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A Slowly Growing Ulcerated Nodule on the Scalp—Diagnosis

A Slowly Growing Ulcerated Nodule on the Scalp—Diagnosis Diagnosis: Metastatic renal cell carcinoma. Microscopic findings, laboratory findings, and clinical course Histopathologic examination demonstrated an intradermal tumor nodule composed of groups of clear cells with abundant clear cytoplasm and oval nucleus in a glandular configuration. The stroma was highly vascular, with many extravasated red blood cells. The findings were consistent with metastatic renal cell carcinoma. Subsequent computed tomography of the abdomen revealed a huge heterogeneous mass in the left kidney, consistent with renal cell carcinoma (Figure 3). A complete blood cell count revealed only mild anemia (hemoglobulin, 12.4 g/dL [reference range, 13.5-17.5 g/dL]). No gross or microscopic hematuria was noted. The results of all other laboratory tests were within normal limits. Figure 3. View LargeDownload The patient underwent radical nephrectomy of his left kidney. Grossly, a 7.5 × 6.0 × 4.3-cm yellow tumor was seen over the lower lobe of the left kidney. Microscopically, the tumor was revealed to be a clear cell adenocarcinoma in a highly vascular stroma, with a microscopic appearance similar to that of the scalp nodule. Interferon alfa and interleukin 2 were administered after surgery. The patient was alive and well at the 2-year follow-up visit. Discussion Cutaneous metastases have been found in 0.7% to 9.0% of all patients with cancer.1 Renal cell carcinoma has accounted for 6.8% of all cutaneous metastases.2 Cutaneous metastases are usually found after diagnosis of the primary malignancy, but occasionally they may be present at the time of diagnosis, and even less commonly, they may be seen as the presenting sign of the internal malignancy, as in the present case. In one series of 7316 patients with cancer, skin involvement was the presenting sign of internal carcinoma in only 59 patients (0.8%).3 This type of presentation is more commonly seen in patients with cancer of the lungs, kidneys, or ovaries.2 Cutaneous metastases of renal cell carcinoma are mostly found on the head and the neck, with a male predominance. The skin lesions are usually nonspecific. Most of them present as the sudden onset of solitary or multiple dermal or subcutaneous nodules that are flesh-colored, pink, or violaceous, or even as a cutaneous horn. An incorrect clinical diagnosis is not uncommon if the renal cell carcinoma is not suspected.2 An interesting feature of metastatic renal cell carcinoma is that the skin lesions are frequently associated with a palpable pulsation, with or without an audible bruit, an association that may be related to the prominent vascularity of these lesions.4 The histopathologic features of the skin lesions are often an indication of their renal origin. Typically, the metastatic lesions are intradermal tumor nodules that are composed of groups of clear cells with abundant clear cytoplasm and oval nuclei in a glandular configuration. The highly vascular stroma, with extravasated red blood cells and hemosiderin deposition, is characteristic. Immunohistochemically, the tumor cells are positive for cytokeratin and epithelial membrane antigen and negative for S100 protein.5 Cutaneous metastases usually represent disseminated disease, and the long-term prognosis is poor. The 1-, 3-, and 5-year cause-specific survival rates after the appearance of cutaneous metastases were found by 1 author to be 50%, 20%, and 0%, respectively.6 However, the prognosis in patients with a solitary cutaneous metastasis without other evidence of disseminated disease is relatively better. The 3- and 5-year survival rates in patients who undergo nephrectomy and removal of skin lesion are 45% and 35%, respectively.7 References 1. Margolis RJ Cutaneous metastases Barnhill RLedHefta Jed Textbook of Dermatopathology New York, NY McGraw-Hill Co1998;801- 812Google Scholar 2. Schwartz RA Cutaneous metastatic disease J Am Acad Dermatol 1995;33161- 182PubMedGoogle ScholarCrossref 3. Lookingbill DPSpangler NSexton FM Skin involvement as the presenting sign of internal carcinoma: a retrospective study of 7316 cancer patients J Am Acad Dermatol 1990;2219- 26PubMedGoogle ScholarCrossref 4. Snow SMadjar DReizner G et al. Renal cell carcinoma metastatic to the scalp: case report and review of the literature Dermatol Surg 2001;27192- 194PubMedGoogle Scholar 5. Waine CJ Metastatic carcinoma of the skin Elder DEedElenitsas RedJaworsky Ced et al. Lever’s Histopathology of the Skin 8th ed. Philadelphia, Pa Lippincott-Raven Publishers1997;1011- 1018Google Scholar 6. Koga STsuda SNishikido M et al. Renal cell carcinoma metastatic to the skin Anticancer Res 2000;201939- 1940PubMedGoogle Scholar 7. Menter ABoyd ASMcCaffree DM Recurrent renal cell carcinoma presenting as skin nodules: two case reports and review of the literature Cutis 1989;44305- 308Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

A Slowly Growing Ulcerated Nodule on the Scalp—Diagnosis

Archives of Dermatology , Volume 140 (11) – Nov 1, 2004

A Slowly Growing Ulcerated Nodule on the Scalp—Diagnosis

Abstract

Diagnosis: Metastatic renal cell carcinoma. Microscopic findings, laboratory findings, and clinical course Histopathologic examination demonstrated an intradermal tumor nodule composed of groups of clear cells with abundant clear cytoplasm and oval nucleus in a glandular configuration. The stroma was highly vascular, with many extravasated red blood cells. The findings were consistent with metastatic renal cell carcinoma. Subsequent computed tomography of the abdomen revealed a huge...
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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.140.11.1393-d
Publisher site
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Abstract

Diagnosis: Metastatic renal cell carcinoma. Microscopic findings, laboratory findings, and clinical course Histopathologic examination demonstrated an intradermal tumor nodule composed of groups of clear cells with abundant clear cytoplasm and oval nucleus in a glandular configuration. The stroma was highly vascular, with many extravasated red blood cells. The findings were consistent with metastatic renal cell carcinoma. Subsequent computed tomography of the abdomen revealed a huge heterogeneous mass in the left kidney, consistent with renal cell carcinoma (Figure 3). A complete blood cell count revealed only mild anemia (hemoglobulin, 12.4 g/dL [reference range, 13.5-17.5 g/dL]). No gross or microscopic hematuria was noted. The results of all other laboratory tests were within normal limits. Figure 3. View LargeDownload The patient underwent radical nephrectomy of his left kidney. Grossly, a 7.5 × 6.0 × 4.3-cm yellow tumor was seen over the lower lobe of the left kidney. Microscopically, the tumor was revealed to be a clear cell adenocarcinoma in a highly vascular stroma, with a microscopic appearance similar to that of the scalp nodule. Interferon alfa and interleukin 2 were administered after surgery. The patient was alive and well at the 2-year follow-up visit. Discussion Cutaneous metastases have been found in 0.7% to 9.0% of all patients with cancer.1 Renal cell carcinoma has accounted for 6.8% of all cutaneous metastases.2 Cutaneous metastases are usually found after diagnosis of the primary malignancy, but occasionally they may be present at the time of diagnosis, and even less commonly, they may be seen as the presenting sign of the internal malignancy, as in the present case. In one series of 7316 patients with cancer, skin involvement was the presenting sign of internal carcinoma in only 59 patients (0.8%).3 This type of presentation is more commonly seen in patients with cancer of the lungs, kidneys, or ovaries.2 Cutaneous metastases of renal cell carcinoma are mostly found on the head and the neck, with a male predominance. The skin lesions are usually nonspecific. Most of them present as the sudden onset of solitary or multiple dermal or subcutaneous nodules that are flesh-colored, pink, or violaceous, or even as a cutaneous horn. An incorrect clinical diagnosis is not uncommon if the renal cell carcinoma is not suspected.2 An interesting feature of metastatic renal cell carcinoma is that the skin lesions are frequently associated with a palpable pulsation, with or without an audible bruit, an association that may be related to the prominent vascularity of these lesions.4 The histopathologic features of the skin lesions are often an indication of their renal origin. Typically, the metastatic lesions are intradermal tumor nodules that are composed of groups of clear cells with abundant clear cytoplasm and oval nuclei in a glandular configuration. The highly vascular stroma, with extravasated red blood cells and hemosiderin deposition, is characteristic. Immunohistochemically, the tumor cells are positive for cytokeratin and epithelial membrane antigen and negative for S100 protein.5 Cutaneous metastases usually represent disseminated disease, and the long-term prognosis is poor. The 1-, 3-, and 5-year cause-specific survival rates after the appearance of cutaneous metastases were found by 1 author to be 50%, 20%, and 0%, respectively.6 However, the prognosis in patients with a solitary cutaneous metastasis without other evidence of disseminated disease is relatively better. The 3- and 5-year survival rates in patients who undergo nephrectomy and removal of skin lesion are 45% and 35%, respectively.7 References 1. Margolis RJ Cutaneous metastases Barnhill RLedHefta Jed Textbook of Dermatopathology New York, NY McGraw-Hill Co1998;801- 812Google Scholar 2. Schwartz RA Cutaneous metastatic disease J Am Acad Dermatol 1995;33161- 182PubMedGoogle ScholarCrossref 3. Lookingbill DPSpangler NSexton FM Skin involvement as the presenting sign of internal carcinoma: a retrospective study of 7316 cancer patients J Am Acad Dermatol 1990;2219- 26PubMedGoogle ScholarCrossref 4. Snow SMadjar DReizner G et al. Renal cell carcinoma metastatic to the scalp: case report and review of the literature Dermatol Surg 2001;27192- 194PubMedGoogle Scholar 5. Waine CJ Metastatic carcinoma of the skin Elder DEedElenitsas RedJaworsky Ced et al. Lever’s Histopathology of the Skin 8th ed. Philadelphia, Pa Lippincott-Raven Publishers1997;1011- 1018Google Scholar 6. Koga STsuda SNishikido M et al. Renal cell carcinoma metastatic to the skin Anticancer Res 2000;201939- 1940PubMedGoogle Scholar 7. Menter ABoyd ASMcCaffree DM Recurrent renal cell carcinoma presenting as skin nodules: two case reports and review of the literature Cutis 1989;44305- 308Google Scholar

Journal

Archives of DermatologyAmerican Medical Association

Published: Nov 1, 2004

Keywords: ulcer,scalp

References