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E-IJD® - CASE REPORT
Year : 2019  |  Volume : 64  |  Issue : 3  |  Page : 251
Nodular lesions on the upper trunk: An uncommon anatomical site of renal tumor metastases


1 Department of Dermatology, Andreas Syggros Hospital, Athens, Greece
2 Department of Pathology, Metropolitan Hospital, Piraeus, Greece
3 First Department of Medical Oncology, Metropolitan Hospital, Piraeus, Greece

Date of Web Publication20-May-2019

Correspondence Address:
Dr. Nikolaos Kostopoulos
Andreas Syggros hospital, I. Dragoumi 5, 161 21, Athens
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_634_16

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   Abstract 


Renal cell carcinoma (RCC) is the most frequent cancer of the kidney and it accounts for 3% of all solid malignancies. Although rare, cutaneous metastases can be an important manifestation of RCC. We present a case of a 56-year-old male with a history of RCC, followed by the development of cutaneous metastases 4 years later with an uncommon clinical presentation. RCC is the most common genitourinary cancer to metastasize to the skin and accounts for 6.8% of cutaneous metastases. These patients have a poor prognosis. It is essential for these patients to perform a complete periodic dermatologic examination for proper restaging and treatment.


Keywords: Cutaneous manifestations, renal cell carcinoma, uncommon anatomical site


How to cite this article:
Kostopoulos N, Platsidaki E, Tzanetakou V, Petraki K, Lekarakou M, Bafaloukos D, Potouridou I. Nodular lesions on the upper trunk: An uncommon anatomical site of renal tumor metastases. Indian J Dermatol 2019;64:251

How to cite this URL:
Kostopoulos N, Platsidaki E, Tzanetakou V, Petraki K, Lekarakou M, Bafaloukos D, Potouridou I. Nodular lesions on the upper trunk: An uncommon anatomical site of renal tumor metastases. Indian J Dermatol [serial online] 2019 [cited 2019 Jun 18];64:251. Available from: http://www.e-ijd.org/text.asp?2019/64/3/251/258634





   Introduction Top


Cutaneous metastasis is considered as a rare condition, but nevertheless, it represents an important entity as it usually indicates a poor prognosis. Moreover, cutaneous metastasis poses a diagnostic challenge to the dermatologists because of the fact that its clinical manifestations may be imitators of benign skin disorders.[1] Excluding malignant melanoma, the most common primary tumors to metastasize to the skin include breast, lung, colon, and ovaries.[2] The percentages of cutaneous metastases vary between 0.3% and 9%.[3]

Renal cell carcinoma (RCC) is the most frequent cancer of the kidney and it accounts for 3% of all solid malignancies.[4] Metastases are present at the time of diagnosis at approximately 25%–30% of patients with RCC.[5] Metastases develop more commonly at lungs, regional lymph nodes, bone, liver, and contralateral kidney, while skin metastases are unusual.[6] The median survival time in patients with metastatic disease is about 10 months;[7] therefore, a high index of suspicion that will aid the early diagnosis could have a significant impact on patients' management.

We present a case report of cutaneous metastases allocated in the upper trunk of a man suffering from RCC.


   Case Report Top


A 56-year-old Caucasian male presented with pink, well-defined, irregular, nodular lesions extending from the left supraclavicular fossa to the lower third of the anterior chest wall [Figure 1]. He had a 4-year history of RCC, followed by nephrectomy. Approximately 1 year earlier, he had been diagnosed with abdominal and supraclavicular lymph node metastases and had been receiving pazopanib therapy since then.
Figure 1: Nodular lesions located on the patient's upper trunk

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Computerized tomography scan revealed disease progression with enlarged mediastinal, axillary, cervical, and para-aortic lymph nodes. Excision biopsy of a single subcutaneous nodule showed a tumoral lesion localized predominantly in the dermis and the subcutaneous tissue. Confluent aggregates of tumor cells with pale-appearing cytoplasm arranged in small clusters and tubular, gland-like structures were present. Infiltration of adnexal structures and necrosis was noticed. The epidermis was not involved and was unremarkable [Figure 2]. Pleomorphisms in the tumor cell nuclei were apparent. The mitotic activity in the tumor cells was high. Immunohistochemistry (IHC) staining for pancytokeratin, vimentin, CD10, and epithelial membrane antigen (EMA) were positive [Figure 3]. Combining the above morphological and immunophenotypic characters with the patient's history, the diagnosis of cutaneous metastasis of RCC was made.
Figure 2: High-grade renal cell carcinoma, papillary subtype, metastatic to the skin. H and E, ×200

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Figure 3: PAX8 nuclear immunoexpression in the metastatic renal cell carcinoma, ×200

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The patient was started on treatment with sunitinib 50 mg once a day for 2 consecutive weeks, followed by 1-week rest period. On a follow-up visit 15 days after initiation of chemotherapy, the patient's skin lesions were clinically improved. Despite that, after 1 month, he was admitted to a hospital feeling unwell with muscle weakness, fever, dyspnea, urine retention, lethargy, and progressive skin lesions. Laboratory tests revealed neutropenia and severe renal impairment. Despite all measures, the patient developed sepsis, acute respiratory, and renal failure on a ground of advanced RCC and died.


   Discussion Top


The skin is a relatively uncommon site for metastasis of internal malignancies, and the most common primary sites are breast, lung, gastrointestinal system, and oral mucosa.[8] Cutaneous metastases form 2.8%–4.4% of skin malignant carcinomas.[9] RCC is the most common genitourinary cancer to metastasize to the skin and accounts for 6.8% of cutaneous metastases. They are more commonly found in men.[3],[10] Regarding the cutaneous metastasis of RCC described in the literature, the most common site was the scalp and neck, followed by the abdominal region,[11] but in our case, the lesions were located on the upper anterior chest wall and left shoulder. Mostly, the development of skin metastases takes places within 6 months to 5 years of the initial diagnosis and after nephrectomy.

Various mechanisms are described for cutaneous metastasis of visceral malignancies. The most frequent is the direct invasion of the skin tissue covering the malignant mass. The rich vascular structure of RCC facilitates hematogenous extension and the development of distant metastases. The most important hematogenous extension route in RCC is the vena cava system, which leads to the lung. Arteriovenous and systemic shunts are thought to facilitate the tumor cell path to the head and neck region.[12] The clinical appearance of cutaneous metastases from RCC has been described as painless or painful nodules, plaques, or pulsatile masses, ranging from flesh colored to violaceous.[3],[13] Clinically, they may mimic epidermoid cysts, fibromas, papillomas, lipomas, or neurofibromas. Vascular endothelial growth factor plays a substantial role in RCC growth; hence, primary tumors as well as metastases tend to be extremely vascular.[14]

In our case, the clinical appearance of the lesions was pink-colored, well-defined, irregular, nodular lesions. The differential diagnoses of cutaneous RCC metastatic lesions are sebaceous carcinoma, sweat gland tumor, and melanoma.[15] RCC cutaneous metastasis is known to have a vascular appearance and should be differentiated from pyogenic granuloma, Kaposi sarcoma, angiosarcoma, and other vascular tumors by histopathology.[16]

Cutaneous metastases can be diagnosed on excisional biopsy or by fine-needle biopsy.[17] Because of the tendency of these lesions to imitate other dermatological diseases, a histopathological survey of biopsied samples containing sufficient dermal tissue is essential for diagnosis. They may have a similar appearance to the primary lesion; however, they are frequently poorly differentiated. The cells tend to be clear, pale staining filled with intracytoplasmic lipid and glycogen embedded in a fibrous and highly vascular stroma.[18] Some protein antigens are evidenced by the use of IHC, such as the EMA, vimentin, keratin, and carcinoembryonic antigen (CEA). The positive results with vimentin, EMA, and keratin are high-probability indicators of RCC,[18] and EMA, CEA, CD10, and RCC-MA are all markers that suggest skin metastases of renal origin.[19] The RCC marker antigen, a monoclonal antibody directed against a normal proximal renal tubule antigen, is a relatively specific marker for cutaneous metastases of RCC.[20]

The development of cutaneous metastasis in RCC is associated with poor prognosis, and most patients die within 6 months of metastasis detection.[21] The mean 5-year survival rate of patients with a cutaneous metastasis is from 13% to 50% if there is one lesion present and 0% to 8% in patients with multiple lesions.[22] Therefore, in the later cases, the treatment options are limited and mostly palliative.

In patients with previous history of malignancy, it is essential for a complete dermatologic examination to be periodically performed, which should include the scalp, as well as a biopsy of any recently appearing cutaneous lesion.[23]

The anatomical site and the allocation of the metastases in our case are rather uncommon as indicated by the bibliography. Nevertheless, it is important to consider RCC metastases in the differential diagnosis of new-onset skin lesions in a patient with a past medical history of renal tumor.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Zook MB, Wu H, Lessin SR. Cutaneous metastases. In: Bolognia JL, Jorizoo JL, Scaffer JV, editors. Dermatology. 3rd ed. Philadelphia: Elsevier; 2012. p. 2049-56.  Back to cited text no. 1
    
2.
Lookingbill DP, Spangler N, Helm KF. Cutaneous metastases in patients with metastatic carcinoma: A retrospective study of 4020 patients. J Am Acad Dermatol 1993;29:228-36.  Back to cited text no. 2
    
3.
Mueller TJ, Wu H, Greenberg RE, Hudes G, Topham N, Lessin SR, et al. Cutaneous metastases from genitourinary malignancies. Urology 2004;63:1021-6.  Back to cited text no. 3
    
4.
Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, editors. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Elsevier; 2006.  Back to cited text no. 4
    
5.
Garnick MB. Primary neoplasms of the kidney. In: Brady HR, Wilcox CS, editors. Therapy in Nephrology and Hypertension: A Companion to Brenner and Rector's – The Kidney. Philadelphia: WB Saunders; 1998. p. 337-40.  Back to cited text no. 5
    
6.
McDougal WS, Wein AJ, Kavoussi LS Novick A, Partin A, Peters CG, et al. Campbell-Walsh Urology. 10th ed. Philadelphia: WB Saunders; 1998.  Back to cited text no. 6
    
7.
Motzer RJ, Mazumdar M, Bacik J, Berg W, Amsterdam A, Ferrara J, et al. Survival and prognostic stratification of 670 patients with advanced renal cell carcinoma. J Clin Oncol 1999;17:2530-40.  Back to cited text no. 7
    
8.
Hu SC, Chen GS, Wu CS, Chai CY, Chen WT, Lan CC, et al. Rates of cutaneous metastases from different internal malignancies: Experience from a Taiwanese medical center. J Am Acad Dermatol 2009;60:379-87.  Back to cited text no. 8
    
9.
White JW Jr. Evaluating cancer metastatic to the skin. Geriatrics 1985;40:67-73.  Back to cited text no. 9
    
10.
Páez Borda A, Nacarino Corbacho L, Diego García A, Prieto Chaparro L, Delgado Martín JA, Salinas Casado J, et al. Cutaneous and gynecologic metastases disclosing renal-cell carcinoma: The diagnostic and therapeutic implications. Arch Esp Urol 1992;45:341-5.  Back to cited text no. 10
    
11.
Brownstein MH, Helwig EB. Patterns of cutaneous metastasis. Arch Dermatol 1972;105:862-8.  Back to cited text no. 11
    
12.
Onak Kandemir N, Barut F, Yılmaz K, Tokgoz H, Hosnuter M, Ozdamar SO, et al. Renal cell carcinoma presenting with cutaneous metastasis: A case report. Case Rep Med 2010;2010. pii: 913734.  Back to cited text no. 12
    
13.
Porter NA, Anderson HL, Al-Dujaily S. Renal cell carcinoma presenting as a solitary cutaneous facial metastasis: Case report and review of the literature. Int Semin Surg Oncol 2006;3:27.  Back to cited text no. 13
    
14.
Amin A, Burgess EF. Skin manifestations associated with kidney cancer. Semin Oncol 2016;43:408-12.  Back to cited text no. 14
    
15.
de Paula TA, da Silva PS, Berriel LG. Renal cell carcinoma with cutaneous metastasis: Case report. J Bras Nefrol 2010;32:213-5.  Back to cited text no. 15
    
16.
Spitz DJ, Reddy V, Selvaggi SM, Kluskens L, Green L, Gattuso P, et al. Fine-needle aspiration of scalp lesions. Diagn Cytopathol 2000;23:35-8.  Back to cited text no. 16
    
17.
Peris K, Fargnoli MC, Lunghi F, Chimenti S. Unusually large cutaneous metastases of renal cell carcinoma. Acta Derm Venereol 2001;81:77-8.  Back to cited text no. 17
    
18.
Kouroupakis D, Patsea E, Sofras F, Apostolikas N. Renal cell carcinoma metastases to the skin: A not so rare case? Br J Urol 1995;75:583-5.  Back to cited text no. 18
    
19.
Arrabal-Polo MA, Arias-Santiago SA, Aneiros-Fernandez J, Burkhardt-Perez P, Arrabal-Martin M, Naranjo-Sintes R, et al. Cutaneous metastases in renal cell carcinoma: A case report. Cases J 2009;2:7948.  Back to cited text no. 19
    
20.
Perna AG, Ostler DA, Ivan D, Lazar AJ, Diwan AH, Prieto VG, et al. Renal cell carcinoma marker (RCC-ma) is specific for cutaneous metastasis of renal cell carcinoma. J Cutan Pathol 2007;34:381-5.  Back to cited text no. 20
    
21.
Mahmoudi HR, Kamyab K, Daneshpazhooh M. Cutaneous metastasis of renal cell carcinoma: A case report. Dermatol Online J 2012;18:12.  Back to cited text no. 21
    
22.
Menter A, Boyd AS, McCaffree DM. Recurrent renal cell carcinoma presenting as skin nodules: Two case reports and review of the literature. Cutis 1989;44:305-8.  Back to cited text no. 22
    
23.
Fernández-Rueda P, Ruiz-López P, Ramírez-Negrín MA, Fuentes-Suárez A, Toussaint-Caire S, Vega-Memije ME, et al. Cutaneous metastasis of renal cell carcinoma: A case report and review of the literature. Gac Med Mex 2015;151:533-7.  Back to cited text no. 23
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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