Axillary skin metastasis of renal cell carcinoma—Case report

Highlights

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Metastatic renal cell carcinoma is encountered in about 25% of cases.
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Metastases are usually found in lymph nodes, lungs, liver, bones and brain.
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Sometimes the metastasis can have unusual sites.
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We present a 35 year old patient with a painful left axillary mass, appeared 2 years after nephrectomy for a left renal cell carcinoma.
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Although the patient received tyrosin kinase inhibitors the metastasis appeared two years after treatment in an unusual site – axilla.

Abstract
Introduction

Metastatic diseases are seen in approximately 25% of all cases with renal cell carcinoma and sometimes they can appear in unusual sites.
Case presentation

We present a 35-year old patient with a painful left axillary mass which causes the functional impairment of the left arm. The axillary mass appeared 2 years after the nephrectomy performed for a left renal cell carcinoma. Numerous metastases have been identified through CT scans during the postoperative evolution of the disease for which the patient underwent adjuvant therapy with tyrosine-kinase inhibitors.
Discussions

Particular to our case is not just the rare metastatic site but also the fact that the tumor appeared despite the adjuvant therapy with tyrosine-kinase inhibitors. Unfortunately, the prognosis of metastatic RCC with skin metastasis is in most cases unfavorable.
Conclusions

We believe that our case could add more information to subsequent measures, complete the frame of rare oncologic cases and consolidate the data published on the topic so far.

Renal cell carcinoma (RCC) accounts for approximately 2–3% of cancers, with a worldwide increasing incidence of about 2% per year. 90% of all cases of renal cell carcinoma are represented by clear cell carcinoma, which has a 91% chance of 5-year cancer specific survival rate for T1 RCC, which decreases to 32% for T4 RCC [1]. Metastatic diseases are seen in about 25% of cases of renal cell carcinoma and sometimes occur as first manifestations of the disease. The most common sites for metastasis after RCC are as follows: lungs, lymph nodes, bones, liver, brain and the adrenal glands [[2], [3]]. Skin metastases of renal cell carcinoma are very rarely seen (1–3.3%) and they usually occur as a late manifestation of the disease [[2], [4]]. The usual sites for skin metastases quoted in the medical literature are the head (scalp), the neck and the trunk [4]. We report the case of a male patient with axillary skin metastasis of clear RCC which appeared 2 years after nephrectomy.

We present a 35-year old patient hospitalized for left axillary pain and functional impotence of the left arm, due to a red protrusive skin tumor of 4/3 cm. The patient is known in our clinic for a left kidney tumor (clear cell carcinoma – T3aN0M0) with a thrombus in the left renal vein diagnosed two years before. At that time, the patient underwent left radical nephrectomy, performed through a peritoneal approach. The patient was closely monitored postoperative and one year later, a CT scan revealed multiple left pulmonary lumps located in the vicinity of the pleura, ranging from 5 to 17 mm in size. The patient’s case was classified in the intermediate-risk group according to the Memorial Sloan-Kettering Cancer Center (MSKCC) Risk Group [1] and immediately benefited of tyrosine-kinase inhibitors (Sunitinib – Sutent). He was closely re-assessed through clinical and imaging examinations every 6 months.

From a clinical point of view, the tumor is described as brown-reddish with a firm consistency, mobile to the deep tissues and with a normal temperature at surface. The axillary ultrasound reveals a left tumor of 44/35/29 mm, with solid consistency and many vascular branches noticed by means of Doppler module (Fig. 1, Fig. 2).

The current chest CT scan reveals multiple lung nodules located in the left inferior lobe, with significant progression (34/44 mm compared to 25/20 mm in the last examination – six months earlier), atelectasis of the anterior inferior pulmonary segment and multiple mediastinal lymph nodes, also with significant dimensional progression. Multiple lymph nodes located laterally to the aorta with dimensions of approximately 34/33 mm are revealed in the abdominopelvic cavity, along with an enlarged right hepatic lobe and a thin lamina of ascites fluid in the Douglas space. The other abdominal organs appear normal.

We performed the surgical excision of the tumor that had numerous blood vessels with radial development. Macroscopically, the histopathological result reveals a tumor of about 4/3/2 cm in size covered by skin, which displays small white lumps in several portions of it. Microscopically are detected neoplastic cells that had similar characteristics to Fuhrman grade III clear cell carcinoma, which correlates with the histopathological result of the left kidney tumor resected 2 years before.