Case report
Calvarial metastases as clinical presentation of renal cell carcinoma: report of two cases and review of the literature

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Summary

Calvarium is a frequent target site of involvement for common neoplasms. Some cases of calvarial metastases have been reported in literature as secondary lesions from renal cell carcinoma (RCC), but only five cases have been described concerning calvarial mass as the first clinical presentation of this kind of tumor. In this report, we discuss the clinical aspects of two further cases we observed, in which the renal cell carcinoma was found thanks to the histological examination of a calvarial mass after surgery. We also briefly review the literature.

Introduction

Renal cell carcinoma (RCC) is notorious for its capacity to give metastases in poorly conventional sites. About 25% of patients with renal cell carcinoma have distant metastatic lesions at the time of initial assessment.

The calvarium is one of the most frequent target site of involvement for common and uncommon malignant neoplasms in adults, i.e. breast and lung cancer, lymphoma, paraganglioma, pheochromocytoma, Merkel tumor, etc. [1].

Some cases of calvarial metastases have been reported in literature as secondary lesions from renal cell carcinoma but, to our knowledge, only five cases have been previously described in literature concerning calvarial mass as the first clinical presentation from a RCC.

In the present report, we discuss the clinical aspects of two further cases with a brief review of the literature.

Section snippets

First case

A 66-year-old man presented with a painless enlarging mass in the occipital region. The neurological evaluation was negative. A Computer Tomography (CT) imaging study revealed a 5 cm mass of the occipital bone (Fig. 1A). The angiographic study showed a rich vascular supply from the occipital branch of the external carotid arteries of both sides (Fig. 1B). At surgery, the mass showed a “cheese”-aspect and was richly supplied by a network of small new blood vessels.

Histological examination showed

Surgical procedure

In both cases, we performed a wide craniectomy based on Neuronavigation landmarks (Vector Vision 2, Brain Lab); it allowed to detect the margins of bone involvement using CT scanning for bone so that the limits of craniectomy were larger than the extension of the tumor, in order to create an island of non-pathological bone and dura around the lesion. We carefully avoided to enter the mass during surgery, removing “en bloc” the mass together with bone and dural components. The use of bone wax

Discussion

Renal cell carcinoma occurs frequently between the fifth and seventh decades of life, and accounts for 3% of all adult cancers [2], [3]. In epidemiological studies, it seems to affect above all men, and a genetic link for this disease has also been reported. In general, metastases occur early, even if a solitary metastasis may appear more than 10 years after treatment of the primary tumor [2]. Renal cell carcinoma can metastasize everywhere, and the most frequent sites are lung, bone, and

Conclusions

Although metastases to the calvarium from RCC are unusual, they should be considered in the differential diagnosis when evaluating whatever unusual subcutaneous mass, even if they are asymptomatic. In patients presenting without cancer history, manifestation with a calvarial metastasis may also suggest the presence of a primitive renal cell carcinoma. Almost in all cases, fortunately, the pathologist can help in the diagnosis.

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