Severe paraneoplastic hypereosinophilia in metastatic renal cell carcinoma

Abstract

Background: Renal cell carcinoma can cause various paraneoplastic syndromes including metabolic and hematologic disturbances. Paraneoplastic hypereosinophilia has been reported in a variety of hematologic and solid tumors. We present the first case in the literature of severe paraneoplastic hypereosinophilia in a patient with renal cell carcinoma.

Case presentation: A 46 year-old patient patient with a history of significant weight loss, reduced general state of health and coughing underwent radical nephrectomy for metastasized renal cell carcinoma. Three weeks after surgery, the patient presented with excessive peripheral hypereosinophilia leading to profound neurological symptoms due to cerebral microinfarction. Systemic treatment with prednisolone, hydroxyurea, vincristine, cytarabine, temsirolimus and sunitinib led to reduction of peripheral eosinophils but could not prevent rapid disease progression of the patient. At time of severe leukocytosis, a considerable increase of cytokines associated with hypereosinophilia was measurable.

Conclusions: Paraneoplastic hypereosinophilia in patients with renal cell carcinoma might indicate poor prognosis and rapid disease progression. Myelosuppressive therapy is required in symptomatic patients.

Figure 1

Preoperative imaging showing a hypervascularized renal tumor with a level I tumor thrombus in the vena cava.

Figure 2

A: axial FLAIR image shows multifocal cortical and subcortical hyperintense lesions (arrows) presumed to be of embolic origin. B and 2 C: axial diffusion-weighted image-DWI (b-value, 1,000 s/mm²) (Figure 2B) and corresponding apparent diffusion coefficient (ADC) map demonstrate marked water diffusion restriction in acute embolic ischemia (arrows). Note the drop in signal intensity on ADC-map (Figure 2C, arrows).

Figure 3

Leukocytes and eosinophilic granulocytes count. Lower bars show doses of applicated drugs.

Figure 4

Peripheral blood smear hypereosinophilia with hypersegmented forms.

Figure 5

Progression of retroperitoneal tumor mass after radical nephrectomy within 4 weeks (coronal CT-images).

Figure 6

A and B: Resection specimen of the right kidney and adrenal gland reveals a poorly, in parts sarcomatoid differentiated renal carcinoma. Gross examination shows infiltration of the adenal gland, renal plevis and macroscopic vascular invasion. A: (H&E, 200×) Spindle like shaped tumor cells with small eosiniphilic cytoplasmn and pleomophic nuclei with eosinophilic nucleoli. Interspersed small amounts of histiocytes and small lymphocytes. The amount of eosinophils is not elevated in viable tumor areas. B: (H&E, 400×): Areas of tumor necrosis withs rims of histiocytes and increased number of eosinophils.