Tumori, 86: 88·90, 2000
METASTATIC RENAL CELL CARCINOMA TO THE HEAD AND NECK AREA
Fatima Navarrol, Javier Vicente 2 , Maria Jose Villanueval, Antonio sanchea', Mariano Provenciol,
and Pilar Espana
1 Department ofMedical Oncology, 2Department of Otorhinolaryngology, Clinica Puerta de Hierro, Universidad Autonoma de Madrid; Spain
Aims and background: Metastases of renal cell carcinoma to the
head and neck are rare. We report on three cases with tumor
spread to this area (nasal cavity, tongue and larynx) and pre-
sent a review of the literature.
Patients: The first patient presented with lung and nasal cavity
metastases five years after renal tumor resection. In patient 2
the diagnosis of primary renal carcinoma and lung and ton-
gue metastases was concomitant. In case 3 a primary kidney
tumor was not suspected until radical resection of a tongue
lesion was performed.
Results: The first two patients received radiation therapy. They
had been previously treated with interleukin + interferon and
Key words: renal cell carcinoma, metastasis, head and neck area.
Introduction
Metastases of infraclavicular primary tumors to the
head and neck area are uncommon. Renal cell carcino-
ma is, after lung and breast carcinoma, the third most
common tumor metastasizing to the head and neck re-
gion. Nearly 8% of patients with renal cell carcinoma
present with symptoms in this area. We present three
cases of patients with renal cell carcinoma and patho-
logically proven metastatic involvement in three differ-
ent locations: nasal cavity, tongue and larynx.
Case reports
Case 1
A 55-year-old male underwent a nephrectomy in Sep-
tember 1987 because of a left renal cell carcinoma. In
November 1989 a single right axillary metastasis, 4 x 5
cm in size, was removed. In February 1991 he was di-
agnosed with bilateral lung metastases and treatment
with interleukin plus interferon-a was started. He re-
ceived two cycles until March 1992 and achieved a par-
tial response. In April 1992 he had several episodes of
epistaxis for which he underwent flexible fiberoptic
laryngoscopy which revealed a friable mass in the right
nasal cavity, spreading into the floor of the cavity and
choana. CT scan showed right nasal and maxillary sinus
occupation. Biopsy confirmed a metastatic renal carci-
noma. Radiation therapy was administered for an overal
dose of 30 Gy. In February 1993 brain metastases were
diagnosed (two right parietal lobe lesions). The patient
died five months after.
To whom correspondence should be addressed: Fatima Navarro, MD, Department of Medical Oncology, Clfnica Puerta de Hierro,
San Martin de Porres 14,28032 Madrid, Spain.
Received March 23,1999; accepted April 23, 1999.
vinblastine + interleukin 2 and achieved a survival of 14 and 16
months, respectively. The third patient has not been given any
treatment to date (apart from surgery) and remains asympto-
matic four years after diagnosis.
Conclusions: In patients with cell carcinoma the occurrence of
lesions in the head and neck area may suggest metastases.
In some cases they may precede the diagnosis of a renal tu-
mor and mimic a primary head and neck tumor; otolaryngolo-
gists should be aware of this possibility. An individualized
treatment approach is recommended. In the case of solitary
metastases a surgical excision should be performed as pal-
liation, if not cure.
Case 2
A 62-year-old male presented with progressively in-
creasing pleuritic pain in his left hemithorax over the
past ten months. A chest CT scan revealed multiple bi-
lateral lung nodules, enlarged mediastinal lymph nodes,
and a left subpleural mass with rib involvement and
chest wall infiltration. Bronchoscopy and ab-
dominopelvic ultrasound were normal. In January 1996
a lung segmentectomy was performed. The histopatho-
logical diagnosis was metastatic clear-cell carcinoma.
The patient was referred to our medical oncology ser-
vice. At examination a well-delimited ectophytic lesion
in the right lateral aspect of the tongue was observed.
Incisional biopsy confirmed the diagnosis of metastatic
renal cell carcinoma. Chemotherapy with vinblastine
and IL-2 was started, but because of evident progres-
sion of the lingual lesion interstitial radiation therapy
with Ir 192 for an overall dose of 70 Gy was administered
and a partial response was obtained. In May 1996 he
noticed a right inguinal lymph node and local radiation
therapy was administered. Shortly after he developed
further pulmonary, cutaneous and osseous metastases.
The patient died in March 1997.
Case 3
A 83-year-old man complained of progressive dys-
phonia, cough and blood-stained sputum in August
1995. Indirect laryngoscopy showed an angiomatous
mass arising from the right ventricle and a biopsy was
carried out. Vocal mobility was preserved. The
histopathological diagnosis was metastatic clear-cell
carcinoma. Cervical CT scan revealed a lesion involv-
METASTATIC RENAL CELL CARCINOMA TO THE HEAD AND NECK AREA
ing the anterior right vocal cord. MRI showed a nodular
ectophytic cervical lesion in the anterior third of the vo-
cal cord. In February 1996 endolaryngeal microsurgery
was performed and a pathological diagnosis of clear-
cell carcinoma was made. Thoracoabdominal CT scan
showed a mass in the right kidney suggesting renal cell
carcinoma; several lung and bone metastases were also
observed. Since the patient was asymptomatic we de-
cided not to perform any further treatment. At present
he is alive and still asymptomatic.
Discussion
Renal cell is a tumor with an unpredictable clinical
course and behavior. The most frequent metastatic loca-
tions are lung, bone, liver and adrenal glands. In the
head and neck area, metastases from infraclavicular tu-
mors are uncommon and the kidney is, after lung and
breast, the third most frequent site of origin", Between
14-16% of patients with renal cell carcinoma have
metastases in this area and in 8% of them this is the first
clinical manifestation of the disease". Literature refer-
ences on metastatic renal cell carcinoma in this area are
scarce. Bernstein et al.' described 36 cases of renal cell
carcinoma with metastases to the paranasal sinuses,
nasal cavity and jaw; Som et al.22 reported eight cases
with a variety of metastatic locations including
paranasal and sphenoid sinuses, base of the skull, thy-
roid, parathyroids and cervical lymph nodes.
Renal cell carcinoma is the primary source of metas-
tases to the nasal cavity and paranasal sinuses (40-
50%)3,9. Metastases to the tongue are rare, taking into
account that of all malignancies in the oral cavity only
1% are metastatic and of this 1% only 5% are located
in the tongue 7 . Zegarelli et al. reported an incidence of
0.2% among 6881 autopsy cases of malignant
disease". Oschner and DeBakey calculated an inci-
dence of 1.6% of lingual metastasis in a study of 3047
cases of lung cancer!". Lung foci appear to be an im-
portant way station before metastases reach the head
and neck area!", but the most important route of metas-
tasis seems to be tumoral embolization via the Batson
plexus, i.e. anastomosis between the avalvular verte-
bral and epidural venous system"; this might explain
the lack of lung metastases in some patients with posi-
tive head and neck lesions, including one of the pa-
tients reported here.
In the medical literature we have found 67 cases of
metastatic renal cell carcinoma to the tongue I6,19,1,11,14,5
and nine to the larynx 16,12,8,24,13,6.
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89
Symptoms at presentation are unspecific and similar
to the symptoms produced by any growing mass in a
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