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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 77-79

Symptomatic isolated metastasis from an asymptomatic primary tumor


1 Junior Resident, MS, DNB Urology, MS, DNB, MCH Urology, Christian Medical College, Ludhiana, Punjab, India
2 Department of Urology, Christian Medical College, Ludhiana, Punjab, India

Date of Web Publication12-Jan-2018

Correspondence Address:
Kim Jacob Mammen
Department of Urology, Christian Medical College, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_32_17

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  Abstract 


Renal cell carcinoma (RCC) is the second most common among all genitourinary malignancies. With the advent of radiological imaging, the presenting triad of fever, hematuria, and abdominal mass is rarely seen. Osseous metastasis of RCC is the second most frequent location after lung metastases. They rarely present as a symptomatic-isolated lesion with an asymptomatic primary tumor. We have identified an unusual facet of the metastatic pattern of this tumor in its unusual propensity to metastasize to the scapula. Scapular metastasis when present, is frequently large, and is generally not part of a picture of disseminated disease. We present a case of symptomatic metastasis with asymptomatic primary (RCC).

Keywords: Renal cell carcinoma, scapular metastasis, symptomatic


How to cite this article:
Pandey S, Tuli A, Mammen KJ. Symptomatic isolated metastasis from an asymptomatic primary tumor. CHRISMED J Health Res 2018;5:77-9

How to cite this URL:
Pandey S, Tuli A, Mammen KJ. Symptomatic isolated metastasis from an asymptomatic primary tumor. CHRISMED J Health Res [serial online] 2018 [cited 2020 Jul 8];5:77-9. Available from: http://www.cjhr.org/text.asp?2018/5/1/77/223115




  Introduction Top


HYPERNEPHROMA is increasing in incidence' and presents as metastatic disease in approximately 25% of patients at presentation. In this tumor 1% to 3% presenting with a solitary visceral metastasis, it is said that aggressive surgical management can result in a 5-year survival rate of 35%.[1] Scapular metastasis may be the presenting symptom, is frequently large, and is generally not part of a picture of disseminated disease.[1] Osseous metastasis of renal cell carcinoma (RCC) is the second most frequent location after lung metastases. They rarely present as a symptomatic isolated lesion with an asymptomatic primary tumor. Their prognosis is better than for multiple bone metastasis, mainly when they develop in peripheral or limb bones.[2] We present a case of symptomatic metastasis with asymptomatic primary (Renal cell carcinoma).


  Case Report Top


A 44-year-old male presented with pain and swelling over the right shoulder for 5 months. On examination, he had a hard mass 15 cm × 10 cm [Figure 1] situated over the posterosuperior aspect of the right shoulder. Magnetic resonance imaging shoulder was suggestive of a large soft-tissue mass in the posterosuperior aspect of the right shoulder encasing the spine of scapula. Incisional biopsy from the right shoulder swelling was suggestive of carcinomatous deposits with papillary architecture. Positron emission tomography-computed tomography (PET-CT) [Figure 2] was suggestive of left renal cell carcinoma (RCC) with isolated right shoulder metastasis. Bone scan showed diffuse vertebral nonhomogenous uptake with dorsolumbar osteopenia with distinct focal osteoblastic lesions representing metastasis at the right shoulder joint. He underwent left radical nephrectomy. Biopsy revealed papillary RCC, type II, left kidney [Figure 3]. The tumor was penetrating the renal capsule and infiltrating the perirenal fat. However, the Gerota's fascia was free of tumor involvement. Vascular invasion was present. The renal vein, renal artery, renal sinus fat, pelvis, and the ureter including its surgical end and adrenal gland were free of tumor involvement. He was started on targeted therapy with Sunitinib 50 mg OD and external beam radiotherapy (EBRT) to the metastatic right scapular region. He is on regular follow-up. The shoulder mass revealed 50% reduction in size after 2 weeks of EBRT and targeted therapy.
Figure 1: Right shoulder mass

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Figure 2: (a) Right shoulder mass arising from acromion process of shoulder. (b) Arrow showing left renal cell carcinoma

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Figure 3: Photomicrograph showing papillary renal cell carcinoma left kidney

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  Discussion Top


RCC is one of the most frequent malignancies of the genitourinary tract having the poorest prognosis of all urologic tumors. It is the seventh leading cause of cancer deaths. Due to the sequestered location of the kidney, many renal masses remain asymptomatic and nonpalpable, until they are advanced. Symptoms of RCC can be due to local tumor growth, hemorrhage, paraneoplastic syndromes, or metastatic disease. Bone metastases (BM) are the next most common site after pulmonary metastasis. Bony lesions rarely are the primary signs of RCC. Isolated BM is rare in RCC accounting for 0.7%–2.5%.[1]

In particular, the majority of scapular metastases from RCC are large and highly symptomatic. We previously noted such an unusual propensity for RCC to metastasis to the scapula.[2] In a series of metastatic disease of bone from a number of tumor types, 5.7% occurred in the scapula compared with 69% in the vertebrae, 41% in the pelvis, 25% in ribs, and 9.6% in the humerus.[3]

Their prognosis is better than for multiple bone metastasis, mainly when they develop in peripheral or limb bones.

More recently, the use of 18F-fludeoxyglucose (FDG) PET in the assessment of BM can offer better specificity. 18F-FDG PET had a sensitivity of 77.3% and specificity of 100% for BM, compared to 93.8% and 87.2% for combined CT and bone scan in the detection of RCC metastases.[4]

Targeted therapies directed against some of these proteins have significantly improved progression-free survival of patients with metastatic RCC as compared to historical treatment options. Sunitinib is currently a standard treatment in RCC, but other anti-vascular endothelial growth factor receptor and anti-platelet-derived growth factor receptor-targeted tyrosine kinase inhibitors such as sorafenib, pazopanib, and axitinib are also used in different stages of the disease. Although roughly 50% of RCC patients receiving sunitinib experience an objective response and 43% achieve disease stabilization, 7% will experience progressive disease at first evaluation due to intrinsic resistance or due to other factors.[5]


  Conclusion Top


Early diagnosis of the primary site of tumor is very crucial when a patient is presenting with a symptomatic lesion suggestive of the secondary involvement. We should use all available radiological technologies to diagnose the primary to plan out proper treatment for the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jung ST, Ghert MA, Harrelson JM, Scully SP. Treatment of osseous metastases in patients with renal cell carcinoma. Clin Orthop Relat Res 2003:223-31.  Back to cited text no. 1
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2.
Gurney H, Larcos G, McKay M, Kefford R, Langlands A. Bone metastases in hypernephroma. Frequency of scapular involvement. Cancer 1989;64:1429-31.  Back to cited text no. 2
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3.
Clain A. Secondary malignant disease of bone. Br J Cancer 1965;19:15-29.  Back to cited text no. 3
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4.
Kang DE, White RL Jr., Zuger JH, Sasser HC, Teigland CM. Clinical use of fluorodeoxyglucose F 18 positron emission tomography for detection of renal cell carcinoma. J Urol 2004;171:1806-9.  Back to cited text no. 4
    
5.
Motzer RJ, Hutson TE, Tomczak P, Michaelson MD, Bukowski RM, Rixe O, et al. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 2007;356:115-24.  Back to cited text no. 5
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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