Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
  Home Print this page Email this page Small font sizeDefault font sizeIncrease font size Users Online: 730  

 
   Table of Contents      
INTERESTING CASES
Year : 2020  |  Volume : 19  |  Issue : 1  |  Page : 89-91

Unexpected rare metastases of renal cell carcinoma


1 Department of Nuclear Medicine, Penang Adventist Hospital, Pulau Pinang, Malaysia
2 Department of Surgery, Penang Adventist Hospital, Pulau Pinang, Malaysia

Date of Submission21-Feb-2019
Date of Acceptance28-May-2019
Date of Web Publication14-Jan-2020

Correspondence Address:
Dr. Alex Cheen Hoe Khoo
Department of Nuclear Medicine, Penang Adventist Hospital, 456, Jalan Burma 10350 Georgetown, Pulau Penang
Malaysia
Login to access the Email id


DOI: 10.4103/wjnm.WJNM_14_19

Rights and Permissions
   Abstract 


Renal cell carcinomas (RCCs) commonly metastasize to the lungs and bones and rarely to the parathyroid, maxillary sinus, and adrenals. It is indeed very rare to have these all these metastases occurring simultaneously in an individual. We share a case of 67-year-old woman provisionally treated for parathyroid carcinoma but subsequently found to actually have metastatic RCC to the left maxillary sinus, parathyroid, lungs, and adrenals on18F-fluorodeoxyglucose positron emission tomography–computed tomography.

Keywords: 18F-fluorodeoxyglucose, maxillary sinus, metastatic, parathyroid, positron emission tomography–computed tomography, renal cell carcinoma


How to cite this article:
Khoo AC, Cheong YT. Unexpected rare metastases of renal cell carcinoma. World J Nucl Med 2020;19:89-91

How to cite this URL:
Khoo AC, Cheong YT. Unexpected rare metastases of renal cell carcinoma. World J Nucl Med [serial online] 2020 [cited 2020 Jul 10];19:89-91. Available from: http://www.wjnm.org/text.asp?2020/19/1/89/275851




   Introduction Top


Renal cell carcinomas (RCCs) are known to have unpredictable patterns of metastases though the common sites are still the lungs and bones. It is rare to have metastases occurring in the parathyroid, maxillary sinus, and adrenals individually but even rarer to have these all these metastases occurring simultaneously.


   Case Report Top


A 67-year-old woman with no past medical history of significance, presented in March 2018, with a progressively enlarging left neck swelling. Fine-needle aspiration of the swelling was inconclusive, and she had total thyroidectomy due to the clinical suspicion of thyroid carcinoma at the inferior pole of the left thyroid gland. However, the histopathological examination of the surgical specimen revealed left inferior pole intrathyroidal clear-cell parathyroid carcinoma with thyroid capsular invasion (measuring 40 mm × 30 mm × 25 mm) and no involved regional lymph nodes. The panel of immunohistochemistry (IHC) tests performed were suggestive of parathyroid carcinoma. As her postsurgical intact parathyroid hormone (iPTH) and calcium levels were normal postsurgery, no further treatment was offered. However, she presented within 5 months with a new swelling at the left thyroid bed with her iPTH and calcium levels still within normal range.18 F-Fluorodeoxyglucose (18 F-FDG) positron emission tomography–computed tomography (PET-CT) was performed as a different pathology was suspected in view of the rapid reoccurrence of disease [Figure 1] and [Figure 2].
Figure 1: The maximal intensity projection of the18F-fluorodeoxyglucose positron emission tomography–computed tomography is shown with intense uptake seen at the left thyroid bed, bilateral lungs and mild uptake at the bilateral suprarenal regions

Click here to view
Figure 2: The fused axial positron emission tomography–computed tomography images – (a-d) show metastatic disease in the left maxillary antrum, left thyroid bed, left lung and left adrenal respectively with increased18F-fluorodeoxyglucose uptake

Click here to view


Based on the imaging findings, the metabolically active lesions were more likely secondary to metastatic clear cell RCC, and this was subsequently reconfirmed with re-examination of the initial surgical specimen and further IHC tests which demonstrated stronger staining for RCC, CD10, and PAX8 markers (compared to focal positivity in the initial IHC test).


   Discussion Top


RCC is a relatively common cancer with the global age-standardized incidence rate of 4.5/100,000 people/year. Unfortunately, the mortality is high despite newer targeted therapies with global age-standardized mortality rate of 1.8 per 100,000 people/year.[1] A large majority of the tumors are clear cell renal carcinoma (75%) followed by Types 1 and 2 papillary renal cancers, microphthalmia-associated transcription family translocation kidney cancers, chromophobe kidney cancer, and oncocytoma.[2]

The identification of clear-cell carcinoma can be challenging due to the overlap in morphologic features from different primary sites. There are many kinds of clear cell carcinoma, including parathyroid, kidney, and liver. In view of IHC results and the rarity of metastatic RCC to the parathyroid gland, the initial diagnosis of parathyroid carcinoma was made. To our best knowledge, this is the 3rd case report in literature of RCC metastasis to the parathyroid gland.[3] The utility of18 F-FDG PET/CT in parathyroid carcinoma is not well established in the literature, but Evangelista et al. have demonstrated its benefit in the staging, restaging, and postsurgery evaluation of parathyroid carcinoma.[4] Retrospectively,18 F-FDG PET/CT could have been beneficial in the initial staging and incidentally establish the presence of metastatic RCC.

Surgery remains the only curative treatment available in spite of all the significant advancement in drug therapies. Unfortunately, curative surgery is only possible for patients with localized, locally advanced, and limited metastatic disease. Immunotherapies (interleukin-2 and interferon-2α) were commonly used in the past, but in the recent years, multikinase inhibitors (sorafenib, sunitinib, and pazopanib) and mammalian target of rapamycin inhibitors (e.g., everolimus) have shown promising outcomes.[5]

Imaging plays a role in the staging of confirmed RCC and detection of metastatic disease.[6] The role of18 F-FDG PET-CT in primary RCC is limited due to masking by physiological urinary excretion as demonstrated by many early clinical observations.18 F-FDG PET-CT is very useful in the detection of metastatic disease, especially in this case where metastatic diseases to the left maxillary antrum, thyroid bed, lungs and adrenals were detected.[7] In fact, a meta-analysis of 14 studies has shown that18 F-FDG PET-CT has a pooled extrarenal lesion sensitivity and specificity of 91% and 88%, respectively.[8] The occurrence of metastatic RCC to the parathyroid gland, maxillary antrum, and adrenals is rare, and unfortunately, all of these lesions were detected in this particular case. It should be highlighted that it is more common for RCC to metastasize to the lungs and bone.[9] Nevertheless, RCC is among the most common infraclavicular tumor to metastasize to the head and neck region after breast and lung cancer.[10]


   Conclusion Top


18 F-FDG PET-CT is indeed a useful modality in staging metastatic RCC and may have a role in staging primary RCC due to the unpredictable metastatic nature of the disease.

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.
Ferlay J, Colombet M, Soerjomataram I, Mathers C, Parkin DM, Piñeros M, et al. Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods. Int J Cancer 2019;144:1941-53.  Back to cited text no. 1
    
2.
Linehan WM. Genetic basis of kidney cancer: Role of genomics for the development of disease-based therapeutics. Genome Res 2012;22:2089-100.  Back to cited text no. 2
    
3.
Torregrossa L, Rotondo MI, Cacciato Insilla A, Galleri D, Guidoccio F, Miccoli P, et al. Metastasis of renal cell carcinoma to the parathyroid gland 16 years after radical nephrectomy: A case report. Oncol Lett 2016;12:3224-8.  Back to cited text no. 3
    
4.
Evangelista L, Sorgato N, Torresan F, Boschin IM, Pennelli G, Saladini G, et al. FDG-PET/CT and parathyroid carcinoma: Review of literature and illustrative case series. World J Clin Oncol 2011;2:348-54.  Back to cited text no. 4
    
5.
Grimm MO, Wolff I, Zastrow S, Fröhner M, Wirth M. Advances in renal cell carcinoma treatment. Ther Adv Urol 2010;2:11-7.  Back to cited text no. 5
    
6.
Liu Y. The place of FDG PET/CT in renal cell carcinoma: Value and limitations. Front Oncol 2016;6:201.  Back to cited text no. 6
    
7.
Sankineni S, Brown A, Cieciera M, Choyke PL, Turkbey B. Imaging of renal cell carcinoma. Urol Oncol 2016;34:147-55.  Back to cited text no. 7
    
8.
Wang HY, Ding HJ, Chen JH, Chao CH, Lu YY, Lin WY, et al. Meta-analysis of the diagnostic performance of [18F] FDG-PET and PET/CT in renal cell carcinoma. Cancer Imaging 2012;12:464-74.  Back to cited text no. 8
    
9.
Gong J, Maia MC, Dizman N, Govindarajan A, Pal SK. Metastasis in renal cell carcinoma: Biology and implications for therapy. Asian J Urol 2016;3:286-92.  Back to cited text no. 9
    
10.
Ofo E, Mandavia R, Jeannon JP, Odell E, Simo R. Renal cell carcinoma metastasis to the parathyroid gland: A very rare occurrence. Int J Surg Case Rep 2014;5:378-80.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
     Introduction
     Case Report
     Discussion
     Conclusion
    References
    Article Figures

 Article Access Statistics
    Viewed352    
    Printed13    
    Emailed0    
    PDF Downloaded89    
    Comments [Add]    

Recommend this journal