Incidentally discovered metastatic renal cell carcinoma

Case contributed by Dr Yair Glick

Presentation

Fell and hit his head. History of IV drug abuse.

Patient Data

Age: 60 years
Gender: Male

Non-displaced nasal bone fracture on right. Soft tissue contusion over left zygoma.

Right occipital intra-axial elliptical lesion with target appearance, isodense to adjacent white matter and measuring 14 mm across, with profuse perifocal edema. Larger lesion in left cerebellar hemisphere with similar appearance, measuring 23 mm across, with perifocal edema involving the vermis and left middle cerebellar peduncle and distorting the fourth ventricle.

Sulcal and ventricular width appropriate ​for age; basal cisterns mildly dilated.
Small left parasagittal lacunar pontine infarct, probably chronic.

Impression:
The intracranial lesions most probably represent metastases; however, taking patient history of drug abuse into consideration, abscesses cannot be ruled out entirely.

Chest X-ray taken after CT head shows rounded lesion 1.5 cm in diameter projected onto right lung lower zone, elliptical lesion measuring 5.4 x 4.0 cm projected onto left lung lower zone.

Width of upper mediastinum, aortic arch and cardiac silhouette all within normal range.

Impression:
Taken together with the findings of the CT head, the patient most probably has a malignancy with metastases to the lungs and brain.

Large hypervascular left renal mass measuring 8.4 x 9.7 x 10.1 cm, with prominent central necrosis. No evidence of tumor thrombus.
Left adrenal node measuring 2.6 x 2.8 x 2.7 cm, with enhancing margins and center, most probably a metastasis.

Many metastases in both lungs; the largest, by far, lies on the interlobar fissure of the left lung and measures 4.8 cm in length.
Suspicious 17 mm-thick subcarinal lymph node with marked peripheral enhancement.

The brain metastases exhibit vivid ring enhancement.

Status post right total hip arthroplasty.

Of note, the renal contrast excretion at the early portal phase is explained by contrast injection a couple of minutes earlier that was aborted due to extravasation of contrast material into the soft tissues of the right arm.

Case Discussion

Reported falling and hitting his head after using heroin and crystal meth.
Non-contrast CT head revealed two cerebral metastases and chest X ray showed a left lung lesion. CT chest-abdomen-pelvis performed in search of the primary neoplasm, along with contrast-enhanced CT brain.
The CT showed a large left renal mass with left adrenal and bilateral lung metastases.

Ultrasound-guided biopsy of the renal lesion was sent for histopathology:

Macroscopic description:
Two white tissue cylinders in formaldehyde, each measuring 1.5 cm in length and 0.1 cm in diameter. Marked with hematoxylin.

Microscopic description:
Cores of fibrotic tissue showing nests composed of clear cells, cytoplasm with slightly irregular nuclei.

Immunostains:
Positive: Pankeratin, RCC, CD10, PAX8.
Negative: CK7.

Based on the morphology and the results of immunostains our favored diagnosis is renal cell carcinoma, clear cell type, grade 1-2.

 

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