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Radiology Quiz Case 1—Diagnosis

Radiology Quiz Case 1—Diagnosis Diagnosis: Metastatic renal cell carcinoma, clear cell type Renal cell carcinoma (also known as hypernephroma, adenocarcinoma of renal parenchyma, and Grawitz tumor) represents 3% of all adult malignant tumors and occurs in a male-female ratio of 1.5:1.0. Between 6% and 16% of the metastases occur in the head and neck region. Approximately 8% of patients have head and neck metastases as the initial presentation1,2; furthermore, renal cell carcinoma may metastasize many years after a successful nephrectomy. The incidence of renal cell carcinoma occurs more frequently in the fifth and sixth decades of life. Distant metastases usually extend to the lungs (76%), the bones (42%), and the liver (41%).1 However, hypernephroma is the most common infraclavicular primary tumor to metastasize to the nasal cavity and paranasal sinuses,1 accounting for 40% to 50% of metastases in these regions.3 The sinonasal tract and, more specifically, the ethmoid sinus are rare sites for metastatic tumors. The maxillary sinus is the most common site at 50%, followed by a nearly equal number in the nasal cavity and the ethmoid and frontal sinuses. The sphenoid sinus is the least common site.4 Usual symptoms include nasal obstruction, recurrent epistaxis, proptosis, diplopia, decreased visual acuity, epiphora, facial swelling, pain, unpleasant nasal crusting, and headache,1-5 none of which was present in our case. Renal clear cell carcinomas arise from the epithelial cell of the intercalated tubules.2 Microscopically, the cells are grouped into nests circumscribed by connective tissue and interspersed with abundant, thin-walled blood vessels. The nuclei are uniform, with little plemorphism and few or absent mitotic figures. The cells are filled with lipid and cholesterol, which are dissolved in usual histologic preparations, creating clear cytoplasm surrounded by a distinct cell membrane (Figure 2). These neutral lipids can be stained with oil red O and Sudan IV. The cytoplasmic glycogen stains with periodic acid–Schiff and is diastase soluble.2,6 Figure 2. View LargeDownload In general, malignant tumors present as soft tissue masses associated with bony destruction, while benign processes cause thickening or remodeling of adjacent bone. Endoscopically and radiographically, our patient's nasal lesion appeared smooth, benign, and circumscribed, without extension. Our main differential diagnosis included inflammatory polyp, mucocele, foreign body, benign expansile process, and metastatic renal cell carcinoma because of the patient's medical history. Renal cell carcinoma is a highly vascular, generally slow-growing tumor. The results of imaging reflect these characteristics. On computed tomographic scans, metastatic renal cell carcinoma usually enhances and may cause bony displacement, remodeling, or destruction. Tumoral calcification and sclerotic borders are absent. Angiography will show a highly vascular tumor, and the signal voids in magnetic resonance images correspond to prominent vessels. The latter can mimic the salt-and-pepper pattern of a paraganglioma.5 The present case demonstrated that physicians should always be aware of the malignant potential of a benign-appearing unilateral mass. This is especially true for renal cell carcinoma, which grows slowly without invading surrounding tissue in the early stage. The tumor may initially have a benign appearance both microscopically and macroscopically. As the tumor progresses, it may become necrotic, hemorrhagic, and infiltrative.2 Endoscopic biopsy should be performed for diagnosis. It is important to to be aware of the possibility of profuse bleeding due to the vascular stroma and hemorrhagic nature of this tumor. Although the biopsy caused minimal bleeding in the present case, Simo et al1 have reported cases in which external carotid artery ligation was required to stop massive bleeding due to biopsy. Renal cell carcinoma is the most frequent tumor to metastasize to the sinonasal tract. Despite the malignant nature of renal cell carcinoma, metastases can present as an isolated, circumscribed mass. The benign appearance of this mass on computed tomographic scans does not rule out its malignant potential. References 1. Simo RSykes JAHargreaves SP et al Metastatic renal cell carcinoma to the nose and paranasal sinuses. Head Neck.2000;22:722-727.PubMedGoogle Scholar 2. Matsumoto YYanagihara N Renal clear cell carcinoma metastatic to the nose and paranasal sinuses. Laryngoscope.1982;92:1190-1193.PubMedGoogle Scholar 3. Navarro FVicente JVillanueva MJSanchez AProvencio MEspana P Metastatic renal cell carcinoma to the head and neck area. Tumori.2000;86:88-90.PubMedGoogle Scholar 4. Mills SEGaffey MJFrierson HF Metastatic neoplasms. In: Rosai J, Sobin LH, eds. Tumors of the Upper Aerodigestive Tract and Ear. Washington, DC: Armed Forces Institute of Pathology; 2000:319-320. Atlas of Tumor Pathology; 3rd ser, pt 26. Google Scholar 5. Som PMBrandwein M Sinonasal cavities: inflammatory diseases, tumors, fractures, and postoperative findings. In: Som PM, Curtin HD, eds. Head and Neck Imaging.Vol 1. 3rd ed. St Louis, Mo: Mosby–Year Book Inc: 1996:126-313. Google Scholar 6. Murphy WMBeckwith JBFarrow GM Tumors of the kidney. In: Rosai J, Sobin LH, eds. Tumors of the Kidney, Bladder, and Related Urinary Structures. Washington, DC: Armed Forces Institute of Pathology; 1993:92-105. Atlas of Tumor Pathology; 3rd ser, pt 11. Google Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Otolaryngology - Head & Neck Surgery American Medical Association

Radiology Quiz Case 1—Diagnosis

Archives of Otolaryngology - Head & Neck Surgery , Volume 130 (7) – Jul 1, 2004

Radiology Quiz Case 1—Diagnosis

Abstract

Diagnosis: Metastatic renal cell carcinoma, clear cell type Renal cell carcinoma (also known as hypernephroma, adenocarcinoma of renal parenchyma, and Grawitz tumor) represents 3% of all adult malignant tumors and occurs in a male-female ratio of 1.5:1.0. Between 6% and 16% of the metastases occur in the head and neck region. Approximately 8% of patients have head and neck metastases as the initial presentation1,2; furthermore, renal cell carcinoma may metastasize many years after a...
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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0886-4470
eISSN
1538-361X
DOI
10.1001/archotol.130.7.894
Publisher site
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Abstract

Diagnosis: Metastatic renal cell carcinoma, clear cell type Renal cell carcinoma (also known as hypernephroma, adenocarcinoma of renal parenchyma, and Grawitz tumor) represents 3% of all adult malignant tumors and occurs in a male-female ratio of 1.5:1.0. Between 6% and 16% of the metastases occur in the head and neck region. Approximately 8% of patients have head and neck metastases as the initial presentation1,2; furthermore, renal cell carcinoma may metastasize many years after a successful nephrectomy. The incidence of renal cell carcinoma occurs more frequently in the fifth and sixth decades of life. Distant metastases usually extend to the lungs (76%), the bones (42%), and the liver (41%).1 However, hypernephroma is the most common infraclavicular primary tumor to metastasize to the nasal cavity and paranasal sinuses,1 accounting for 40% to 50% of metastases in these regions.3 The sinonasal tract and, more specifically, the ethmoid sinus are rare sites for metastatic tumors. The maxillary sinus is the most common site at 50%, followed by a nearly equal number in the nasal cavity and the ethmoid and frontal sinuses. The sphenoid sinus is the least common site.4 Usual symptoms include nasal obstruction, recurrent epistaxis, proptosis, diplopia, decreased visual acuity, epiphora, facial swelling, pain, unpleasant nasal crusting, and headache,1-5 none of which was present in our case. Renal clear cell carcinomas arise from the epithelial cell of the intercalated tubules.2 Microscopically, the cells are grouped into nests circumscribed by connective tissue and interspersed with abundant, thin-walled blood vessels. The nuclei are uniform, with little plemorphism and few or absent mitotic figures. The cells are filled with lipid and cholesterol, which are dissolved in usual histologic preparations, creating clear cytoplasm surrounded by a distinct cell membrane (Figure 2). These neutral lipids can be stained with oil red O and Sudan IV. The cytoplasmic glycogen stains with periodic acid–Schiff and is diastase soluble.2,6 Figure 2. View LargeDownload In general, malignant tumors present as soft tissue masses associated with bony destruction, while benign processes cause thickening or remodeling of adjacent bone. Endoscopically and radiographically, our patient's nasal lesion appeared smooth, benign, and circumscribed, without extension. Our main differential diagnosis included inflammatory polyp, mucocele, foreign body, benign expansile process, and metastatic renal cell carcinoma because of the patient's medical history. Renal cell carcinoma is a highly vascular, generally slow-growing tumor. The results of imaging reflect these characteristics. On computed tomographic scans, metastatic renal cell carcinoma usually enhances and may cause bony displacement, remodeling, or destruction. Tumoral calcification and sclerotic borders are absent. Angiography will show a highly vascular tumor, and the signal voids in magnetic resonance images correspond to prominent vessels. The latter can mimic the salt-and-pepper pattern of a paraganglioma.5 The present case demonstrated that physicians should always be aware of the malignant potential of a benign-appearing unilateral mass. This is especially true for renal cell carcinoma, which grows slowly without invading surrounding tissue in the early stage. The tumor may initially have a benign appearance both microscopically and macroscopically. As the tumor progresses, it may become necrotic, hemorrhagic, and infiltrative.2 Endoscopic biopsy should be performed for diagnosis. It is important to to be aware of the possibility of profuse bleeding due to the vascular stroma and hemorrhagic nature of this tumor. Although the biopsy caused minimal bleeding in the present case, Simo et al1 have reported cases in which external carotid artery ligation was required to stop massive bleeding due to biopsy. Renal cell carcinoma is the most frequent tumor to metastasize to the sinonasal tract. Despite the malignant nature of renal cell carcinoma, metastases can present as an isolated, circumscribed mass. The benign appearance of this mass on computed tomographic scans does not rule out its malignant potential. References 1. Simo RSykes JAHargreaves SP et al Metastatic renal cell carcinoma to the nose and paranasal sinuses. Head Neck.2000;22:722-727.PubMedGoogle Scholar 2. Matsumoto YYanagihara N Renal clear cell carcinoma metastatic to the nose and paranasal sinuses. Laryngoscope.1982;92:1190-1193.PubMedGoogle Scholar 3. Navarro FVicente JVillanueva MJSanchez AProvencio MEspana P Metastatic renal cell carcinoma to the head and neck area. Tumori.2000;86:88-90.PubMedGoogle Scholar 4. Mills SEGaffey MJFrierson HF Metastatic neoplasms. In: Rosai J, Sobin LH, eds. Tumors of the Upper Aerodigestive Tract and Ear. Washington, DC: Armed Forces Institute of Pathology; 2000:319-320. Atlas of Tumor Pathology; 3rd ser, pt 26. Google Scholar 5. Som PMBrandwein M Sinonasal cavities: inflammatory diseases, tumors, fractures, and postoperative findings. In: Som PM, Curtin HD, eds. Head and Neck Imaging.Vol 1. 3rd ed. St Louis, Mo: Mosby–Year Book Inc: 1996:126-313. Google Scholar 6. Murphy WMBeckwith JBFarrow GM Tumors of the kidney. In: Rosai J, Sobin LH, eds. Tumors of the Kidney, Bladder, and Related Urinary Structures. Washington, DC: Armed Forces Institute of Pathology; 1993:92-105. Atlas of Tumor Pathology; 3rd ser, pt 11. Google Scholar

Journal

Archives of Otolaryngology - Head & Neck SurgeryAmerican Medical Association

Published: Jul 1, 2004

Keywords: diagnostic radiologic examination,radiology specialty

References