Renal cell carcinoma (RCC) commonly metastasizes to the lung, liver, bones, and brain; however, cutaneous metastases remain rare with few reported cases. Since RCCs have the propensity to metastasize to highly vascular areas, the scalp and skin of the head and neck region are likely locations for cutaneous metastases. We report a rare case of a large, exophytic, cauliflower-like, hemorrhagic, metastatic mass of the posterior neck. This is the first reported case of a head and neck cutaneous RCC metastasis treated with endovascular embolization prior to surgical resection. Due to the increased vascularity of RCCs and risk of excessive hemorrhage during resection, adjunctive embolization of cutaneous head and neck metastasis may have a role. Essential characteristics to our treatment strategy are discussed with a review of pertinent literature.
Renal cell carcinomas (RCC) commonly metastasizes to the lung, liver, bones, and brain; however, cutaneous metastases remains rare with few reported cases. Since RCCs have the propensity to metastasize to highly vascular areas, the scalp and skin of the head and neck region are likely locations for cutaneous metastases. We report a rare case of a large, exophytic, cauliflower–like, hemorrhagic, metastatic mass of the posterior neck. This is the first reported case of a head and neck cutaneous RCC metastasis treated with endovascular embolization prior to surgical resection. Essential characteristics to our treatment strategy are discussed with a review of pertinent literature.
A man in his 60s presented to the emergency room with large, exophytic posterior neck mass continuous with a yellow-tan nodule in the subcutaneous tissue measuring a 5.7×5.0 cm that was bleeding (
On examination, the neck mass was cauliflower-shaped, grey-tan in color, rubbery in consistency, with some bleeding originating from the necrotic center (
The patient was counseled about these findings and given the extensive arterial supply, prior spontaneous hemorrhage, the surgical team requested preoperative embolization prior to resection. Direct puncture of the lesion was considered given the long distance and tortuosity of the primary occipital artery feeders. However, the unusually large diameter of the occipital artery feeders and safer hemostatic control associated with a femoral puncture influenced us to proceed with a femoral approach transarterial occipital artery embolization.
The left external carotid feeders were selectively catheterized using a Scepter (MicroVention, Aliso Viejo, CA, USA) microcatheter over a Synchro 14 microwire (Stryker, Freemont, CA, USA). Partial embolization was performed using a slow controlled injection of Onyx-18 (EV3, Irvine, CA, USA) (
The patient had an uncomplicated immediate postoperative period and reported improvement in local symptoms. Surgical resection was then performed with less than 50 mL of blood loss. Microscopic examination was consistent with RCC and the gross specimen demonstrated large areas of necrosis and embolization material (
RCCs account for 2% to 3% of solid malignancies in adults with 25% to 30% of patients having metastatic disease at the initial diagnosis; furthermore, about 90% of new diagnoses are discovered due to symptoms related to the metastatic disease [
The typical hematologic pathway favors the lungs via the vena cava system, hence those with head and neck metastasis often have pulmonary disease burden as well [
Differential diagnosis for a highly vascular tumor includes angioma, metastasis, pyogenic granuloma, sweat gland tumor, angiosarcoma, Kaposi sarcoma, basal cell carcinoma, amelanotic melanoma, and sebaceous carcinoma. Skin lesions may mimic benign dermatological conditions and have patterns of nodular, inflammatory, sclerodermoid, and zosteriform findings, with nodular patterns being the most common [
Treatment of metastatic RCC includes nephrectomy and chemotherapy (angiogenesis/multikinase inhibitors, interferon). Cutaneous lesions often require surgical removal and at times additional radiotherapy [
Onyx was used in this case as its non-adhesive nature provided slower, intermittent and controlled injection, minimizing the potential risk of unintentional embolic material traveling into anastomotic vessels. In this case, bilateral occipital arteries are the major contributors of tumor vascularity and potential anastomosis into the VA and the stylomastoid branch need to be carefully monitored [
Preoperative embolization in our case allowed successful removal of the lesion with clear margins and minimal blood loss. Although preoperative embolization of vascular tumors is common, it has not been described for treatment of a cutaneous metastatic lesion. Embolization may be a useful preoperative surgical technique to aid with resection for similar presenting cutaneous vascular metastasis.
In conclusion, cutaneous RCC metastasis is rare but can present as a large hemorrhagic neck mass. Endovascular embolization followed by surgical resection is an effective method to treat highly vascularized cutaneous RCC metastasis. This description of a preoperative cutaneous head and neck tumor embolization highlights the use of primary transarterial approach embolization using a liquid embolic agent via the primary feeder despite extensive arterial supply. Cutaneous metastasis; however, have a poor prognosis and management decisions need to be individualized.
None.
Consent was obtained by patient’s spouse for publication of this report.
The authors have no conflicts to disclose.
Concept and design: MGK, LAT, VR, and MC. Analysis and interpretation: DEK. Data collection: DEK, MGK, LAT, SP, VR, and MC. Writing the article: DEK, MGK, and LAT. Critical revision of the article: DEK, MGK, LAT, SP, VR, and MC. Final approval of the article: DEK, MGK, LAT, SP, VR, and MC. Statistical analysis: none. Obtained funding: none. Overall responsibility: DEK, MGK, LAT, SP, VR, and MC.
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