|Year : 2013 | Volume
| Issue : 1 | Page : 117-118
Renal cell carcinoma presenting with oral tongue metastasis: A rare case presentation
Amitabh Ray, Jibak Bhattacharya, Subir Ganguly
Department of Radiotherapy, NRS Medical College and Hospital, Kolkata, West Bengal, India
|Date of Web Publication||10-Apr-2013|
Department of Radiotherapy, NRS Medical College and Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Renal cell carcinoma is the most frequent kidney neoplasm, with a high tendency to metastasize. The occurrence of renal carcinoma metastasis to the head and neck region is extremely rare. Here we present one such case where the tongue metastasis was the initial presenting feature of disease.
Keywords: Metastatic renal cell carcinoma, Tongue metastasis, Atypical metastatic site
|How to cite this article:|
Ray A, Bhattacharya J, Ganguly S. Renal cell carcinoma presenting with oral tongue metastasis: A rare case presentation. J Can Res Ther 2013;9:117-8
| > Introduction|| |
The incidence of RCCs has been rising steadily over the last few years.  The lack of benefit from adjuvant treatment has made surgery the corner stone of treatment for this disease. Indeed, the advent of biologics like sunitinib, sorafenib, temserolimus, everolimus, pazopanib and bevacizumab has marginally improved the bleak prognosis of metastatic disease, but the cost of therapy remains prohibitive. Newer areas of interest include the impact of modern radiation oncology techniques and biologics in the adjuvant setting for high risk RCCs.
The usual presentation of RCC is hematuria with or without obvious flank mass. The gamut of paraneoplastic syndromes associated range from polycythemia to non metastatic hepatic dysfunction. The usual presentation of metastatic disease is with lung, liver, soft tissue and bone and brain metastases. The incidence of metastasis to other sites is relatively rare. Here we present a rare case of RCC with metastasis to anterior tongue.
| > Case Report|| |
Mr. RNS, a 65 year old male presented with growth in anterior tongue of about 2 months duration [Figure 1]. He also gave a 4 month history of reddish discoloration of urine. On examination, he was noted to have a 3 × 2 cm solitary pedunculated lesion on the right side of the anterior two-thirds of his tongue crossing the midline. His tongue mobility was normal and there was no palpable cervical lymphadenopathy.
Systematic examination of chest revealed decreased air entry bilaterally without any adventitious sounds. Abdominal examination was normal.
He was advised biopsy from tongue growth along with standard metastatic workup for head and neck carcinoma. The associated finding of reddish discoloration of urine was investigated with routine examination of urine with culture sensitivity testing to exclude infection. Excision of growth in anterior tongue revealed a 2.6 cm tumor composed of sheets and nests of clear cells with centrally placed round or oval nuclei. The overall impression was suggestive of a hyper nephroid tumor reminiscent of renal cell carcinoma. Urine analysis revealed hematuria without any evidence of infection. In view of this a contrast enhanced CT scan of abdomen with guided FNAC was suggested. The chest x ray done as a part of routine metastatic workup showed discrete nodular opacities at both lungs suggestive of secondary deposits. CECT abdomen demonstrated 7.3 × 7.86 cm heterogeneously enhancing mass with undulated margin at upper pole of right kidney with calyceal distortion and perinephric fat stranding, multiple para-aortic lymphadenopathy, right renal vein and inferior vena cave involvement and invasion into right psoas muscle and right dome of diaphragm [Figure 2]. FNAC from right renal mass was suggestive of renal cell carcinoma.
Mr. RNS was evaluated for right sided cytoreductive nephrectomy for which urosurgery consultation was sought. The general condition of patient precluded such an approach. He did not complain of pain or bleeding from the tongue pathology and hence, palliative local treatment in the form of radiotherapy was withheld. He has been started of Sunitinib 50 mg OD on a 4 week on and 2 week off schedule.
| > Discussion|| |
Metastasis of cancer to the mouth cavity, and particularly to the tongue, is extremely rare. In a review of 6881 cancers, 0.2% incidence of lingual metastasis was observed by Zegarelli.  The rarity of lingual metastasis is possibly explained in terms of the inhospitable nature of the site. The tongue is subject to mechanical, chemical and thermal variation, all of which function to inhibit colonization. Further, it is now recognized that skeletal muscle secretes several factors that have anti-cancer activity including TNF-α, TGF-β, lymphocyte infiltrating factor, interferon, lactic acid, proteolytic enzymes and adenosine receptor agonists. , Cancers which are commonly known to metastasize to the tongue include Kidney (28%), Lung (28%) Skin melanoma (11%) and Breast (9%). 
About 30% of patients with RCCs present with metastatic disease.  75% of these patients have metastases to the lung, 36% to soft tissues, 20% to bone, 18% to liver, 8% to cutaneous sites, and 8% to the central nervous system.  Approximately 15% of renal cell carcinomas metastasize to the head and neck region - specifically, to the paranasal sinuses, larynx, jaws, temporal bones, thyroid gland, and parotid glands. ,
An exhaustive literature review on tongue metastasis as a presenting feature of renal cell carcinoma was done recently by Azam et al.  They were able to identify 28 such cases in a period from 1911 to 2008. Out of these, only 3 cases presented initially with tongue metastases before the diagnosis of primary renal cell carcinoma. The case being presented here constitutes the fourth such case reported in the literature.
Management of metastatic RCC (mRCC) is one of the exciting new areas of research with a host of molecules now available for therapy. As per literature patients with a good performance status and only one site of metastasis are considered candidates for immunotherapy. This represents fewer than 5% of the population of mRCC patients. All other patients are considered candidates for anti-angiogenics based on the results of phase III trials, with sunitinib considered standard treatment as was used in this case, and bevacizumab plus IFN-α being an option. 
The importance of eliciting proper history and evaluation of all presenting symptoms and signs is very well demonstrated in this case. The rarity of secondary tongue cancers requires a very high index of suspicion for diagnosis. However, systematic approach usually reveals the primary site in a majority of cases.
| > References|| |
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[Figure 1], [Figure 2]