CASE REPORTS

HOARSENESS;AUNIQUE CLINICALPRESENTATION
FOR RENAL CELL CARCINOMA

RICHARD E. GREENBERG, M.D. R. MELVYN RICHTER, M.D.

JEFFERY COOPER, M.D. HOWARD KESSLER, M.D.
ROBERT L. KRIGEL, M.D. ROBERT 0. PETERSEN, M.D.

From the Departments of Surgery/Urology, Medical Oncology,

Radiation Therapy, Radiology, and Pathology, The Fox Chase
Cancer Center, Philadelphia, and the Division of Otolaryngology of
Abington Memorial Hospital, Abington, Pennsylvania

ABSTRACT-The first reported case of an isolated metastasis to the larynx

from a regionally localized renal cell carcinoma presenting clinically as hoarse-
ness is discussed. Aggressive management and outcome are presented.

Renal cell carcinoma is a common geni-
tourinary malignancy known both for its pro-
pensity for early, widespread metastases and its
associated poor survival rates. It is unresponsive
to radiation and chemotherapy such that ag-
gressive surgery represents the only possibility
for cure. Renal cell carcinoma has multiple and
diverse methods of presentation. It has been re-
ferred to as the “internist’s tumor” in that next
to syphilis, renal cell carcinoma is the great im-
itator.’ The clinical triad of flank pain, mass,
and hematuria is as unusual as its presentation
secondary to metastases outside the geni-
tourinary system. The world literature has
multiple reports of renal cell carcinoma metas-
tasizing to the head and neck region.2-5 How-
ever, we believe this is the first report of an iso-
lated metastasis to the larynx from a renal cell
carcinoma.
Case Report
The patient was a relatively healthy fifty-
five-year-old white man with mild hyperten-
sion. He presented for evaluation of hoarseness
which had been present for approximately six
weeks. Physical examination at that time was
unremarkable. Indirect laryngoscopy demon-
strated only a general subglottic fullness, but no
obvious mucosal lesions. This was confirmed at
the time of direct laryngoscopy and biopsy.
Prior to the biopsy, the patient had a computer-
ized axial tomography (CAT) scan of the neck
which showed a 1.5 cm subglottic tumor on the
left side (Fig. 1A). Microscopic review of biopsy
tissue demonstrated clear cell carcinoma. Ret-
rospective questioning still failed to generate
any significant urinary symptoms, or any sig-
nificant constitutional symptoms. The patient
then underwent a CAT scan of the abdomen
which demonstrated a localized left renal mass
consistent with a renal cell carcinoma (Fig. 1B).
Extensive additional metastatic evaluation
failed to reveal any other sites of me&stases.
Following the original biopsy the patient re-
quired a tracheostomy. Since the major clinical
problem at this point was the laryngeal lesion,
the patient underwent local irradiation using a
6 MeV radiation source for a total treatment
dose of 5,000 rad to the subglottic region. This
was given in 25 fractions over forty-four days.
Next, the patient had a repeat extent-of-dis-
ease evaluation which included CAT scans of
the head, neck, thorax, and abdomen, bone
scan, and full chemical profile. All of these
studies continued to show only the primary left
renal mass and the solitary laryngeal lesion,
both without change. Six months after his ini-
tial presentation the patient underwent a total
laryngectomy. Obvious residual metastatic
clear cell carcinoma was seen in the submucosal

UROLOGY i AUGUST1992 / VOLUME40,NUMBER2 159


FICURE~. (A) CT scan of neck at level of true cord.
Exophytic mass displacing left true cord medially
(arrows). Destruction of arytenoid and cricoid carti-
lage is also seen (arrowheads) in addition to destruc-
tion of thyroid cartilage (curved arrow). (B) Con-
trast-enhanced CT scan of abdomen demonstrates
solid, partially necrotic 6 x 8 cm-mass originating
from inferior aspect of left kidney (arrows); l-cm
cyst is seen in medial aspect of right kidney.
tissues. Three months later a repeat evaluation
again failed to demonstrate any evidence of
either locally recurrent disease in the neck, pro-
gression of the primary left renal tumor, or new
metastases.
The patient subsequently underwent a left
radical nephrectomy including a para-aortic
lymphadenectomy. The final pathologic
diagnosis was renal cell carcinoma, clear cell
type, confined to the kidney. The patient’s post-
operative course was entirely without compli-
cation. He is now five years status post nephrec-
tomy and five and one-half years since his initial
presentation. He remains clinically free of dis-
ease being re-evaluated for evidence of both lo-
cally recurrent disease as well as new metastases
every three months.
160
Comment
The natural history of renal cell carcinoma is
certainly unpredictable for the individual pa-
tient. Despite the increased incidence of finding
incidental, localized and therefore unexpected
renal cancers by the newer imaging modalities,
approximately 40 percent of malignant renal
tumors will have multiple metastases at the
time of presentation. Equally disheartening for
the urologist is the extremely poor prognosis
that this advanced stage of renal cell carcinoma
portends. Indeed, the median survival of meta-
static renal carcinoma is less than eight months,
with 80 percent of patients dead within one
year and virtually no survivors at two years.
Furthermore, in 50 percent of those patients
surgically treated for clinically “curable” dis-
ease metastases will develops; yet, prolonged
survival is documented. Two reports in the mid-
1960s demonstrated the delayed clinical onset
of metastatic disease of over thirty years.7,8
The role of the “adjunctive nephrectomy” has
been discussed in detail in the literature. Ini-
tially done for purposes of symptomatic pallia-
tion, it is now rarely performed except in the
context of specific experimental protocols
where large amounts of tissue are required or
where debulking of tumor volume is thought to
be of some benefit. There does not appear to be
any statistical survival advantage in performing
a nephrectomy in the presence of multiple
metastatic lesions.e-12 The exception to this
general rule may be multiple osseous metastases
where adjuvant nephrectomy has been re-
ported to significantly prolong life.13
Solitary metastasis from a renal cell car-
cinoma is a rare finding and reported in ap-
proximately 2 percent of large series. It is in this
small subgroup of those patients with metas-
tases that aggressive surgical management ap-
pears to offer the best possibility for long-term
survival and possibly cure.14-le Following re-
moval of the primary tumor and a solitary me-
tastasis 45 percent of patients survived three
years and 34 percent at least five years.17
Solitary synchronous metastasis from renal
cell carcinoma that present clinically with signs
and symptoms referable to the metastasis, in
the context of an undiagnosed renal cell car-
cinoma primary, as exemplified by this case, are
even more uncommon. There are 110 cases re-
ported in the literature.rs Of these, only ap-
proximately 10 percent of patients are alive af-
ter two years. This poor outcome in part may
be secondary to a lack of surgical aggressiveness
UROLOGY I AUGUST1992 / VOLUME40,NUMBER2
in the management of these patients. For our
patient, who has already outlived the predicted
survival for an individual with metastatic renal
cell carcinoma, and others with an isolated me-
tastasis, the surgically aggressive approach ta-
ken in this case seems justified.
Fox Chase Cancer Center
7701 Burholme Avenue
Philadelphia, Pennsylvania 19111
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