Posts
Abstract
Cutaneous metastases from renal cell carcinoma (RCC) are uncommon, but may be painful and deforming. A review of the English language literature yields no references regarding the use of radiotherapy in the palliation of cutaneous RCC metastases. We report the first documented case of a patient with a single RCC facial metastatic nodule treated with hypofractionated electron beam radiotherapy followed by administration of sorafenib. The patient achieved a complete resolution of the cutaneous metastasis.
Introduction
Renal cell carcinoma (RCC) represents approximately 85 percent of all primary renal neoplasms. Up to one third of patients with RCC present with metastatic disease; lung and bone are the most common sites. Cutaneous metastases from RCC are uncommon, with an incidence of approximately 2.4-6.4 percent.[1,2] The clinical appearance of cutaneous metastases from RCC has been described as painless or painful nodules, plaques, or pulsatile masses, ranging from flesh-colored to violaceous.[3-6]
Historically, renal cell carcinoma has been regarded as a radio-resistant tumor when treated with radiotherapy using standard fractions of 180-200 cGy. Advances in stereotactic radiotherapy over the past decade have made possible the safer delivery of fewer, but larger doses of radiation, termed hypofractionation, to deeply seated tumors. Stereotactic radiosurgery to metastatic RCC sites in the brain and extracranial sites has resulted in higher than 85 percent local control rates, with approximately one fifth of metastases achieving a complete response.[7-12] Therefore, the stereotactic literature supports the notion that hypofractionation is more effective than standard fractionation in RCC.
A review of the English-language literature yields no references regarding the use of radiotherapy in the palliation of cutaneous RCC metastases. We report the first documented case of a patient with a single RCC facial metastasis treated with hypofractionated electron beam radiotherapy followed by the administration of sorafenib. The patient achieved a complete resolution of the metastatic nodule.
Clinical Synopsis
A 51-year-old man had an 8 month history of weakness, fatigue, and 15 pound weight loss. Prior to admission to the hospital, he experienced several days of hematuria. A CT scan of the abdomen showed a large left renal mass measuring 9.3 x 7.2 cm in the axial plane, replacing the left upper kidney. The scan also showed invasion of the perinephric fat, left renal vein, and inferior vena cava (IVC), at least to the level of the intrahepatic IVC. Moderate adenopathy in the left paraaortic region and left renal hilum were demonstrated. A CT scan of the chest revealed multiple pulmonary metastases. There was significant dilation of the inferior vena cava due to multiple thrombi. A fine needle aspiration (FNA) of the left kidney mass revealed renal cell carcinoma, clear cell type (Fig. 1). Immunoperoxidase studies showed the tumor cells to be positive for vimentin, epithelial membrane antigen, and AE1-3 pancytokeratin. The immunoprofile, Oil Red-O positivity, and morphology were consistent with clear cell renal cell carcinoma. The pathologic slides were reviewed at the Memorial Hospital for Cancer and Allied Diseases in New York, NY and the diagnosis remained unchanged. The patient was deemed unresectable and did not undergo surgery. The patient had completed 4 cycles of IL2 seven months after diagnosis, but further IL2 therapy was discontinued because of side effects during the infusion of the fifth cycle.
The patient noticed a left facial preauricular skin nodule that appeared approximately 10 months after diagnosis. The nodule grew slowly and subsequently became painful. The nodule was violaceous, fixed, and pulsatile. An FNA of the nodule showed malignant cells, consistent with metastatic renal cell carcinoma (Fig. 2). The atypical cells were positive for pancytokeratin (AE1/3), vimentin, and EMA. A CT scan of the head revealed the depth of the lesion (Fig. 3). The patient was referred for palliative radiotherapy. At the time of clinical examination, the nodule measured close to 2 cm in diameter at its base. The patient received a palliative hypofractionated course of electron beam radiotherapy consisting of 13 fractions of 375 cGy for a total of 4875 cGy. A custom bolus made from alginate impression material was placed over the lesion to create better dose homogeneity. A planning CT scan with the bolus in place was obtained to help select the electron energy that would cover the tumor and minimize radiation to the left temporal lobe (Fig. 4). The electron field encompassed the lesion with a 2 cm peripheral margin.
Because of transient mental status changes, an MRI scan of the brain was obtained the day radiotherapy was completed, but there was no evidence of brain metastases or edema. Incidentally, the MRI scan showed that the facial nodule was flush with the skin by the end of treatment (Fig. 5) with effective palliation. Fig. 6 illustrates the visual evolution of the lesion.
One week after completing radiotherapy the patient was started on sorafenib. He received sorafenib intermittently for the next 9 months. At the 2 month follow-up visit the facial metastatatic site was flat and painless, but it was unclear whether there was still some residual disease (Fig. 6, panel D). The next visit was 4 months later and a complete response was evident (Fig. 6, panel E); some hyperpigmentation remained at the irradiated area. The patient died of progressive disease 10 months after the completion of radiotherapy, but had enjoyed durable palliation of his skin lesion.
Registration of your site
