Abstract: Renal cell carcinoma (RCC) is one of the most frequent urological malignancies in adults. It represents for aproximately %3 of all adult malignancies and accounts %90 of neoplasms arising from kidney. RCC often metastasizes to other organs, but very rarely to the head and neck region including maxilla and mandible. A 62-year-old man with metastatic renal cell carcinoma to the mandible was presented in this work. Key Words: Renal cell carcinoma, Mandible, Metastasis, Head and Neck neoplasms. ,
Renal cell carcinoma (RCC) accounts for 3% of all tumors in adult individuals and has the highest incidence in industrialized countries. RCC is the most common malignant tumor of the kidney (90-95%) and is usually seen in men aged 30-60 years. It is the neoplasm that most metastasizes from the outside of the head and neck region to the oral cavity after lung and breast tumors. RCC is often spread to the organs; Rarely metastasizes to the head and neck region. RCC metastases the thyroid, parotid, tonsil, tongue, sinonasal region, mandible and head and neck of the head and neck region and is diagnosed by biopsy.
The main symptoms seen in the metastases of the oral cavity are swelling, pain, bleeding and tooth loss. In this study, we present a case of RCC metastasizing to the mandible due to its interesting clinical features and histologic features. 61 years old male patient applied to Cumhuriyet university faculty of dentistry oral and maxillofacial surgery clinic, Due to painful swelling on the right side of his face on February 2015. The current swelling began about 2 months ago, It was learned that only the antibiotic treatment was advised by the various dentists at this period.
The patient has systemic hypertension and diabetes mellitus, On the panoramic radiograph, 1 premolar tooth extending to second molar tooth Radiolucent area observed with normal boundaries. Panoramic radiography of the patient 1 premolar tooth extending to second molar tooth Radiolucent area observed with normal boundaries. The lesion, which is thought to be a radicular cyst from a radiographic image, Under local anesthesia, in the cyst was enucleated and decided remove to second premolar.
Premolar teeth were removed from the socket during dismantling existing contant prosthesis before surgery It was observed that there was bleeding in the amount of time and more than normal, while performing incision and flap operations, the same abnormal bleeding situation still continued , When the bleeding could not be controlled, the dental spongostane was placed, than bloodstoper (Ankara, Turkey) was applied. The bleeding was stopped together with medical treatment and gauze ped(“Picture Yada Figure” 2 ) and the region was sutured as a primer.
Figure 2: Medical treatment and was under control bleeding as a result of the application of press During the operation, cyst fluid and mucosa membrenes were not observed in the lesion ,As a result of the first histopathological examination in the external center “Xanthoma fibroma” was considered as an upper institution for differential diagnosis was referred to the CUFF Pathology AD; Where clear cell lesion (Figure: 3. A) for differential diagnosis. It’s clear cell lesion (Figure: 3. A) for differential diagnosis S100, CD1a, CD34, CD68 and PANCK Immunohistochemistry (IHK) paint panel applied; Only diffuse cytoplasmic staining was obtained in tumor cells with PANCK (Figure 3. B) others are unpainted.
On about this topic “epithelial malignant tumor metastasis” and primarily RCC metastasis are considered, made in this direction scanning archives as a primary tumor, the patient underwent nephrectomy operation approximately one year ago and histopathologically similar to those of the mandibular mass “RCC” was reached and the lesion in the mandible was the result of metastasis of this tumor (Figure 3 C, D, E, F).
Figure 3: A) Tumor metastasis to the mandible (red arrow shows spicule of the bone) (HE x 40). B) Immunohistochemistry of the lesion in the jawbone. Tumor cells were stained with PAN-CK diffuse cytoplasmic staining (IHK x 40). C) Overview of the primary clear cell tumor (RCC) adjacent to the kidney tissue at the left flank. The whole body examination of the patient later revealed that the general condition was good. Whole body bone scan mandible markedly increased osteoblastic focal uptake was observed in the right part.
In addition, osteoblastic increased activity was detected in a small focus at the 1/3 distal portion of the right femur and proximal to the left tibia (Figure 4). , Whole body bone scintigraphy. Osteoblastic increased activity in the mandibular right femur, also in a small focus at the 1/3 distal portion of the right femur and proximal to the left tibia 1/3. The patient was scheduled for palliative treatment after consulting with the Oncology Clinic following enucleation. The region was healed by rinsing with rifamycin (Rifocin 250 mg / ml) for two weeks (Figure 5).
RCC makes up about 3% of all adult tumors. RCC is the most common malignant kidney tumor and is responsible for approximately 90-95% of all kidney cancers. Most cases of RCC occur in individuals age between 30-60 years and the male / female ratio is 2: 1. North America and Scandinavia are the geographical regions with the highest incidence. 9,10 Approximately ? of the RCCs are clear cell RCCs. 11 The clinical description of RCC, Mass in the kidney (10% patient on first admission), Classic threesome consisting of pain and hematuria other than symptomatology, Many non-specific paraneoplastic symptoms a wide spectrum that varies as much as . 9
RCC usually progresses slowly, makes young metastasis and metastasis occurs in 20% to 40% of patients. 2,12. However, certain parts of patients are diagnosed after metastasis has occurred. 13 Metastatic RCC, treatment is known as one of the most resistant tumors. Recovery is very rare and the average life span after diagnosis is less than 1 year. 14 RCC is known to make distant metastases to many tissues and organs. 15-19 RCC is one of the most common tumors that metastasize to the head and neck region following lung and breast cancer.
15% of cases have multiple metastases to the head and neck region. 0,21 The thyroid gland is the most common area where this tumor metastasizes to this region. Other areas are; Paranasal sinuses, parotid gland, eye, orbital rim, inner ear, outer auditory canal, mandible and hard palate. 22 Soft tissue metastases, such as oral gingiva, tongue, uvula and lip, have also been reported. 13,23,24 Mandibular metastasis 4-5 times more observed than maxillary metastasis. This difference is related to the amount of red bone marrow and blood flow. RCC metastasizes to the head and neck region in 3 ways.
This situation without Batson plexus lymphatic, explain to V renalis ve V cava inferior way. ,6 (burasini hic anlamad? m esra)The majority of distant metastases occur within the first 2 years after definitive treatment of the primary tumor. 25 In our patient metastasis to the mandible was performed after 1 year to nephrectomy. Mandibular metastasis is usually evidence of extensive spread of the disease and It shows a serious prognosis. The time from the onset of metastasis to death may not be a few months long26. and more than two-thirds of patients with metastatic carcinoma in their jaws die within 1 year; The 4-year survival rate is only about 10%. 27 We lost our patient 1. 5 years after surgical enucleation.
The reason why metastatic tumors in the jawbone are rare they are mostly centralized , nonspecific symptoms such as pain and swelling show in the late period, radiographic indications are not specific too and In the other part of the body, the previously unidentified primer is detected before the tumor, the detection of a previously unidentified primary tumor in another part of the body makes it difficult to diagnose lesions. 28 Osteomyelitis at the differential diagnosis , pyogenic granuloma, mandibular cysts, primitive malign tumors of jaws, bone diseases such as Langerhans cell histiocytosis, oral metastases should be considered for RCC. In this case, the radiographic image of the metastatic tumor gave a cystic lesion appearance.
Such clear cell lesions in the jawbone may resemble “fibroxantomas” and Langerhans cell histiocytoses. For their differential diagnosis, IHK dyeing methods are applied today. For differential diagnosis in this case S-100, CD1a, CD34, CD68 and PAN-CK applied to IHK painted panel and fibroxantom and Langerhans cell histiocytosis excluded , epithelial tumor metastasis was diagnosed with PAN-CK positivity from which the archive was scanned and the primary focus was reached on the RCC.
Surgically removing the tissue, radiotherapy-chemotherapy and hormonal therapy can be used in the treatment of metastases. 4 Palliative treatment is recommended if extensive examination reveals that the primary tumor has spread or that metastasis can not be removed by resection. Although clear-cell RCC is a radiotherapy-resistant tumor , radiotherapy may be useful in the treatment of metastatic disease. 29 Although the answer to treatment is less than 25%, chemotherapy (IL-2, interferon-? , 5-FU) It may be useful in cases of residual disease after resection. (de ne alaka bilmiyom ayarla kendin)
However, after the enucleation, the prognosis is usually weak, especially when the right femur is 1/3 of the left femur and the proximal of the left tibia is 1/3 In accordance with a joint decision with the CINF Oncology AD, the patient was treated with palliative treatment in the form of a wash with 250 mg / day for 2 weeks. As a result, during the operation, along with other clinical features the possibility of metastatic tumors should be kept in mind when experiencing excessive hemorrhage after surgery.
