Renal cell carcinoma (RCC) is divided into
clear-cell, papillary, oncocytoma and collecting duct subtypes
which exert different invasion and metastatic potentials (1). The clear-cell carcinoma subtype
represents <85% of reported cases, according to the United
States National Centre for Health Statistics report (2). Recurrence of the disease following
surgery can be observed in one-third of the cases and one-fourth of
the patients exhibit metastatic disease at the time of a diagnosis
(1,2). RCC metastases are often regarded as
radioresistant tumors, which was observed in the present case
(2–4). For this reason, metastases are usually
treated with relatively high biologically effective doses.
Metastasis to adjacent organs and bone are common, but distant
metastases to the head and neck region are rare. Of these
previously reported cases, the facial skin area has been the most
common location. The present study demonstrates the case of rapidly
growing and radiotherapy-resistant RCC metastasis to the lower lip
and chin which was treated with surgery. The functional and
esthetic outcome was satisfactory despite the large gap generated
by the metastasis resection. This case provides evidence that
palliative surgery may achieve a higher quality of life for
end-stage oncological patients.
The current study presents the case of a 71-year-old
male patient who was diagnosed with RCC in September 2011. At that
time, the disease was at an advanced stage. The primary tumor in
the lower pool of the right kidney was infiltrating the adjacent
structures and the patient exhibited synchronous mediastinal and
pleural metastases, with the latter causing persistent pleural
effusion and markedly declining lung function. Due to the poor
performance status and risk of side effects, the patient refused to
initiate the disease-controlling sunitinib treatment and chose to
proceed to the optimum supportive care. The patient presented with
subcutaneous metastases to the lower lip and back of the neck 11
months after the diagnosis. The patient received palliative
radiotherapy (split course, 15/5 Gy) to the rapidly growing lower
lip metastasis. The tumor diameter was 1.5 cm when the treatment
was initiated. However, no clinical response to radiotherapy was
obtained, and three weeks following the treatment the tumor had
more than tripled in diameter. Thus, the patient was evaluated at
the Department of Oral and Maxillofacial Diseases (Helsinki
University; Helsinki, Finland). At the time of admission the
patient had a spontaneously bleeding mass (size, 60×60 mm) in the
lower lip and the anterior mandible area (Fig. 1A). In addition to this, there was a
group of smaller subcutaneous metastases located at the
subcutaneous nuchal area, which did not exhibit symptoms. Resection
of the lip metastasis was performed with 5-mm clinical margins and
for this reason, the resection was extended to the bony surface of
the mandible. The lower lip was also partially resected as the
small subcutaneous metastases had continued to spread into the lip
mucosa (Fig. 1B). To prevent wound
tension following closure, the skin was dissected subcutaneously
from the resection line to the upper neck, pulled over the chin to
cover visible bone, and resuspended with transcutaneous sutures to
the titanium plate (MatrixMFACE Plating System; Synthes Holding AG,
Solothurn, Switzerland) in the mandible (Fig. 1B and C). The patient was satisfied
with the outcome at the three-week postoperative follow-up and no
clinical sign of recurrence was observed (Fig. 1D). Histological examination via
immunohistochemical staining (Fig.
2) identified the tumor as metastatic RCC and the mass was
resected with clear lateral margins.
RCC commonly metastases to adjacent organs, and up
to one-fourth of patients have metastases present at the time of
the diagnosis (1,2). Four major subtypes of RCC exist
(clear-cell, papillary, oncocytoma and collecting duct carcinoma),
with different invasion and metastatic potentials. However, none of
them have been reported to be particularly invasive to the head and
neck region (1,2). Of the 75 previously reported cases of
metastatic RCC to the head and neck region, the majority were
already diagnosed with RCC, however, certain patients exhibited
oral metastasis as the initial manifestation of the disease. This
highlights the importance of full body imaging to identify whether
the patient has previously undergone surgery for head and neck
neoplasms, to avoid inaccurately diagnosing a newly formed
metastasis as the recurrence of a former tumor. A third of the
previously identified cases of patients with head and neck RCC
metastases have been reported on the facial skin area (4–11),
although the parotid gland, paranasal sinuses and tongue are also
common locations. In addition, single cases of nephroblastoma (also
termed, Wilms’ tumor) and renal sarcomas have been reported in the
head and neck area (12,13). According to earlier reports, none of
the RCC subtypes preferentially metastasize to the head and neck
area. The locations of previously reported metastases are listed in
Table I (4–51).
In conclusion, surgery is rarely the first option
when treating RCC patients with multiple metastases. However, it is
important to consider palliative surgery for certain patients, as
surgical management of the metastasis may provide an improved
quality of life although this type of surgery does not affect the
final outcome.
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