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Letter to Editor
Bilateral renal cell carcinoma presenting as fracture tibia a
Sir, A 75-year-old man presented to the orthopedic out-patient department (OPD) with acute worsening of his chronic leg pain. He reported a 6 months history of gradually worsening right lower leg pain with difficulty in walking for past few days. It was not associated with back pain or any history of trauma, weakness, paresthesia, or numbness in the right lower limb. There was no history of bladder or bowel incontinence. The patient reported weakness, fatigue, vague lower abdominal pain, and weight loss over for the past few months. His past medical and surgical history was insignificant. He was poorly built and nourished and had mild pallor. Local examination revealed swelling, tenderness, erythema, and raised temperature over the distal portion of the right leg. On per abdominal examination, diffuse masses were palpated in the right and left lumbar region. X-ray leg revealed an expansile lytic lesion in the distal right tibia associated with an undisplaced fracture [Figure 1a]. Magnetic resonance imaging (MRI) of the right leg revealed a 5.5 × 2.5 × 2.3 cm T2 hyperintense to isointense soft tissue intensity lesion located in the distal third shaft of tibia with cortical erosion and destruction; suggestive of metastasis [Figure 1b]. Radionuclide whole body scan showed increased tracer uptake in the lower third shaft of right tibia with central photon deficiency. Physiological distribution of tracer was seen in rest of the skeleton [Figure 1c]. The above features favored a metastatic lesion. Additional imaging studies were undertaken to hunt for the primary lesion. His chest X-ray was unremarkable. Computed tomography (CT) scan of abdomen and pelvis revealed a 15.4 × 13.1 cm, lobulated, heterogeneously enhancing mass lesion in right kidney with foci of calcification and necrosis. The mass was extending in right renal vein and inferior vena cava. A similar lesion measuring 7.8 × 7.5 cm was seen arising from lower pole of left kidney [Figure 1d]. The liver showed three focal lesions measuring 3.7, 2.9, and 2.4 cm, respectively. His routine hematological and biochemical investigations, renal function tests, and prostatic specific antigen levels were within normal limits. Based on the above findings, a final diagnosis of bilateral renal cell carcinoma (RCC) with metastasis to liver and right tibia was offered. 316
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Figure 1: (a) X-ray leg revealing an expansile lytic lesion in the distal right tibia associated with an undisplaced fracture. (b) MRI of the right leg showing a 5.5 × 2.5 × 2.3cm T2 hyperintense to isointense soft tissue intensity lesion located in the distal third shaft of tibia with cortical erosion and destruction. (c) Radionuclide whole body scan showing increased tracer uptake in the lower third shaft of right tibia with physiological distribution in rest of the skeleton. (d) CT scan of abdomen and pelvis showing bilateral renal masses
Internal fixation of the tibial fracture with intramedullary interlocking nailing was done. Intraoperatively, a tiny biopsy was taken from the lytic lesion and sent for histopathology. Microscopic examination revealed a tumor comprising cells arranged in nests and cords separated by delicate fibrovascular stroma. The cells had abundant clear cytoplasm and hyperchromatic nuclei and were infiltrating the bony trabeculae [Figures 2a and b]. Immunohistochemical examination confirmed the diagnosis of metastatic RCC. The postoperative period was uneventful and the patient was further referred to a tertiary care center for the treatment of RCC. 29–57% of the patients with RCC develop metastases by the time the tumor is diagnosed. Of these, between 0.7 and 2% have a solitary bony metastasis.[1] The most common sites of metastatic RCC are the lung (75% of the cases), liver (40%), bone (40%), soft tissue (34%), and pleura (31%). [2] The bones most often involved are the pelvis and femur, but there is also a predilection for sternum, scapula, and small bones of hands and feet.[3] Involvement of the tibia is rare. Symptoms include severe pain, neurologic compromise, and pathological fracture. [4] Bony metastases from RCC are purely lytic, expansile, and highly vascular. [2] They have an unpredictable response to chemotherapy and radiotherapy. [1] Patients with widespread bony metastases may benefit from internal fixation and Indian Journal of Cancer | July-September 2012 | Volume 49 | Issue 3
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Figure 2: (a) Microscopic examination revealing a tumor comprising cells arranged in nests and cords separated by delicate fibrovascular stroma (H and E, ×100). (b) Tumor cells with abundant clear cytoplasm and hyperchromatic nuclei (H and E, ×400)
packing with cement. Patients with solitary bony metastasis should be managed by reconstructive surgery with an endoprosthetic replacement. These patients have a better prognosis following nephrectomy.[1] While metastases are notoriously associated with poor outcome, solitary bone lesions have increased associated survival when compared to multiple bony lesions or a combination of bone and other organ involvement.[5] The present case is rare because it presented as tibial fracture, which surprisingly on further investigation turned out to be a metastasis from incidental bilateral RCC. Anand M, Deshmukh SD, Gulati HK, Devasthali DA1 Departments of Pathology and 1Orthopedics, Smt. Kashibai Navale Medical College and General Hospital, Narhe, Pune, Maharashtra, India
References 1. 2. 3. 4. 5.
Baloch KG, Grimer RJ, Carter SR, Tillman RM. Radical surgery for the solitary bony metastasis from renal-cell carcinoma. J Bone Joint Surg Br 2000;82:62-7. Setlik DE, McCluskey KM, McDavit JA. Best cases from the AFIP: Renal cell carcinoma manifesting as a solitary bone metastasis. Radiographics 2009;29:2184-9. Ordonez NG, Juan R. Urinary tract. In: Rosai J, editor. Rosai and Ackerman’s Surgical Pathology. 9th ed. New Delhi (India): Thompson Press; 2004. p. 1251-64. Weber KL, Doucet M, Price JE. Renal cell carcinoma bone metastasis: Epidermal growth factor receptor targeting. Clin Orthop Relat Res 2003;415: S86-94. Parada SA, Franklin JM, Uribe PS, Manoso MW. Renal cell carcinoma metastases to bone after a 33-year remission. Orthopedics 2009;32:446. Access this article online Quick Response Code:
Correspondence to: Dr. Mani Anand, E-mail:
[email protected]
Website: www.indianjcancer.com DOI: 10.4103/0019-509X.104500 PMID: *******
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