Metastases in the paranasal sinuses are rare; renal cell carcinoma is the most common cancer that metastasizes to this region. We present the case of a patient with a 4-month history of a rapidly growing mass of the nasal pyramid following a nasal trauma, associated with spontaneous epistaxis and multiple episodes of hematuria. Cranial CT scan and MRI showed an ethmoid mass extending to the choanal region, the right orbit, and the right frontal sinus with an initial intracranial extension. Patient underwent surgery with a trans-sinusal frontal approach using a bicoronal incision combined with an anterior midfacial degloving; histological exam was compatible with a metastasis of clear cell renal cell carcinoma. Following histological findings, a total body CT scan showed a solitary 6 cm mass in the upper posterior pole of the left kidney identified as the primary tumor. Although rare, metastatic renal cell carcinoma should always be suspected in patients with nasal or paranasal masses, especially if associated with symptoms suggestive of a systemic involvement such as hematuria. A correct early-stage diagnosis of metastatic RCC can considerably improve survival rate in these patients; preoperative differential diagnosis with contrast-enhanced imaging is fundamental for the correct treatment and follow-up strategy.
Renal cell carcinoma (RCC) is the most common kidney cancer, with approximately 35,000 new cases in the US each year [
We present the case of a patient with a single, rapidly growing mass in the upper portion of the nasal pyramid, with late, postnasal surgery histological diagnosis of renal cell carcinoma that allowed primary tumor identification.
A 72-year-old man was referred to our institution with a 4-month history of a voluminous mass in the upper portion of the nasal pyramid following a nasal trauma. He had been treated a few weeks earlier at a different ENT service for a massive spontaneous epistaxis. The patient also reported a long history of hematuria, previously attributed to renal tuberculosis occurring over 40 years before. At admission, a cranial CT scan showed a large soft tissue ethmoid mass extending to the right and left choanal region, the right orbit, the right frontal sinus, and an initial intracranial extension with partial erosion of the crista galli. MRI confirmed the evidence found at computed tomography (Figure
MRI in the axial (a) and sagittal (b) planes showing a soft tissue ethmoid mass extending to the right and left choanal region, the right orbit, the right frontal sinus, and an initial intracranial extension with partial erosion of the crista galli.
The patient underwent surgery with a trans-sinusal frontal approach using a bicoronal incision combined with an anterior midfacial degloving to excise the mass; however, the right orbital and especially the initial intracranial extension did not allow a complete removal of the neoplasm. Considerable bleeding occurred during surgery. The histological exam revealed a clear cell renal cell carcinoma (Figure
The excised mass; histological exam was consistent with a clear cell renal cell carcinoma.
Nasal cavity and paranasal sinus cancers are usually primary tumors. Metastases to the paranasal sinuses are rarely found; among them, renal cell carcinoma is the most common cancer to metastasize to this region (49%) followed, respectively, by bronchus, urogenital ridge, breast, and gastrointestinal tract [
RCC tumor cells can reach the sinonasal region via two routes: the first includes inferior vena cava, lungs, heart, and the maxillary artery; the second involves the communication of the avalvular vertebral venous plexus and the intracranial venous plexus [
Metastatic RCC to the sinonasal district has been reported as the presenting sign of this disease in a few cases [
The key point in RCC presenting with a sinonasal metastasis is differential diagnosis with primary tumors such as adenocarcinomas, angiofibromas, hemangiopericytomas, melanomas, hemangiomas, metastatic tumors from the breast and lungs, and, more rarely, systemic diseases such as Wegener’s and midline granulomas [
In this case, CT scan allowed the identification of a neoformed paranasal sinus mass; however, only histological exam identified the mass as a metastasis of RCC and led to the execution of total body CT scan to identify primary tumor. Although difficult, differential preoperative diagnosis is fundamental for the correct treatment and follow-up strategy; contrast-enhanced imaging plays a central role since a preoperative biopsy of the nasal mass may be difficult in these patients due to massive recurring bleeding and, in some cases, may result in only necrotic tissue inconclusive on histopathology [
Prognosis of metastatic RCC is poor; however, a correct early-stage diagnosis of metastatic disease can considerably improve survival rate: literature reports that excision of solitary metastatic lesion of renal cell carcinoma following nephrectomy results in a 41% survival at 2 years and 13% survival at 5 years [
Although metastatic RCC is often resistant to chemotherapy and radiotherapy, numerous agents targeting VEGF and non-VEGFR pathways should be taken into account for the treatment of advanced RCC. Multitargeted VEGF tyrosine kinase inhibitors (TKIs) include sorafenib [
In conclusion, metastatic renal cell carcinoma should always be suspected in patients with nasal or paranasal masses, especially if associated with symptoms suggestive of a systemic involvement such as hematuria; early-stage diagnosis of metastatic disease can considerably limit perioperative complications and improve survival rate.
The authors declare that they have no competing interests.