Epistaxis presenting as sentinel feature of metastatic renal cell carcinoma: A case report and review of literature

Abstract

About 30% of all newly diagnosed renal cell carcinoma (RCC) patients present with synchronous metastatic disease. Usual organs of involvement are lung (75%), soft tissues (36%), bone (20%), liver (18%), cutaneous sites (8%), and central nervous system (8%). Metastases to the paranasal sinuses (PNS) are relatively common and may be a part of synchronous multiorgan involvement or present in follow-up after radical nephrectomy (metachronous); but primary presentation as isolated paranasal mass before the diagnosis of RCC is extremely rare. Here, we report a case of 74-year-old female presented with epistaxis and nasal obstruction. On evaluation by magnetic resonance imaging (MRI), a heterogeneously enhancing mass was found involving left PNS. Biopsy from mass revealed clear cell RCC. Later on, contrast-enhanced computed tomography (CECT) of chest, abdomen, and pelvis showed enhancing mass from the upper pole of the left kidney with no evidence of metastasis elsewhere. The patient was started on pazopanib 800 mg once a day. At 6 months follow-up scan, there was a partial response at both primary as well as metastatic site.

Keywords: Epistaxis; metastatic renal cell carcinoma; paranasal sinus; tyrosine kinase inhibitor.

Figure 1

MRI head and neck showing T2 hyperintense lesion involving left frontal and ethmoid sinus with anterior cranial fossa extension

Figure 2

Rinoscopy showing proliferative mass

Figure 3

Diffuse spread of tumor cells in sheets, glands, and trabeculae having vacuolated clear cytoplasm and rounded nuclei and prominent nucleoli consistent with clear cell RCC (H & E ×40)

Figure 4

Tumor cells positive of RCCag (×40)

Figure 5

Coronal section CECT of the abdomen and pelvis showing heterogeneous enhancing mass at the mid and lower pole of the left kidney