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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 237-239

Renal cell carcinoma manifests primarily as endobronchial mass: An unusual presentation


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2 Medical Officer
3 Senior Resident
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Date of Web Publication9-Mar-2015

Correspondence Address:
Debjit Banerjee
120/1 K. N Mukherjee Road, P.O Talpukur, Dist 24 PGS (N), Pin 700123

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-0513.148938

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  Abstract 

Endobronchial metastasis (EBM) from renal cell carcinoma (RCC) is a very rare entity, though pulmonary metastasis of RCC is common. Here, we present a case of RCC with EBM, in which the primary tumor was detected after the detection of secondary. A 60-year-old man presented with cough for last 2 months. Contrast enhanced computed tomography (CECT) chest followed by bronchoscopy revealed an endobronchial mass at left bronhi. CECT whole abdomen revealed a left-sided renal space occupying lesion (SOL). CT guided fine needle aspiration cytology of the SOL proved it as a RCC. Palliative bronchoscopic removal of endobronchial mass by snaring diathermy was done.

Keywords: Endobronchial metastasis, lung collapse, renal cell carcinoma


How to cite this article:
Mukherjee R, Banerjee J, Mondal M, Banerjee D. Renal cell carcinoma manifests primarily as endobronchial mass: An unusual presentation. Clin Cancer Investig J 2015;4:237-9

How to cite this URL:
Mukherjee R, Banerjee J, Mondal M, Banerjee D. Renal cell carcinoma manifests primarily as endobronchial mass: An unusual presentation. Clin Cancer Investig J [serial online] 2015 [cited 2020 Apr 7];4:237-9. Available from: http://www.ccij-online.org/text.asp?2015/4/2/237/148938


  Introduction Top


Endobronchial metastasis (EBM) was defined as bronchoscopically visible lesions, histopathologically identical to the primary tumor in patients with extrapulmonary malignancies. EBM from extrapulmonary malignant tumors is rare. The most common extrathoracic malignancies associated with EBM are breast, renal, and colorectal carcinomas. [1] Lung is the common site of metastasis for renal cell carcinoma (RCC). [2] However, EBM as a first manifestation of RCC seems to be uncommon. [3],[4] The electrosurgical snaring as palliative therapy for endobronchial mass has become widespread, especially to treat obstructive endobronchial tumors. [5] We report a rare case of RCC primarily presented with EBM and palliative recanalization of the left bronchus was done by electrosurgical snaring.


  Case report Top


A 60-year-old nonsmoker male presented with dry cough for last 2 months. Patient was nonalcoholic with no history of fever or weight loss. On examination, blood pressure was 136/86 with no lymphadenopathy. Percussion and auscultation of the chest revealed dullness and diminished breath sound on the left side of the chest.

Routine hematological and biochemical investigations were within normal limit except raised erythrocyte sedimentation rate (70). Contrast enhanced computed tomography (CECT) chest shows left lower lobe collapse with left upper lobe consolidation with bilateral upper lobe nodules which are probably metastatic [Figure 1].
Figure 1: Contrast enhanced computed tomography chest shows consolidation of left lung

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With the increase of respiratory distress, fibreoptic bronchoscopy was done (to exclude any endobronchial mass), which revealed an occluding mass on the left sided large bronchus. Biopsy was taken but the result was unsatisfactory. Repeat bronchoscopy was done for removal of mass by snaring diathermy and palliative recanalization of the left bronchus [Figure 2]. CECT whole abdomen done for detection of primary, which revealed a left sided the renal space occupying lesion (SOL) (posterior aspect), infiltrating into the perinephric fat [Figure 3]. A CT guided fine needle aspiration cytology of renal SOL proved it as RCC-papillary variant [Figure 4] and [Figure 5]. Now the patient is planned radical left nephrectomy followed by chemotherapy.
Figure 2: Bronchoscopic photograph shows an occluding endobronchial mass (at left main bronchus) removal by snaring diathermy

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Figure 3: Contrast enhanced computed tomography (CT) abdomen during CT guided fine needle aspiration cytology (FNAC) shows a left renal space occupying lesion (SOL) and FNAC needle within the SOL

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Figure 4: Photomicrograph of fine needle aspiration cytology (×40) shows papillary structures with prominent fibrovascular core, lined by malignant cells

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Figure 5: Photomicrograph of fine needle aspiration cytology (×100) shows papillary structure lined by pleomorphic cells with large nuclei, prominent nucleoli and moderate amount of clear cytoplasm, favoring features of renal cell carcinoma (papillary variant)

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  Discussion Top


The lung is a common site for metastasis from extrathoracic tumors, but EBMs are rare. [6] EBM are a late manifestation in the course of solid tumor. [5],[7],[8] In the majority of the cases clinical manifestation of the primary extrathoracic tumor antedated the diagnosis of EBM. [5],[7],[8] Occasionally clinical and roentogenographic features of EBM preceded the recognition of the primary tumor. [3],[4] However, the mean interval from the initial diagnosis of the primary tumor to the diagnosis of EBMs ranges from 0 to 112 months. [1],[9],[10] In our case, patient presented with symptoms of EBM and it is detected before the detection of RCC.

Most typical symptoms of EBM are cough and hemoptysis, while dyspnea is seen less frequently. [8] In our case, patient presented with dry cough without hemoptysis and dyspnea develops later. EBMs can involve any airway level but have a predilection for the right lung in up to 80% of cases, although the reason for this is not clear. [11] This case was rather unique in that the tumor occluded the left main bronchus.

Renal cell carcinoma metastasizes most frequently to the lungs (50-60% of patients with metastases) and also commonly to the bones, liver, renal fossae, brain, and by direct extension, beyond Gerota's fascia. [12] Metastasis usually occurs by hematogenous spread to the parenchyma of other organs. For patients with lung metastases, hilar or mediastinal lymph node involvement (or both) occurs in 22-30% of cases and is associated with worse outcomes. [11],[13] Radiological changes of atelectasis are usually the earliest indication of endobronchial disease, [14] and obstructive atelectasis most often associated with obstruction of lobar bronchi. [15] In our case, patient having both upper lobe collapse and lower lobe atelectasis of left lung along with multiple metastatic nodules at upper lobe of both lungs without any hilar or mediastinal lymphadenopathy.

The therapeutic approach to an endobronchial tumor is determined by the characteristics of the primary tumor, biological behavior, anatomic location of the EBM, and the patient's performance status. [13] We choose snare diathermy for its convenience and safety. In conclusion, endobronchial techniques, such as snare diathermy, can relieve obstruction, providing symptom palliation even in advanced disease.[15]

 
  References Top

1.
Akoglu S, Uçan ES, Celik G, Sener G, Sevinç C, Kilinç O, et al. Endobronchial metastases from extrathoracic malignancies. Clin Exp Metastasis 2005;22:587-91.  Back to cited text no. 1
    
2.
Lim DJ, Carter MF. Computerized tomography in the preoperative staging for pulmonary metastases in patients with renal cell carcinoma. J Urol 1993;150:1112-4.  Back to cited text no. 2
    
3.
Maytum CK, Vinson PP. Pulmonary metastasis from hypernephroma with ulceration into a bronchus simulating primary bronchial carcinoma. Arch Otolaryngol 1936;23:101-4.  Back to cited text no. 3
    
4.
Carlin BW, Harrell JH 2 nd , Olson LK, Moser KM. Endobronchial metastases due to colorectal carcinoma. Chest 1989;96:1110-4.  Back to cited text no. 4
    
5.
Sakumoto N, Inafuku S, Shimoji H, Nomura K, Honma K, Kawabata T, et al. Endobronchial metastasis from renal cell carcinoma: Report of a case. Surg Today 2000;30:744-6.  Back to cited text no. 5
    
6.
Braman SS, Whitcomb ME. Endobronchial metastasis. Arch Intern Med 1975;135:543-7.  Back to cited text no. 6
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7.
Baumgartner WA, Mark JB. Metastatic malignancies from distant sites to the tracheobronchial tree. J Thorac Cardiovasc Surg 1980;79:499-503.  Back to cited text no. 7
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8.
Katsimbri PP, Bamias AT, Froudarakis ME, Peponis IA, Constantopoulos SH, Pavlidis NA. Endobronchial metastases secondary to solid tumors: Report of eight cases and review of the literature. Lung Cancer 2000;28:163-70.  Back to cited text no. 8
    
9.
Kim JH, Min D, Song SH, Lee JH, Jeong HC, Kim EK. Endobronchial metastases from extrathoracic malignancies: Recent 10 years′ experience in a single university hospital. Tuberc Respir Dis (Seoul) 2013;74:169-76.  Back to cited text no. 9
    
10.
Park CM, Goo JM, Choi HJ, Choi SH, Eo H, Im JG. Endobronchial metastasis from renal cell carcinoma: CT findings in four patients. Eur J Radiol 2004;51:155-9.  Back to cited text no. 10
    
11.
Fourquier P, Regnard JF, Rea S, Levi JF, Levasseur P. Lung metastases of renal cell carcinoma: Results of surgical resection. Eur J Cardiothorac Surg 1997;11:17-21.   Back to cited text no. 11
    
12.
Motzer RJ, Bander NH, Nanus DM. Renal-cell carcinoma. N Engl J Med 1996;335:865-75.  Back to cited text no. 12
    
13.
Pfannschmidt J, Hoffmann H, Muley T, Krysa S, Trainer C, Dienemann H. Prognostic factors for survival after pulmonary resection of metastatic renal cell carcinoma. Ann Thorac Surg 2002;74:1653-7.  Back to cited text no. 13
    
14.
Kiryu T, Hoshi H, Matsui E, Iwata H, Kokubo M, Shimokawa K, et al. Endotracheal/endobronchial metastases: Clinicopathologic study with special reference to developmental modes. Chest 2001;119:768-75.  Back to cited text no. 14
    
15.
Schoenbaum S, Viamonte M. Subepithelial endobronchial metastases. Radiology 1971;101:63-9.  Back to cited text no. 15
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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