Between 10% and 45% of malignant renal tumors will have metastasized by the Accepted for publication February 25, 1994. * Requests for reprints: Section of Urology, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr., Lebanon, New Hampshire 03756-0001.
FIG. 1. Cutaneous lesion of chin
time of presentation. 6 Metastasis to the lungs, lymph nodes and bones occurs with the highest frequency. 7 The skin is a rare site for metastatic carcinoma compared to other organs such as lung and bone. In 1972 Brownstein and Helwig reviewed 742 cases of internal malignancy metastatic to the skin and found 30 cases of renal cell carcinoma (6.4%). 8 Brady et al studied 100 patients with internal neoplasms metastatic to the skin and noted that 6% resulted from the kidney. 9 In 1943 Hale and Burkland reported 54 cases of unrecognized renal cell carcinoma in 6,577 autopsies and indicated that the skin was the seventh most common site of metastatic renal cell carcinoma. 10 A predilection for the scalp has been described by many authors 11- 13 although skin lesions may appear in any anatomical area. 14• 15 Patients with facial, head or neck lesions present earlier for treatment due to the visibility of the lesions. Between 100 and 200 cases of renal cell carcinoma are diagnosed each year by presentation of cutaneous metastases. 16 In 2.8 to 6.8% of patients with renal cell carcinoma cutaneous metastases develop that, when discovered, usually indicate widespread disease. 17 Approximately 80% of cutaneous lesions are found after the primary renal neoplasm has been discovered and 10 to 20% of patients present with cutaneous lesions before the primary malignancy is documented. 17 Skin metastases may result from tumor cells passing unfiltered through the pulmonary venous vasculature, and may be disseminated to the head and neck through the paravertebral venous plexus. Patients with multiple metastases from renal cell carcinoma usually die of the disease. The prognosis of widespread or advanced stage renal cell carcinoma is poor with a median survival rate of less than 8 months independent of surgery7 and a 5-year survival
2094
2095
C1JTA.lfE01JS REN-,_<\L CELL Cl:..RCI1'-T01\!Il~,_
tomatic relief and cosmetic concerns. The renal tumor may be resected to TinwrmCs the quality of life decreasing pain, rnass effect the risk of bleeding as well as to provide substrate for tumor vaccines. Our case represents the ominous implications of cutaneous renal cell carcinoma metastasis. The patient presented with a single cutaneous nodule that after thorough evaluation heralded widely disseminated disease. Rapid death illustrates the typical end point of metastatic renal cell carcinoma. We encourage urologists to examine the skin during tumor evaluation as part of the physical examination and to evaluate aggressively skin lesions in patients with renal cell carcinoma to rule out cutaneous metastasis. REFERENCES
1. Wagle, D. G. and Seal, D.R.: Renal cell carcinoma-a review of
Fm. 2. Microscopic view of lesion shows dermis infiltrated by tumor, which is composed of epithelial cells with granular cytoplasm and small nucleoli arranged in glandular and organoid pattern consistent with metastatic renal cell carcinoma. Reduced from X 100.
rate of less than 20%. 1 s In 1993 Couillard and de Vere White noted that the 5-year survival rate for solitary metastasis after resection was 13 to 50% and the 5-year survival rate for multiple metastases was O to 8%. Renal cell carcinoma metastatic to the skin presents a therapeutic dilemma for urologists. Since cutaneous metastasis is generally regarded as a late manifestation of renal cell carcinoma, it is highly ~c,c,u,v,c_y that a skin metastasis is solitary. Brady et al reported that the average interval from the appearance of skin lesions to death was 12.7 months. 9 If a cutaneous renal cell carcinoma metastasis is discovered, exhaustive metastatic evaluation should be completed. Diffuse metastasis should be treated with appropriate systemic therapy while the focal cutaneous lesion is resected for symp-
256 cases. J. Surg. Oncol., 2: 23, 1970. 2. deKernion, J. B. and Belledegrun, A.: Renal tumors. In: Campbell's Urology, 6th ed. Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D. Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 2, chapt. 27, pp. 1053-1093, 1992. 3. Silverberg, E.: Cancer statistics. CA, 30: 23, 1980. 4. Boring, C. C., Squires, T. S. and Tong, T.: Cancer statistics, 1992. CA, 42: 19, 1992. 5. Swanson, D. A. and Johnson, D. E.: The management of renal cell carcinoma. Weekly Urology Update Series, vol. 1, lesson 36, 1978. 6. Ramon, C. V. and Taylor, H. B.: Hepatic dysfunction associated with renal carcinoma. Cancer, 29: 1287, 1972. 7. Couillard, D. R. and deVere VVhite, R. W.: Surgery of renal cell carcinoma. Urol. Clin. N. Amer., 20: 263, 1993. 8. Brownstein, M. H. and Helwig, E. B.: Metastatic tumors of the skin. Cancer, 29: 1298, 1972. 9. Brady, L. W., O'Neil, E. A. and Farber, S. H.: Unusual sites of metastases. Sem. Oncol., 4: 59, 1977. 10. Hale, N. G. and Burkland, C. E.: Unrecognized renal tumors: study of 54 cases in 6,577 autopsies and personal cases. J. Urol., 49: 426, 1943. 11. Connor, D. H., Taylor, H. B. and Helwig, E. B.: Cutaneous metastasis of renal cell carcinoma. Arch. Path., 76: 339, 1963. 12. Livingston, W. D., Jr., Becker, D. W., Jr. and Lentz, C. W., III: Solitary scalp metastasis as the presenting feature of a renal carcinoma. Brit. J. Plast. Surg., 30: 319, 1977. 13. Rosenthal, A. L. and Lever, W. F.: Involvement of the skin in renal carcinoma: report of two cases with review of the literature. Arch. Dermatol., 76: 96, 1957. 14. Vveigensberg, I. J.: Metastatic renal cell carcinoma: unusual and deceptive presenting features. South. Med. J., 65: 611, 1972. 15. Potter, G. K., Strauss, H. and Potter, R. C.: Delayed appearance of metastatic renal cell carcinoma subcutaneously in the left fifth toe after ipsilateral nephrectomy. J. Foot Surg., 30: 147, 1991. 16. Lumpkin, L. R. and Tschen, J. A.: Renal cell carcinoma metastatic to skin. Cutis, 34: 143, 1984. 17. Menter, A., Boyd, AS. and McCaffree, D. M.: Recurrent renal cell carcinoma presenting as skin nodules: two case reports and review of literature. Cutis, 44: 305, 1989. 18. deKernion, J. B. and Berry, D.: The diagnosis and treatment of renal cell carcinoma. Cancer, suppl., 45: 1947, 1980.