51 year old man with two year history of renal cell carcinoma.
CT scan ordered to evaluate enlarging left- sided skull masses
â€¢ Enhancing lesion left frontal bone
â€¢ Enhancing lesion left temporal bone with associated bone destruction
â€¢ Lytic lesion left parietal bone.
â€¢ Metastatic disease
Â» Renal cell carcinoma
â€¢ Multiple Myeloma
Dx: Renal Cell Carcinoma with metastatic lesions to the skull
Dx Confirmed by: History and scan findings
Renal cell carcinoma is the most common primary tumor of the kidney and accounts for 2.6 percent of all adult cancers. While the cause is unknown, cigarette smoking has been identified as an environmental risk factor. Sporadic tumors are most common, but familial settings, such as von Hippel-Lindau syndrome, have been identified. The carcinoma develops from the proximal tubule cells of the kidney. Clear cell, papillary, chromophobe, collecting duct, and sarcomatoid are the different histologic types. These different patterns do not affect treatment.
Renal cell carcinoma has two potential staging systems: the Robson classification and the TMN classification. CT is reported to be 91% accurate in staging renal cell carcinoma. The TMN classification is considered more precise because of its clear definition of the anatomic extent of the tumor. With respect to the TMN classification, T1 is reserved for tumors less than 7 cm and T2 for tumors greater than 7 cm. T3 is broken down into three groups based on tumor position. T3a indicates spread to the perinephric fat. T3b indicates that the tumor is present in the renal vein only. T3c describes a tumor in the infradiaphragmatic IVC. T4a and T4b describe tumors with direct invasion of adjacent organs and presence in the supradiaphragmatic IVC, respectively. N1-3 are reserved for regional lymph node metastases and M1a-d for distant metastases.
The Robson classification is staged I-IV. I is given to a tumor confined within the renal capsule. II indicates spread to the perinephric fat. IIIA describes the presence of a venous thrombus, whereas IIIB describes regional lymph node metastases. IVA indicates direct invasion of adjacent organs and IVB indicates distant metastases.
The common presentation of renal cell carcinoma includes gross or microscopic hematuria, flank pain or pass, systemic symptoms, or a solid renal mass on imaging.
Many renal cell carcinomas are found incidentally on imaging. CT is the most valuable imaging modality. It can confirm the nature of the mass and stage the tumor by providing visualization of the lymph nodes, renal vein, and hepatic involvement. The contralateral kidney and other body organs can also be examined.
Treatment for renal cell carcinoma varies based on the patient. Radical nephrectomy is common for a localized renal cell carcinoma. The indications for partial nephrectomy are reviewed in the discussion. Radiofrequency and cryosurgical ablation are new techniques being studied. Chemotherapy is not effective in treatment of metastatic renal cell carcinoma. Cryoreductive nephrectomy is recommended for patients who are in good status and have metastatic primary disease. Disease-free five-year survival is 90-100 percent for patients with tumors confined by the renal capsule. Tumors extending beyond the capsule have a 50-60 percent rate of disease-free five-year survival. The five-year disease-free survival drops to 0-15 percent for node-positive tumors.
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