Renal cell carcinoma presenting as epistaxis

Journal of Surgical Oncology 14: 153-1 57 (1980)

Renal Cell Carcinoma Presenting as Epistaxis .......................................................................................... .......................................................................................... SATINDER KATHURIA, MD, ZELMA MOLNAR, MD, PhD, and CESAR V. REYES, MD Acase of renal cell carcinoma presenting as a nosebleed of three-week duration is described. Light microscopy of a nasal lesion showed a richly vascular tumor, forming glands and uniformly consisting of clear cells. Cytochemically and ultrastructurally, the presence of abundant lipid droplets and glycogen within the neoplastic cells indicated a renal origin. An extended clinical search for a primary kidney tumor was undertaken in view of a negative intravenous tomographic pyelography and renal scan findings. An angogram' finally revealed an intrarenal mass which was proven pathologically as a renal cell carcinoma.

................................................................................... ................................................................................... Key words: epistaxis, metastatic carcinoma, renal cell carcinoma

INTRODUCTION Renal cell carcinoma is known t o metastasize t o the nose and paranasal sinuses

[l-71. As the mode of clinical presentation of the tumor, however, it is unusual [ 1,3-71. This brief report describes such a case along with the light, cytochemical, and electron microscopic features of the neoplasm. CASE REPORT A 60-year-old man was admitted to Hines Veterans Administration Medical Center with a three-week history of epistaxis. Pertinent physical finding was a red, hemorrhagic, soft, polypoid mass occupying the nasal cavity measuring 1 X 1 cm. The clinical impression was pyogenic granuloma, and the lesion was subsequently excised.

From the Laboratory Service, Hines VA Medical Center, the Department of Pathology, Abraham Lincoln School of Medicine, University of Illinois, and the Department of Pathology, Stritch School of Medicine, Loyola University of Chicago, Illinois. Address reprint requests t o Dr. C. V. Reyes, Laboratory Service (113), Hines VA Medical Center, IL 60141.

0022-4790/80/1402-0153$01.40 0 1980 Alan R. Liss, Inc.

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PATHOLOGIC FINDINGS Gross. The surgical specimen consisted of multiple, light brown t o dark red, friable fragments of soft tissue and blood clot measuring in aggregate 1.5 X 1 cm. Light Microscopic, The tumor formed poorly defined glands of epithelial cells with clear cytoplasm and distinct cytoplasmic borders. The nuclei were fairly uniform and located centrally with moderate variation in size and shape. The surrounding stroma within the tumor was highly vascular (Fig. 1). Periodic-acid-Schiff stain was strongly positive for glycogen within the neoplastic cells. There was no evidence of muco-substance production. The overlying, thinned-out mucosa of respiratory epithelium exhibited focal areas of squamous metaplasia. Toluidine blue-stained epon sections of the tumor tissue showed copious glycogen and osmiophilic lipid droplets in the cytoplasm o f neoplastic cells (Fig. 2). Electron Microscopic. The tumor cells contained abundant glycogen and lipid droplets in their cytoplasm. The luminal surface of the glandular formation demonstrated microvilli (Fig. 3). FOLLOW-UP

The Ear-Nose-Throat Pathology Branch of the Armed Forces Institute of Pathology was consulted and reaffirmed the diagnosis of renal cellcarcinoma. A clinical investigation to establish a primary kidney tumor was undertaken. An angiographic examination eventually demonstrated a right intrarenal mass of fivecentimeter dimension. The patient underwent a right nephrectomy three weeks after the initial nasal biopsy. Pathologic findings. The right kidney weighed 165 grams and measured 12 X 6.5 X 2.5 cm. The capsule and fat stripped with ease. In the mid-portion of the kidney and about two cm from the hilum, there was a soft, yellow, and fairly well circumscribed tumor measuring 3.5 X 3 X 2 cm. On sectioning, the entire thickness of renal parenchyma was involved with extension into the peripelvic adipose tissue. The segment of renal artery, vein, and ureter appeared t o be free of tumor engrossment. Microscopically, the renal tumor was essentially similar t o the lesion in the nasal cavity (Fig. 4). Light microscopy of the epon preparation and the ultrastructural studies of the renal tumor displayed more abundant lipid droplets in the glycogen-laden cytoplasm of the neoplastic cells than in the metastatic nasal lesion (Fig. 5 ) . DISCUSSION A case of renal cell carcinoma initially manifesting as a nosebleed due t o a highly vascular metastasis in the nasal cavity is reported. The light microscopic, cytochemical, and fine structural features of the neoplasm are emphasized in the diagnosis. Only the angiogram eventually demonstrated the primary kidney tumor among the investigative procedures performed. The triad of hematuria, flank pain, and mass considered classic for the diagnosis of renal cell carcinoma is not always manifest [ 1, 3, 71. Its peculiarity of being a clinically silent tumor and the propensity for vascular invasion presumably account for the significant occurrence of distant metastasis as the initial presentation. The latter is usually variI

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1 Fig. 1. Light microscopy of a hi&ly vascular tumor composed of clear cells (Hematoxylin and eosin, X 190. Fig. 2. Epon section reveals rich glycogen and lipid droplets within the cytoplasm of neoplastic cells (Toluidine blue, X 85 0).

Fig. 3. Electron micrograph of the nasal lesion shows abundant glycogen and lipid droplets and luminal surface microvilli (X4,400).

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Fig. 4. Photomicrograph of the primary clear cell carcinoma of the hght kidney (Hematoxylin and eosin, X40).

Fig. 5. Ultrastructure of the primary renal tumor confirms the diagnosis (X4,400).

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able and may include pain, swelling, nasal obstruction, and, more frequently, epistaxis [l, 3, 71. As in the present case, the nosebleeding is attributed t o a very vascular tumor [3]. A biopsy of the metastatic lesion can result in hemorrhage 171. The dissemination of renal cell carcinoma may be hematogenous, lymphogenous, or both [2]. Metastasis t o the sino-nasal, head and neck area is probably via vascular invasion of the vertebral veins bypassing the pulmonary circulation [ 7 ] . The differential consideration in the present case comprises salivary gland neoplasms, namely muco-epidermoid carcinoma and acinic cell carcinoma 121. The lack of mucinous secretion by the tumor cells and the fine structural findings negate these possibilities. Equally, the presence of abundant glycogen and lipid droplets within the cytoplasm of neoplastic cells by cytochemical and ultrastructural studies confirm the diagnosis of renal cell carcinoma [8]. The outlook for patients with metastatic renal cell carcinoma to the nose and paranasal sinuses is generally poor unless the secondary lesion is solitary. The resection of the nasal metastasis and the primary kidney tumor may effect a better survival [ 1 , 3 ] . In the present case, so far there is no evidence of recurrence or metastases in other sites a little over a year after diagnosis. ACKNOWLEDGMENTS

The authors thank G. Graham, R. Keis, and J. Kompare for technical assistance. REFERENCES 1. Batsakis J, McBurney T (1971): Metastatic neoplasm to the head and neck. Surg Gynecol Obstet 133:673. 2 Bennington JL, Beckwith JB (1975): Tumors of the kidney, renal pelvis and ureter. Atlas of Tumor Pathology, fasc. 12. Armed Forces Institute of Pathology, Washington, p 168. 3. Bernstein JM, Montgomery WW, Balogh K (1966): Metastatic tumors t o the maxilla, nose and paranasal sinus. Laryngoscope 76:621. 4. Crocker DW (1967): Renal tumors. In Sommers SC (ed): “Pathology Annual.” New York: AppletonCentury-Crofts, p 243. 5. Friedman I, Osborn DA (1965): Metastatic tumors in the ear, nose and throat region. J Laryngol Otol 79:576. 6. Nahum AM, Bailey BJ (1963): Malignant tumors metastatic to the nose and paranasal sinuses: Case report and review of the literature. Laryngoscope 73:942. 7. Schantz JC, Miller SH, Graham WP 111 (1976): Metastatic hypernephroma t o the head and neck. J Surg Oncol 8: 183. 8. Tannenbaum M (1971): Ultrastructural pathology of human renal cell tumors. In Sommers SC (ed): “Pathology Annual.” New York: Appleton-Century-Crofts, p 249.