Breast metastases from renal cell cancer

Case contributed by Assoc Prof Craig Hacking

Presentation

Pathological fracture of the distal femur. Lucent lesion in the proximal tibia. Exclude cancer.

Patient Data

Age: 50 years
Gender: Female

There are several pulmonary nodules bilaterally, the largest is in the left lower lobe measuring 17 mm. Bilateral pleural posterior basal atelectasis. No pleural thickening or pleural effusion. Heart size is normal. No pulmonary embolus identified in a non-dedicated contrast study. No lymphadenopathy within the chest.

The left breast contains two peripherally dense irregular masses measuring 11 mm superiorly and 10 mm laterally. There is no axillary, supraclavicular or internal mammary lymphadenopathy.

There is a large irregular peripherally enhancing centrally necrotic right renal mass which measures 90 x 79 x 99 mm (AP x LR x CC) arising from the lower pole of the kidney. Laterally there is stranding of the perirenal fat and large recruited vessels. Medially the lesion abuts the psoas major muscle without evidence of muscular invasion. No hydronephrosis. The right renal vein and IVC are clear. The left kidney contains a simple cortical cyst (42 mm). No retroperitoneal lymphadenopathy.

No hepatic, parenchymal, splenic or adrenal lesion. The large and small bowel is unremarkable. The appendix incidentally contains an appendicolith. The uterus appears irregular with multiple fibroids internally. Cystic ovaries are noted bilaterally. No free fluid or free gas. Small enhancing nodule in the left inguinal canal.

Thoracic and lumbosacral alignment is normal. No vertebral metastatic lesion is evident. No pelvic or proximal femoral lesion identified.

IMPRESSION

Large right lower pole renal lesion with central necrosis most in keeping with a primary renal malignancy such as RCC. There is no evidence of vascular invasion or lymphadenopathy.

Multiple pulmonary metastases. No osseous metastasis identified within the axial skeleton.

Two peripherally dense left breast lesions may represent metastases also given the absence of lymphadenopathy. Breast US and mammography is suggested.

Ultrasound of the left breast demonstrates two circumscribed lesions in the upper outer quadrant at 1 o'clock, 3cm from the nipple and at 3 o'clock 6cm from the nipple, both spherical, vascular and measuring 14 and 11mm respectively. A few small cysts in the left breast.

The right breast was unremarkable (images not included).

US-guided biopsy of the 1 o'clock lesion performed.

Case Discussion

The breast biopsy histology confirmed metastatic RCC.

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