Abstract

Background: Renal cell carcinoma (RCC) comprises 80% of primary renal cancers in the USA. Most cases are discovered incidentally during imaging for other reasons. The majority of patients are asymptomatic upon diagnosis, yet 25% have advanced disease. The most common locations for metastasis include liver, lymph nodes, bone, and lungs. RCC presents as skin metastasis in 6% of cases. Here, we present an even rarer occurrence: of recurrent RCC presenting with cutaneous metastases following nephrectomy and immunotherapy. Case Report: A 75 year-old white male presented to his physician for a yearly exam. Routine urinalysis revealed microcytic hematuria. Ultrasound demonstrated a solid mass in the upper pole of the right kidney. CT scan of the chest revealed pulmonary nodules. Patient underwent a right radical cyto-reductive nephrectomy, biopsy of mesenteric mass, and left thoracotomy with biopsy. Final pathology revealed grade 4 RCC, clear-cell type. Patient had treatment with interferon Alpha and then interleukin-2. As third line treatment, patient was switched to bevacizumab. While on treatment, patient presented a lesion on his left back and diffuse bone pain. During physical exam, a 2 x 2.5 cm firm, immobile, subcutaneous nodule was noted. Pathological analysis revealed a tumor consistent with metastatic RCC. MRI of the brain revealed calvarial lesions with some break into the scalp soft tissue and into the epidural space. Erlotinib was added to bevacizumab. Conclusion: This case helps highlight the ubiquity of RCC metastasis. The most common locations for metastasis include lung, liver, local lymph nodes, bone, and brain. In RCC, skin lesions have been described in the literature more specifically as pustules, painful and painless nodules, and macular lesions. The differential diagnosis of a skin lesion include non-specific drug reactions, opportunistic skin infections, and metastatic disease. The definite diagnosis of metastasis is made through tissue biopsy.

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