Pakistan Journal of Medical Sciences

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CASE REPORT

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Volume 25

October - December 2009 (Part-II)

Number  6


 

Abstract
PDF of this Article

Epistaxis and Proptosis - Unusual primary
manifestations of metastatic renal cell carcinoma

Mutahir Ali Tunio1, Altaf Hashmi2, Mansoor Rafi3

ABSTRACT

Metastasis to the paranasal sinuses is rare presentation. We report a case of a patient with metastasis to the maxillary antrum from renal cell carcinoma.

KEYWORDS: Rare metastasis, Maxillary antrum, Renal cell carcinoma.

Pak J Med Sci    October - December 2009 (Part-II)    Vol. 25 No. 6    1012-1014

How to cite this article:

Tunio MA, Hashmi A, Rafi M. Epistaxis and Proptosis - Unusual primary manifestations of metastatic renal cell carcinoma. Pak J Med Sci 2009;25(6):1012-1014.


1. Dr. Mutahir Ali Tunio, MBBS, FCPS (Radiotherapy)
Assistant professor,
Radiation Oncology
2. Dr. Altaf Hashmi, MBBS, MS, MCPS(Urology)
Professor, Urology
3. Dr. Mansoor Rafi, MBBS.
Resident, Radiation Oncology
1-3. Sindh Institute of Urology & Transplantation (SIUT)
Karachi - Pakistan.

Corespondence:

Dr. Mutahir Ali Tunio, MBBS, FCPS (Radiotherapy)
Assistant professor, Radiation Oncology
Sindh Institute of Urology & Transplantation (SIUT)
Karachi - Pakistan.
Email: drmutahirtonio@hotmail.com

* Received for Publication: May 23, 2009

* Accepted Date: September 8, 2009


INTRODUCTION

Renal cell carcinoma (RCC) has unpredictable and diverse behavior. The classic triad of haematuria, loin pain and abdominal mass is found in only 4–17%.1 About, 25–30% of patients are found to have metastases at diagnosis. A further 30–50% of patients develop metastases during the course of their illness.2 Many tumors like bronchus, breast, colon and thyroid have been reported to have metastasized to the paranasal sinuses.3 Metastatic deposits of renal cell carcinoma to the head and neck region are infrequent.

CASE REPORT

A 55 year-old female who underwent left radical nephrectomy three years back for renal cell carcinoma, during her routine follow visit in March 2009, complained of epistaxis, right eye bulging and doubling of vision. She had no other symptoms. On physical examination, the patient was in good health, afebrile, with a prominent swelling of left cheek and proptosis of right orbit with right trochlear never palsy. The chest and abdomen examination were negative.

Baseline investigation including full blood count, urea and electrolytes, liver function tests and chest X-ray were normal. CT scan of paranasal sinuses (Figure-1) showed soft tissue mass completely filling the right maxillary antrum, measuring 4.7×2.7 cm extending into in right Ethmoidal sinus and right sphenoid sinus. Medially was extending into the nasal cavity, also eroding the nasal septum and laterally extending into infra-temporal fossa with no intra cranial extension. Differential diagnoses were a polyp, primary malignancy, least likely a metastatic deposit. The biopsy of the antral mass showed the cells with clear cytoplasm, and rich in blood vessels consistent with renal cell carcinoma (Figure2). Surprisingly, the bone scan was negative, and she was referred to radiation oncology department for palliative radiotherapy. Patient gave consent for publishing her case but refused publication of photographs.

DISCUSSION

Primary tumors of the paranasal sinuses are rare, constitute only 3% of all head and neck tumors.4 Metastatic tumors to paranasal sinuses are even rarer, only 0.25% to 5% of all sinus neoplasms.5

Due to their rare occurrence, many of the metastatic tumors are diagnosed by chance. In our patient, she already had nephrectomy done for renal cell carcinoma three years back, and diagnosis of metastasis was only made on routine follow up.

The maxillary sinus is the most common site (50%) of paranasal sinuses metastasis, followed by the ethmoidal sinuses, frontal sinuses, nasal cavity and sphenoid sinuses. In this patient, the metastasis was already extensive upon diagnosis. It was difficult to comment as to which sinus was first involved.

Presentation of symptoms varies according to the site. In our patient, epistaxis was due to the vascularity of the tumor. Epistaxis was the chief presenting complaint of more than 70% of renal cell carcinoma metastases to the paranasal sinuses.6 Cranial nerve palsies (II, III, IV, V and VI) are also seen in sphenoidal metastases.7

The possible route for metastasis suggested is the presences of valveless interconnecting vertebral veins allow intra-abdominal metastases to bypass the heart and lungs and communicate directly with the veins of the head and neck region. The vertebral veins in turn communicate superiorly with the pterygoid plexus, carvernous sinus and superior portion of the pharyngeal plexus, hence providing a pathway for metastasis to the paranasal sinuses. The para nasal sinuses metastasis is a poor prognostic factor with poor survival outcome 35%.8

CONCLUSION

Metastasis at the time of diagnosis frequently occurs in RCC; rare in paranasal sinuses. Clinicians should be aware of the possibility of metastatic malignancy in patients presenting with antral masses, therefore a careful examination is required in patients with RCC.

ACKNOWLEDGEMENT

We are thankfull to Dr. Adibul Hasan Rizvi and Dr. Syed Anwar Naqvi, department of Urology, Sindh Institute of Urology & Transplantation (SIUT), Karachi, for their constant support.

REFERENCES

1. Fekak H, Bennani S, Taha A, Rabii R, Joual A, Sarf S et al. Kidney cancer. Report of 170 cases. Ann Urol (Paris). 2001;35(5):249-56.

2. Pavlakis GM, Sakorafas GH, Anagnostopoulos GK. Intestinal metastases from renal cell carcinoma: A rare cause of intestinal obstruction and bleeding. Mt Sinai J Med 2004;71:127–30.

3. Kaminski B, Kobiorska-Nowak J, Bien S. Distant metastases to nasal cavities and paranasal sinuses, from the organs outside the head and neck. Otolaryngology Pol 2008;62:422-5.

4. Zhang M, Higashi T. Comparison of time trends in noses, middle ear, sinuses cancer incidence (1973-1997) in East Asia, Europe and USA, from Cancer Incidence in Five Continents Vols IV-VIII. Jpn J Clin Oncol 2008;38:791-2.

5. Viswanatha B.Prostatic carcinoma metastatic to the paranasal sinuses: A case report. Ear Nose Throat J 2008;87:519-20.

6. Huang CT, Hong RL. Nasion swelling as the presenting symptom of lung adenocarcinoma. J Thorac Oncol 2009;4:555-8.

7. Shields JA, Shields CL, Brotman HK, Carvalho C, Perez N, Eagle RC Jr. Cancer metastatic to the orbit: the 2000 Robert M. Curts Lecture. Ophthal Plast Reconstr Surg 2001;17:346-54.

8. Torres Muros B, Solano Romero JR, Baro Rodriguez JG, Bonilla Parrilla R. Maxillary sinus metastasis of renal cell carcinoma. Actas Urol Esp 2006;30:954-7.


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