Late-Term Presentation of Metastatic Renal Cell Carcinoma to the Sinonasal Cavity

Renal cell carcinoma is a relatively rare tumor, accounting for 3% of all adult malignancies. Metastatic disease is theorized to occur through hematogenous spread and to occur most often to bone, lung, and liver. However, the head and neck area has been reported as a site of metastasis in up to 15% of patients. Metastatic disease tends to present at or near the time of initial diagnosis, with only a handful of cases reporting metastatic disease greater than 10 years after primary tumor treatment. Sinonasal metastases often present with nasal obstruction and epistaxis, and these symptoms should raise concern for metastatic disease in any patient with a nasal mass and history of renal cell carcinoma. Workup should include pre-biopsy imaging. As these lesions are highly vascular, biopsy should be performed in a controlled setting. Pathologic specimens will demonstrate clear cytoplasm and show cells arranged in nests. AE1, AE3, and CAM 5.2, as well as RCC antigen staining, are positive. Once the diagnosis is established, local radiation therapy has been the treatment of choice, with or without concurrent chemotherapy. Surgical resection of the mass has been controversial, and usually reserved for debulking after primary radiotherapy.

We present the case of a 53-year-old gentleman with a 4-month history of left-sided nasal congestion and facial pressure without epistaxis. Greater than 10 years prior to presentation, he had undergone a right nephrectomy for a T1 renal cell carcinoma that required no further therapy. On examination, nasal endoscopy was remarkable for a mass in the left nasal cavity. A CT scan revealed a vascular, expansile polypoid soft tissue mass within the region of the left superior turbinate and sphenoethmoid recess, extending into the sphenoid sinus and choana. It measured 4 × 3 × 2 cm and exhibited bony remodeling along the medial maxillary wall. The initial biopsy resulted in extensive bleeding, and pathology was suggestive of a benign process, such as hemangioma. Therefore, preoperative embolization and subsequent excision of the mass was performed. The entirety of the mass was removed endoscopically en bloc with minimal intraoperative bleeding. The final pathology was consistent with renal cell carcinoma. The patient received postoperative radiation therapy and is completely disease free 1 year after resection of the metastasis.

As a rare entity, renal cell carcinoma metastatic to the sinonasal cavity has been traditionally treated with radiation with or without chemotherapy. We report a patient who underwent preoperative embolization, complete surgical resection of the mass, and postoperative radiation, who is currently free of disease.