Sinonasal Metastases of Clear-Cell Renal Cell Carcinoma: Two Case Reports and Literature Review

Metastases to nasal cavity and paranasal sinuses are unusual, clear-cell renal cell carcinoma (ccRCC) being the most common tumor that metastasizes to this region (49–54% in different series). It could present in a patient with a history of kidney cancer, even years after nephrectomy; however, it could present as an initial manifestation of the primary tumor. There should be a high degree of suspicion in patients with a previous history of malignancy who present with new sinonasal symptoms such as nasal obstruction or unilateral epistaxis.

A 64-year-old female had a history of headache, nasal obstruction greater in her left side, epistaxis, decreased visual acuity and diplopia. Her physical examination showed left ptosis, III and VI cranial nerve compromise and bilateral papilledema greater in her left side, no clear evidence of nasal tumor at examination. Her brain magnetic resonance imaging (MRI) revealed an osteolytic mass with posterior ethmoidal, sphenoid and clivus involvement ([Fig. 1]). An endoscopic biopsy was performed. Meanwhile, the patient suffered a severe abdominal pain with vomiting, lethargy, and elevated inflammatory parameters. A computed tomography (CT) showed a solid hypervascularized right renal mass of 8.7 cm without vascular involvement and 9-mm pulmonary metastases. The patient was diagnosed with a kidney tumor with necrosis and bacterial infection, therefore a right radical nephrectomy was performed. During hospitalization, the nasal tumor biopsy result was obtained. Pathology showed dense fibroconnective tissue with clear cells with sharp edges and prominent nucleoli, hemorrhagic and necrotic surface areas. The immunohistochemical study was positivity for AE1/AE3 cytokeratins and CD10, and negative for S100, supporting the diagnosis of ccRCC metastasis. Palliative radiotherapy treatment was decided given the widespread extension of the primary tumor.

An 84-year-old male with history of right radical nephrectomy 6 years ago from RCC, chronic kidney disease and pacemaker user. He presented with a 3-month history of pulsatile headache and recurrent right-side epistaxis, requiring posterior packing and 2 units of red blood cell transfusion. On physical examination, a purplish-red pulsatile mass was identified in the middle meatus. A CT revealed a vascularized tumor involving right maxillary sinus, right anterior and posterior ethmoidal, lamina papyracea erosion without extension to the skull base ([Fig. 2]). A biopsy was taken in-office without incidents. Pathology showed respiratory epithelium with squamous metaplasia, cells with hyperchromatic nuclei and abundant cytoplasm. Immunohistochemistry was positive for CD10 and RCC and negative for CK7, CK20, and CD117, supporting diagnosis of ccRCC metastasis. A palliative tumor resection was performed as treatment for recurrent epistaxis.

The definitive diagnosis of a nonspecific nasal tumor is through the histological and immunohistochemical study of the biopsy. In general, the prognosis of ccRCC metastases is poor due the late diagnosis and disseminated nature of the disease, so treatment is usually palliative with surgery to prevent epistaxis, airway obstruction, or cranial nerves compression. In unresectable cases, radiotherapy or immunotherapy is an option.

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Publication History

Article published online:
12 February 2021