Laryngeal Metastasis 7 Years After Radical Nephrectomy Simpson L. Dee, MD; Majic Eshghi, MD; Clifton $. Otto, MO © Metastasis of renal cell carcinoma to the head and neck, especially the laryn, is an extremely rare event. Most pre- viously reported cases have involved a presenting laryngeal lesion that lead to the discovery of an underlying primary renal cell carcinoma. Even mare unusual is the occurrence of an isolated laryngeal metastasis revealing itself years af- ter nephrectomy, with an interim of undetected recur. rence. We believe this case to be the first reported example of an isolated supraglottic laryngeal renal cell carcinoma metastasis occurring 7 years after radical nephrectomy. La- cal excision of such isolated lesions seems to offer a fa. vorable prognosis, (Arch Pathol Lab Med. 2000;124:1833-1834) jenal cell carcinoma (RCC) typically metastasizes via the bloodstream and is known to involve almost ev- ery organ of the body. Common sites for metastasis in- clude the lungs, bone, lymph nodes, pancreas, adrenal glands, soft tissues, pleura, and brain’! However, isolated RCC metastases to the head and neck, especially the lar- ynx, are extremely rare, Although cases of presenting la- ryngeal metastases leading to the discovery of an under- lying RCC have been reported previously,’ there have been only 2 reports in the English literature of metastasis to the larynx occurring years after initial nephrectomy, both of which were not isolated recurrences.‘ Review of the literature has revealed only 2 reported cases in the German literature of isolated laryngeal metastasis to the anterior commissure and the false vocal cords, both oc- curring 6 years after nephrectomy.* We believe this case to be the first example of an isolated intralaryngeal, sux praglottic RCC metastasis, occurring 7 years after poten- tially curative radical nephrectomy REPORT OF A CASE A A8:year-old, previously healthy man came to our attention in 1991 after experiencing left ak pain and gross Rematuria for 3 weeks, Neither costoverkebal angle tenderness st palpable renal mass was evident on physical examination. Inleavenous py- ‘dogram revealed a left renal mass, which was confirmed by ab Gdominal and pelvic computed tomographic scan. A left radical nephrectomy with exploratory laparotomy was performed. all ther intreabdominal organs were gresly free of tumor. The Kidney tumor was a clear cell RCC. ‘The patient's postoperative course and follow-up, including yearly thoracosbdominapelvic computed tomographic scan and ‘Accepted for publication May 78, 2000. From the Departments of Pathology (Or Dee) and Urology (Ds Esh hi and Orta), New York Medics! College, Valhalla, NV. Reprints: Simpson L, Dee, MD, PO! Hex 62, Havwthowne, NY 10532- 062. Arch Pathol Lab Med-—Vol 124, December 2000, urine cytology were all unremarkable. The patient was asymp- tomatic until | year after the last follow-up visit in 199%, when he developed hoarseness. Laryngoscopy revealed a 1.2-cm, tan- pink, polypoid, supraglottic mass. The tumor was locally excised and revealed metastatic clear cell RCC. MATERIALS AND METHODS Tissues from the primary kidney tumor andl metastatic nodule were fixed in 10% neutral buffered formalin, embedded in par- affin, sectioned, and stained with. hematoxylin-eosin by routine methods. Histochemistry included periodic acid-Schiff reaction (MeManus, Carson, and Pickett) and periodic acid-Schiff reaction with diastase digestion (Luna) for demonstration of glycogen. Im- ‘munohistochemistry was performed on formalin-fixed, paraffin embedded tissue sections using avidin-biotin-peroxidase tech- nique after enzymatic digestion with proteinase K. Antibodies tused were low-molecular-Wweight anti-human cytokeratin cocktail BA1?/MINEL16 (Dako Corporation, Carpinteria, Calif), high-mo- Jecular-weight anti-human cytokeratin 356HL1 (Dako), and anti- vimentin elane Vim 3B4 (Dako). RESULTS ‘The superior pole of the resected left kidney contained 2 5.5 x 4-em, ovoid, yellow-tan tumor with foci of hem- orrhage and cystic changes. Histology showed a typical clear cell RCC with sheets of polyhedral cells exhibiting, clear cytoplasm and well-defined cell borders (Figure 1). Delicate fibrovascular septae separated these cells into moderately sized lobules. The nuclei were hyperchromatic with mild atypia, rare mitoses, and indistinct nucleoli Histochemistry showed periodic acid Schiff-positive and diastase-sensitive intracytoplasmic granules, confirming the presence of glycogen. Immunohistochemical stains showed isolated cells positive for both low-molecular- weight cytokeratin and vimentin, Tumor invaded both the renal capsule and perinephric fat. There was no evidence oof vascular invasion. Resection margins around the peri- nephric fat, renal vessels, and ureter were free of tumor. The tumor was that of a clear cell RCC, American Joint Committee on Cancer stage Ill, Fuhrman nuclear grade ML ‘The excised laryngeal tumor showed clear cells with Aistinct cytoplasmic borders displaying architecture sim- ilar to that of the RCC removed 7 years earlier (Figure 2) ‘The tumor was distinctly separate from the overlying nor- mal squamous mucosa of the larynx. Histochemical and jimmunohistochemical staining patterns were identical to ‘those of the original renal tumor, thus confirming, the la- ryngeal mass to be metastatic RCC. COMMENT Renal cell carcinoma is one of the great imitators that ‘has an ertatic clinical course. Rare involvement of the lat- ‘Metastasis of Renal Cell Carcinoma tothe Larymx—Dee et al 1833