Oral Oncology EXTRA (2004) 40 50–53

http://intl.elsevierhealth.com/journal/ooex

CASE REPORT

Metastatic renal cell carcinoma presenting as

a clear cell tumour in the head and neck region
P.R. Jayasooriyaa, I.A.N.S. Gunarathnaa, A.M. Attygallab,
W.M. Tilakaratnea,*

a
Department of Oral Pathology, Faculty of Dental Sciences, University of Peradeniya,
Peradeniya, Sri Lanka
b
Department of Oral Surgery, Faculty of Dental Sciences, University of Peradeniya, Peradeniya, Sri Lanka

Received 15 December 2003; accepted 22 December 2003

KEYWORDS Summary Renal cell carcinoma (RCC) is the most frequent urological malignancy in
adults and has a male preponderance. It accounts for approximately 3% of adult
Renal cell carcinoma; malignancies and 90–95% of neoplasms arising from the kidney. RCC usually
Metastasis; metastasizes to lungs, bone and regional lymph nodes but very rarely to the head
Clear cell tumours and neck region. The following report is based on a female patient with a previously
undiagnosed RCC, which metastasized and presented as a clear cell tumour in the
head and neck region. A histopathological differential diagnosis for clear cell
tumours together with the contributing factors that led to the diagnosis of
metastatic RCC will be discussed.

c 2004 Published by Elsevier Ltd.

Case report compressing the naso-pharynx on the left side

A 57 year old female presented with painful
swellings on the left side of the face, which
developed over a period of three weeks. Her face
was asymmetrical due to the swellings on the left
parotid and temporal regions (Fig. 1). Intra orally,
00
3 · 3 oval shaped, hard swelling was observed on
the left buccal mucosa. A computed tomography
(CT scan) revealed a large mass of mixed density
measuring 10 · 9 · 6 cm involving left mandible and
maxilla. Moreover, the tumour was seen extending
in to the temporal fossa and retropharyngeal space
* Corresponding author. Tel.: +94-81-2387500; fax: +94-81-
238-8948.
E-mail address: wmtilak@pdn.ac.lk (W.M. Tilakaratne).
(Fig. 2). However, no metastases were observed in
the brain. Thereafter, exploratory biopsy was
performed to arrive at a definitive diagnosis under
general anesthesia. H&E stained sections of the
lesion showed unencapsulated tumour containing
abundant clear cells with moderate degree of
cytological atypia. PAS/DPAS (periodic acid Schiff/
diastase resistant periodic acid Schiff) stained
sections showed the presence of glycogen, but
there was no evidence of mucin in the clear cells.
Moreover, the tumour was markedly vascular (Fig.
3). These histopathological features were sugges-
tive of a metastatic RCC. Thereafter, the patient
was referred to a radiologist for imaging studies
and the ultra sound scan of the abdomen revealed a
large (7.4 · 9.8 cm) upper polar mass in the left

1741-9409/$ - see front matter c 2004 Published by Elsevier Ltd.
doi:10.1016/j.ooe.2003.12.005
Metastatic renal cell carcinoma
Figure 1 Clinical photograph to show the extra oral
presentation of the lesions.
kidney with no further secondaries in the lower
abdomen. However, a metastatic deposit was ob-
served in the left humerus.
Two weeks after referring the patient to an
oncologist for palliative treatment, uncontrolled
bleeding occurred from the oral lesion. Initially,
adrenalin packs, tranexamic acid and vitamin K
were used to control bleeding. However, as this
treatment failed, secondly, blood was transfused
with prior medication of hydrocortisone and
promethezine. Despite pre-medication the patient
developed a transfusion reaction. Then as a third
Figure 2 CT scan to show the extent of the lesion.
51
attempt to stop bleeding; ligature of the carotid
artery was attempted. However, it was not suc-
cessful and resulted in patients’ death and pa-
tients’ family turned down subsequent request for
an autopsy.
Discussion
Renal cell carcinoma occurs most frequently in
the 5th and the 6th decade of life and has a male
preponderance.1 Approximately, three fourth (3/4)
of all RCC detected are clear cell RCCs. The classic
triad of presenting symptoms of RCC is hematauria,
back pain and mass in the flank.1 However, our
patient did not have any of the above symptoms
and instead the lesions on the oral-maxillofacial
region were the first indication of the undiscovered
RCC. An overview on meatstatic tumours to the
head and neck region indicated 30% of the meta-
static tumours to be of previously undiscovered
distant primaries.2;3
Metastases to the oral-maxillofacial region are
uncommon and account for approximately 1% of all
malignant tumours in the region. However, autop-
sies of patients with carcinoma reveal higher level
of metastatic deposits in the facial bones, which do
not manifest clinically.3 The common sites of oral
soft tissues for metastases are attached gingiva
followed by the tongue while in the jaws mandible
is more commonly affected compared to the max-
illa.2–10 However, as our patient had extensive
lesions involving both soft tissue and bone the
original site of the tumour could not be deter-
mined. The most common primary sources of
metastases to the oral soft tissues are lung, kidney
and skin in decreasing order when considering
both genders. However, a difference exists
52
Figure 3 Photomicrograph to show the histopathological presentation of the metastatic renal cell carcinoma (·40).
Note: Abundant clear cells and vascularity of the lesion.
between genders as in females, tumour metastases
from breast, genital organs, lung and bones are
more common compared to kidney.2
Clear cells are a feature of majority of salivary
gland tumours such as mucoepidermoid carci-
noma, acinic cell carcinoma, epithelial myoepi-
thelial carcinoma, sebaceous carcinoma,
sebaceous adenoma, oncocytoma;11 odontogenic
tumours namely clear cell odontogenic carcinoma,
calcifying epithelial odontogenic tumour and
metastatic lesions such as renal and thyroid
primaries and in melanomas. In addition, alveolar
soft part sarcoma and paraganglioma that occur in
the head and neck region also contain clear
cells.12 Because of the rarity of metastatic tu-
mours to the oral region as well as due to pres-
ence of other lesions with clear cells, diagnosis of
metastatic clear cell RCC in the oral cavity can be
very difficult. Particularly if the metastatic lesion
is the first sign of the disease similar to our pa-
tient. The majority of the clear cell tumours that
occur in the head and neck region are malignant.
However, unlike metastatic clear cell RCC where
clear cells are abundant and form the predomi-
nant cellular component, salivary gland carcino-
mas particularly, mucoepidermoid and acinic cell
carcinoma in addition to foci of clear cells also
contain squamous cells and granular basophilic
cells resembling acini respectively. Moreover,
presence of glycogen without mucin in clear cells
of RCC is helpful to differentiate salivary gland
lesions, as both glycogen and mucin are positive
in the latter tumours. In addition co-expression of
cytokeratin and vimentin, which is unusual among
other carcinomas, can also be used as an indicator
to suggest a renal primary.1
Thirty percent of the patients with primary RCC
have metastases at the time of primary cancer
P.R. Jayasooriya et al.
diagnosis.13 Seventy percent of these involve a
solitary organ while 30% may involve multiple or-
gans. Surgical excision, radiotherapy, chemother-
apy or hormonal therapy can be used to treat
metastases. However, due to overall poor progno-
sis only palliative treatment was given to our pa-
tient. Moreover, our patient died three months
after the discovery of the tumour and supports the
previous reports that indicate a relatively poor
survival rate of only 6–9 months for patients with
metastatic RCC.13
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