Clinical Imaging 39 (2015) 155–157
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Solitary metastasis of renal cell carcinoma in infratemporal fossa Tommaso D’Angelo, Alfredo Blandino, Giorgio Ascenti, Sergio Vinci, Michele Gaeta, Silvio Mazziotti ⁎ Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98100, Messina, Italy
a r t i c l e
i n f o
Article history: Received 14 April 2014 Received in revised form 21 July 2014 Accepted 28 July 2014 Keywords: Renal cell carcinoma Infratemporal fossa Solitary metastasis Magnetic resonance Computed tomography
a b s t r a c t Renal cell carcinoma can recur at any time after nephrectomy, and it is not unusual to detect late metastases even decades after surgical excision of the primary tumor. Despite being infrequently reported, head and neck metastases may be linked to renal cell carcinoma in up to 15% of cases. We present an unusual case of a single metachronous renal cell carcinoma metastasis in the infratemporal fossa, with a 13-year late onset from the primary. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Late tumor recurrence of renal cell carcinoma (RCC) many years after the initial treatment can occasionally occur. The most common sites of tumor spread are the lung (50–60%), liver (30–40%), and bone (30%) [1]. Metastatic spread of RCC to the head and neck region is rarely seen, despite that head and neck metastases may be linked to RCC in up to 15% of cases [2]. In this study, we present a case of a single, solitary RCC metachronous metastasis in the infratemporal fossa (ITF), with a 13year late onset from the primary. This is a very seldom case of distant metastasis of RCC in the ITF. In particular, the additional peculiarity of this case was the lack of disease elsewhere in the body. 2. Case report A nonsmoker 67-year-old male, with a history of right nephrectomy for RCC in 2001 (T2, N0, M0, and Grade 3 according to the Fuhrmann grading system), came to our observation for persistent mild swelling of the left cheek and infraorbitary region, associated with masticatory discomfort and dull facial pain [3]. A magnetic resonance (MR) examination was performed on 1.5 T scanner (Gyroscan Intera, Philips, Best, The Netherlands) with the following scan parameters: TSE T1-weighted sequence along the axial plane: TR 646 ms, TE 16 ms, turbo factor 4, matrix 512×512; TSE T2-weighted sequence along axial and coronal planes: TR 3656 ms, TE 90 ms, turbo factor 15, 512×512 matrix; TSE T1-weighted sequence with fat suppression (selective partial inversion recovery: SPIR) along the axial plane: TR 528 ms, TE 8 ms, turbo factor 4,
⁎ Corresponding author. Dept. of Radiological Sciences, Policlinico “G. Martino,” Via Consolare Valeria, 1, 98100 Messina, Italy. Tel.: +39-0-902213092; fax: +39-0-902213720. E-mail address: [email protected] (S. Mazziotti). http://dx.doi.org/10.1016/j.clinimag.2014.07.013 0899-7071/© 2015 Elsevier Inc. All rights reserved.
352×352 matrix, obtained before and after iv injection of Gadolinium at a dosage of 0.2 mmol/kg and a flow rate of 3 ml/s, followed by a bolus of 10-ml isotonic saline at 3-ml/s flow rate. MRI revealed a highly enhanced space-occupying soft tissue mass centered in the left ITF with extension in the adjacent pterygopalatine fossa and masticatory space. The lesion caused the scalloping and remodeling of the posterior wall of maxillary antrum. Moreover, a minor posterosuperior projection of the lesion was also seen; it determined the erosion of the anterior wall of middle cranial fossa but without any signs of infiltration of the temporal lobe (Fig. 1). Subsequently, a total-body contrast-enhanced multidetector computed tomography (CE-MDCT) was executed with a 64-row multislice CT scanner (Somatom Definition 64, Siemens Medical Solutions, Forchheim, Germany). However, a contrast-enhanced study of the maxillofacial district was firstly considered to be crucial and compulsory, and it was performed with dynamic acquisition techniques obtained after iv administration of 80 ml of iodinated contrast agent, differentiating the purely arterial phase (to better delineate the vascularization of the lesion) from the venous and interstitial phase. Scan parameters were set as follows: 64×0.75-mm scan collimation, reconstruction increment 0.70 mm, pitch 0.75, mAs 80, potential (kV) 120, CDTIvol (mGy) 6.24, isotropic voxel, FOV 200 mm, rotation time 0.50 s; matrix of acquisition 512×512, matrix of reconstruction 512×512. Images were reconstructed using both a soft tissue (kernel h31) and a high-resolution bone algorithm (kernel h60) with 1-mm thickness. Subsequently, after a further iv injection of 50 ml of iodinated contrast agent, CE-MDCT was extended to thoracic and abdominal regions. CE-MDCT emphasized the early enhancement of the mass in left ITF and the use of multiplanar reconstructions (MPR) with bone algorithm better defined the focal erosion of the anterior wall of the left greater wing of sphenoid bone (Fig. 2). However, no other lesion was demonstrated elsewhere in the body.
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T. D’Angelo et al. / Clinical Imaging 39 (2015) 155–157
Fig. 1. Axial T1-weighted (a) and T2-weighted MR images (b) show a mildly hyperintense oval-shaped soft-tissue mass (6 cm×4 cm×4 cm), in the left ITF, displacing anteriorly the posterior wall of the maxillary antrum (arrowheads). Note the medial extension to the pterygopalatine fossa (asterisk) and the erosion of the anterior wall of middle cranial fossa (black arrows). No cerebral infiltration can be seen. Intralesional serpiginous “flow-voids” (white arrows) come out in favor of high vascularization. Axial fat-suppressed T1-weighted MR image, obtained after intravenous injection of contrast medium (c) confirmed homogeneous hyper-enhancement and the presence of intralesional small vessels (black arrows).
Prior to biopsy, the patient underwent selective external carotid angiography (Fig. 3), followed by a therapeutic embolization to reduce the risk of severe bleeding. The transoral biopsy was successively obtained via the gingivolabial sulcus. Microscopic examination (not shown) revealed a clear cell adenocarcinoma consistent with the patient's primary renal tumor. The lesion was considered to be unresectable due to the involvement of pterygopalatine fossa and to its extension toward the middle cranial fossa. Therefore, the patient rapidly underwent to systemic chemotherapy treatment with antiangiogenic drugs. Follow-up at 3 months showed only a mild reduction of the volume of the lesion that was not considered to be enough significant to indicate metastasectomy.
3. Discussion RCC accounts for 3–5% of all malignant tumors in adults [4]. RCC can recur at any time after nephrectomy, and it is not unusual to detect late metastases even decades after the potentially curative surgical excision of the primary tumor [5–7].
The location of metastases and their clinical features, onset, evolution, and prognosis are very variable in RCC. The most common sites of tumor spread are the lung (50–60%), liver (30–40%), bone (30%), and brain (5%) [1,4]. Despite being infrequently reported, metastases in head and neck region may be linked to RCC in up to 15% of cases, even though they are almost always associated with other lesions in the most common sites [1,2,8]. Moreover, RCC is the third most frequent neoplasm to metastasize to head and neck region, preceded only by breast and lung cancer. The nose and paranasal sinuses are most commonly affected and are followed by the oral cavity [8–11]. Although it has been recently described a rare case of metastatic RCC (mRCC) in ITF that was associated with the involvement of other sites (i.e., lung, contralateral kidney), our case is the first in which an ITF lesion represents the first and the solitary sign of mRCC [12]. This very unusual location raises difficulties about the differential diagnosis with the other more common lesions of this anatomic region. Anatomically, the ITF lies on the lateral aspect of the cranial base and deep to the zygomatic arch, the masseter muscle, and the mandibular ramus. Diseases within the ITF are usually infectious or neoplastic. In our case, the lack of erythema, drainage, fever, and of
Fig. 2. Sagittal CT image reformatted with bone algorithm (a) clearly shows the anterior displacement of the posterior wall of the left maxillary antrum (small arrows) and the erosion of the anterior wall of the left greater wing of sphenoid bone (arrowheads). Postcontrast coronal (b) reformatted CT images, obtained in the arterial phase, confirms the early enhancement of the mass with evidence of small arterial vessels in its context (arrows). Note the intracranial extension of the lesion, through the floor of middle cranial fossa (arrowheads).
T. D’Angelo et al. / Clinical Imaging 39 (2015) 155–157
Fig. 3. Preembolization carotid angiogram demonstrating the rich vascularization of the lesion with afferences from left internal maxillary artery (asterisks) and its main trunks.
elevated white blood cell count were all inconsistent with the hypothesis of an infection. Neoplasms involving the ITF may originate from the tissues of this region, but they are more often the result of an extension of tumors arising from the neighboring structures [13]. Benign mesenchymal neoplasms that can be found in the ITF include neurilemmoma, chordoma, paraganglioma, angiofibroma, hemangioma, and arteriovenous malformation [13,14]. Among these lesions only nasopharyngeal angiofibroma shows similar MR and CT findings (i.e., expansile hypervascular solid lesion), but it is well known how angiofibroma typically affects young adults, with only a few cases reported in older people [14]. Benign epithelial neoplasms including inverted papilloma, as well as salivary gland tumors such as pleomorphic adenoma, should also be considered, but all these lesions very rarely show hypervascularity [13]. Finally, malignant neoplasms including a variety of sarcomas, carcinomas of salivary gland origin, lymphoma, and metastatic foci from distant sites elsewhere can also be remotely considered [13,15]. The metastatic patterns of RCCs are not yet defined with accuracy, and RCC has been associated with rare metastatic sites and occasionally with atypical presenting symptoms, deriving from the distant metastatic sites and/or from disseminated disease. Because of its concealed location and multiple structures that lie within it, diseases involving the ITF may present with a variety of signs and symptoms that make difficult an early diagnosis even because of their late onset. Usually surgery should be offered as the treatment of choice for the solitary metastasis of RCC, since it has been seen to increase the overall survival. However, the proximity of this area to the intracranial structures, the paranasal sinuses, the nasopharynx, the orbit and the facial area demands a careful preoperative planning of surgical excision. For such reason the usage of multiplanar imaging has become a mandatory step to evaluate this region. In fact, while US imaging is often limited either by the deep location of these lesions (frequently covered by facial bones) or by the relative dependence on
157
a skilled operator, MR and CT imaging well depict the anatomic structures of this area. In fact, due to its excellent contrast resolution, MRI is essential to delineate any lesion from the nearby soft tissues and to evaluate any intralesional bleeding. Likewise, CE-MDCT, thanks to its elevated spatial resolution, is crucial to evaluate the maxillofacial district, highlighting any bone erosion or disruptions as well as depicting the supplying vessels of a lesion [16]. Numerous surgical approaches, including the infratemporal approach, the orbitozygomatic approach, facial dismasking, and the maxillary swing approach, have been developed over the years [13]. However, in our case, surgery was not feasible due to the local infiltration of pterygopalatine fossa and to the erosion of the anterior wall of middle cranial fossa. As a consequence, the patient rapidly underwent to a systemic neoadjuvant chemotherapy treatment with antiangiogenic drugs to further reduce the vascularization and the volume of the metastasis. The follow-up at 3 months showed only a mild volume reduction of the metastasis, not yet significant for the indication of metastasectomy [17]. Finally, our case further confirms that, in patients who had undergone to potentially curative surgical excision of the primary RCC, it should always be considered the possibility of mRCC as a differential diagnosis when an unusual solitary hypervascular lesion manifests in head and neck, even long time after the surgery.
References [1] Ritchie AWS, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983;10:390–400. [2] Gottlieb MD, Roland JT. Paradoxical spread of renal cell carcinoma to the head and neck. Laryngoscope 1998;108:1301–5. [3] Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982;6:655–63. [4] Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11–30. [5] Griffin N, Gore ME, Sohaib SA. Imaging in metastatic renal cell carcinoma. AJR Am J Roentgenol 2007;189:360–70. [6] Ascenti G, Visalli C, Genitori A, Certo A, Pitrone A, Mazziotti S. Multiple hypervascular pancreatic metastases from renal cell carcinoma: dynamic MR and spiral CT in three cases. Clin Imaging 2004;28:349–52. [7] Mazziotti S, Zimbaro F, Pandolfo A, Racchiusa S, Settineri N, Ascenti G. Usefulness of contrast-enhanced ultrasonography in the diagnosis of renal pseudotumors. Abdom Imaging 2010;35:241–5. [8] Pritchyk KM, Schiff BA, Newkirk KA, Krowiak E, Deeb ZE. Metastatic renal cell carcinoma to the head and neck. Laryngoscope 2002;112:1598–601. [9] Sountoulides P, Metaxa L, Cindolo L. Atypical presentations and rare metastatic sites of renal cell carcinoma: a review of case reports. J Med Case Rep 2011;5:429. [10] Hong SL, Jung DW, Roh HJ, Cho KS. Metastatic renal cell carcinoma of the posterior nasal septum as the first presentation 10 years after nephrectomy. J Oral Maxillofac Surg 2013;71:1813.e1–7. [11] Sotiriadou K, Kalogeridi MA, Roupakia A, Mpozios G, Kyrgias G. Unusual site of metastatic renal cell carcinoma at pterygopalatine fossa and maxillary sinus. Case report. Oral Oncol 2013;49:139–40. [12] Ziania Y, Abira B, Chahdib H, Albouzidib A, Abouchadia A, ElKhatiba K. Infratemporal metastasis from a renal cell carcinoma. Rev Stomatol Chir Maxillofac Chir Orale 2014;115:181–4. [13] Tiwari R, Quak J, Egeler, Smeele L, Waal IV, Valk PV, Leemans R. Tumors of the infratemporal fossa. Skull Base Surg 2000;10:1–9. [14] Gupta M, Motwani G, Gupta P. Extranasopharyngeal angiofibroma arising from the infratemporal region. Indian J Otolaryngol Head Neck Surg 2006;58: 312–5. [15] Morita N, Morimoto K, Yonezawa K, Otsuki N, Nibu KI. Infratemporal fossa metastasis of papillary thyroid cancer. Head Neck 2013;35:119–21. [16] Sohns JM, Staab W, Sohns C, Schwarz A, Streit U, Hosseini AS, Spiro JE, Kertész A, Zwaka PA, Lotz J. Current perspective of multidetector computed tomography (MDCT) in patients after midface and craniofacial trauma. Clin Imaging 2013;37: 728–33. [17] Escudier B, Eisen T, Porta C, Patard JJ, Khoo V, Algaba F, Mulders P, Kataja V. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23:65–71.
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Solitary metastasis of renal cell carcinoma in infratemporal fossa Tommaso D’Angelo, Alfredo Blandino, Giorgio Ascenti, Sergio Vinci, Michele Gaeta, Silvio Mazziotti ⁎ Department of Biomedical Sciences and Morphological and Functional Imaging, University of Messina, Policlinico “G. Martino” Via Consolare Valeria 1, 98100, Messina, Italy
a r t i c l e
i n f o
Article history: Received 14 April 2014 Received in revised form 21 July 2014 Accepted 28 July 2014 Keywords: Renal cell carcinoma Infratemporal fossa Solitary metastasis Magnetic resonance Computed tomography
a b s t r a c t Renal cell carcinoma can recur at any time after nephrectomy, and it is not unusual to detect late metastases even decades after surgical excision of the primary tumor. Despite being infrequently reported, head and neck metastases may be linked to renal cell carcinoma in up to 15% of cases. We present an unusual case of a single metachronous renal cell carcinoma metastasis in the infratemporal fossa, with a 13-year late onset from the primary. © 2015 Elsevier Inc. All rights reserved.
1. Introduction Late tumor recurrence of renal cell carcinoma (RCC) many years after the initial treatment can occasionally occur. The most common sites of tumor spread are the lung (50–60%), liver (30–40%), and bone (30%) [1]. Metastatic spread of RCC to the head and neck region is rarely seen, despite that head and neck metastases may be linked to RCC in up to 15% of cases [2]. In this study, we present a case of a single, solitary RCC metachronous metastasis in the infratemporal fossa (ITF), with a 13year late onset from the primary. This is a very seldom case of distant metastasis of RCC in the ITF. In particular, the additional peculiarity of this case was the lack of disease elsewhere in the body. 2. Case report A nonsmoker 67-year-old male, with a history of right nephrectomy for RCC in 2001 (T2, N0, M0, and Grade 3 according to the Fuhrmann grading system), came to our observation for persistent mild swelling of the left cheek and infraorbitary region, associated with masticatory discomfort and dull facial pain [3]. A magnetic resonance (MR) examination was performed on 1.5 T scanner (Gyroscan Intera, Philips, Best, The Netherlands) with the following scan parameters: TSE T1-weighted sequence along the axial plane: TR 646 ms, TE 16 ms, turbo factor 4, matrix 512×512; TSE T2-weighted sequence along axial and coronal planes: TR 3656 ms, TE 90 ms, turbo factor 15, 512×512 matrix; TSE T1-weighted sequence with fat suppression (selective partial inversion recovery: SPIR) along the axial plane: TR 528 ms, TE 8 ms, turbo factor 4,
⁎ Corresponding author. Dept. of Radiological Sciences, Policlinico “G. Martino,” Via Consolare Valeria, 1, 98100 Messina, Italy. Tel.: +39-0-902213092; fax: +39-0-902213720. E-mail address: [email protected] (S. Mazziotti). http://dx.doi.org/10.1016/j.clinimag.2014.07.013 0899-7071/© 2015 Elsevier Inc. All rights reserved.
352×352 matrix, obtained before and after iv injection of Gadolinium at a dosage of 0.2 mmol/kg and a flow rate of 3 ml/s, followed by a bolus of 10-ml isotonic saline at 3-ml/s flow rate. MRI revealed a highly enhanced space-occupying soft tissue mass centered in the left ITF with extension in the adjacent pterygopalatine fossa and masticatory space. The lesion caused the scalloping and remodeling of the posterior wall of maxillary antrum. Moreover, a minor posterosuperior projection of the lesion was also seen; it determined the erosion of the anterior wall of middle cranial fossa but without any signs of infiltration of the temporal lobe (Fig. 1). Subsequently, a total-body contrast-enhanced multidetector computed tomography (CE-MDCT) was executed with a 64-row multislice CT scanner (Somatom Definition 64, Siemens Medical Solutions, Forchheim, Germany). However, a contrast-enhanced study of the maxillofacial district was firstly considered to be crucial and compulsory, and it was performed with dynamic acquisition techniques obtained after iv administration of 80 ml of iodinated contrast agent, differentiating the purely arterial phase (to better delineate the vascularization of the lesion) from the venous and interstitial phase. Scan parameters were set as follows: 64×0.75-mm scan collimation, reconstruction increment 0.70 mm, pitch 0.75, mAs 80, potential (kV) 120, CDTIvol (mGy) 6.24, isotropic voxel, FOV 200 mm, rotation time 0.50 s; matrix of acquisition 512×512, matrix of reconstruction 512×512. Images were reconstructed using both a soft tissue (kernel h31) and a high-resolution bone algorithm (kernel h60) with 1-mm thickness. Subsequently, after a further iv injection of 50 ml of iodinated contrast agent, CE-MDCT was extended to thoracic and abdominal regions. CE-MDCT emphasized the early enhancement of the mass in left ITF and the use of multiplanar reconstructions (MPR) with bone algorithm better defined the focal erosion of the anterior wall of the left greater wing of sphenoid bone (Fig. 2). However, no other lesion was demonstrated elsewhere in the body.
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T. D’Angelo et al. / Clinical Imaging 39 (2015) 155–157
Fig. 1. Axial T1-weighted (a) and T2-weighted MR images (b) show a mildly hyperintense oval-shaped soft-tissue mass (6 cm×4 cm×4 cm), in the left ITF, displacing anteriorly the posterior wall of the maxillary antrum (arrowheads). Note the medial extension to the pterygopalatine fossa (asterisk) and the erosion of the anterior wall of middle cranial fossa (black arrows). No cerebral infiltration can be seen. Intralesional serpiginous “flow-voids” (white arrows) come out in favor of high vascularization. Axial fat-suppressed T1-weighted MR image, obtained after intravenous injection of contrast medium (c) confirmed homogeneous hyper-enhancement and the presence of intralesional small vessels (black arrows).
Prior to biopsy, the patient underwent selective external carotid angiography (Fig. 3), followed by a therapeutic embolization to reduce the risk of severe bleeding. The transoral biopsy was successively obtained via the gingivolabial sulcus. Microscopic examination (not shown) revealed a clear cell adenocarcinoma consistent with the patient's primary renal tumor. The lesion was considered to be unresectable due to the involvement of pterygopalatine fossa and to its extension toward the middle cranial fossa. Therefore, the patient rapidly underwent to systemic chemotherapy treatment with antiangiogenic drugs. Follow-up at 3 months showed only a mild reduction of the volume of the lesion that was not considered to be enough significant to indicate metastasectomy.
3. Discussion RCC accounts for 3–5% of all malignant tumors in adults [4]. RCC can recur at any time after nephrectomy, and it is not unusual to detect late metastases even decades after the potentially curative surgical excision of the primary tumor [5–7].
The location of metastases and their clinical features, onset, evolution, and prognosis are very variable in RCC. The most common sites of tumor spread are the lung (50–60%), liver (30–40%), bone (30%), and brain (5%) [1,4]. Despite being infrequently reported, metastases in head and neck region may be linked to RCC in up to 15% of cases, even though they are almost always associated with other lesions in the most common sites [1,2,8]. Moreover, RCC is the third most frequent neoplasm to metastasize to head and neck region, preceded only by breast and lung cancer. The nose and paranasal sinuses are most commonly affected and are followed by the oral cavity [8–11]. Although it has been recently described a rare case of metastatic RCC (mRCC) in ITF that was associated with the involvement of other sites (i.e., lung, contralateral kidney), our case is the first in which an ITF lesion represents the first and the solitary sign of mRCC [12]. This very unusual location raises difficulties about the differential diagnosis with the other more common lesions of this anatomic region. Anatomically, the ITF lies on the lateral aspect of the cranial base and deep to the zygomatic arch, the masseter muscle, and the mandibular ramus. Diseases within the ITF are usually infectious or neoplastic. In our case, the lack of erythema, drainage, fever, and of
Fig. 2. Sagittal CT image reformatted with bone algorithm (a) clearly shows the anterior displacement of the posterior wall of the left maxillary antrum (small arrows) and the erosion of the anterior wall of the left greater wing of sphenoid bone (arrowheads). Postcontrast coronal (b) reformatted CT images, obtained in the arterial phase, confirms the early enhancement of the mass with evidence of small arterial vessels in its context (arrows). Note the intracranial extension of the lesion, through the floor of middle cranial fossa (arrowheads).
T. D’Angelo et al. / Clinical Imaging 39 (2015) 155–157
Fig. 3. Preembolization carotid angiogram demonstrating the rich vascularization of the lesion with afferences from left internal maxillary artery (asterisks) and its main trunks.
elevated white blood cell count were all inconsistent with the hypothesis of an infection. Neoplasms involving the ITF may originate from the tissues of this region, but they are more often the result of an extension of tumors arising from the neighboring structures [13]. Benign mesenchymal neoplasms that can be found in the ITF include neurilemmoma, chordoma, paraganglioma, angiofibroma, hemangioma, and arteriovenous malformation [13,14]. Among these lesions only nasopharyngeal angiofibroma shows similar MR and CT findings (i.e., expansile hypervascular solid lesion), but it is well known how angiofibroma typically affects young adults, with only a few cases reported in older people [14]. Benign epithelial neoplasms including inverted papilloma, as well as salivary gland tumors such as pleomorphic adenoma, should also be considered, but all these lesions very rarely show hypervascularity [13]. Finally, malignant neoplasms including a variety of sarcomas, carcinomas of salivary gland origin, lymphoma, and metastatic foci from distant sites elsewhere can also be remotely considered [13,15]. The metastatic patterns of RCCs are not yet defined with accuracy, and RCC has been associated with rare metastatic sites and occasionally with atypical presenting symptoms, deriving from the distant metastatic sites and/or from disseminated disease. Because of its concealed location and multiple structures that lie within it, diseases involving the ITF may present with a variety of signs and symptoms that make difficult an early diagnosis even because of their late onset. Usually surgery should be offered as the treatment of choice for the solitary metastasis of RCC, since it has been seen to increase the overall survival. However, the proximity of this area to the intracranial structures, the paranasal sinuses, the nasopharynx, the orbit and the facial area demands a careful preoperative planning of surgical excision. For such reason the usage of multiplanar imaging has become a mandatory step to evaluate this region. In fact, while US imaging is often limited either by the deep location of these lesions (frequently covered by facial bones) or by the relative dependence on
157
a skilled operator, MR and CT imaging well depict the anatomic structures of this area. In fact, due to its excellent contrast resolution, MRI is essential to delineate any lesion from the nearby soft tissues and to evaluate any intralesional bleeding. Likewise, CE-MDCT, thanks to its elevated spatial resolution, is crucial to evaluate the maxillofacial district, highlighting any bone erosion or disruptions as well as depicting the supplying vessels of a lesion [16]. Numerous surgical approaches, including the infratemporal approach, the orbitozygomatic approach, facial dismasking, and the maxillary swing approach, have been developed over the years [13]. However, in our case, surgery was not feasible due to the local infiltration of pterygopalatine fossa and to the erosion of the anterior wall of middle cranial fossa. As a consequence, the patient rapidly underwent to a systemic neoadjuvant chemotherapy treatment with antiangiogenic drugs to further reduce the vascularization and the volume of the metastasis. The follow-up at 3 months showed only a mild volume reduction of the metastasis, not yet significant for the indication of metastasectomy [17]. Finally, our case further confirms that, in patients who had undergone to potentially curative surgical excision of the primary RCC, it should always be considered the possibility of mRCC as a differential diagnosis when an unusual solitary hypervascular lesion manifests in head and neck, even long time after the surgery.
References [1] Ritchie AWS, Chisholm GD. The natural history of renal carcinoma. Semin Oncol 1983;10:390–400. [2] Gottlieb MD, Roland JT. Paradoxical spread of renal cell carcinoma to the head and neck. Laryngoscope 1998;108:1301–5. [3] Fuhrman SA, Lasky LC, Limas C. Prognostic significance of morphologic parameters in renal cell carcinoma. Am J Surg Pathol 1982;6:655–63. [4] Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin 2013;63:11–30. [5] Griffin N, Gore ME, Sohaib SA. Imaging in metastatic renal cell carcinoma. AJR Am J Roentgenol 2007;189:360–70. [6] Ascenti G, Visalli C, Genitori A, Certo A, Pitrone A, Mazziotti S. Multiple hypervascular pancreatic metastases from renal cell carcinoma: dynamic MR and spiral CT in three cases. Clin Imaging 2004;28:349–52. [7] Mazziotti S, Zimbaro F, Pandolfo A, Racchiusa S, Settineri N, Ascenti G. Usefulness of contrast-enhanced ultrasonography in the diagnosis of renal pseudotumors. Abdom Imaging 2010;35:241–5. [8] Pritchyk KM, Schiff BA, Newkirk KA, Krowiak E, Deeb ZE. Metastatic renal cell carcinoma to the head and neck. Laryngoscope 2002;112:1598–601. [9] Sountoulides P, Metaxa L, Cindolo L. Atypical presentations and rare metastatic sites of renal cell carcinoma: a review of case reports. J Med Case Rep 2011;5:429. [10] Hong SL, Jung DW, Roh HJ, Cho KS. Metastatic renal cell carcinoma of the posterior nasal septum as the first presentation 10 years after nephrectomy. J Oral Maxillofac Surg 2013;71:1813.e1–7. [11] Sotiriadou K, Kalogeridi MA, Roupakia A, Mpozios G, Kyrgias G. Unusual site of metastatic renal cell carcinoma at pterygopalatine fossa and maxillary sinus. Case report. Oral Oncol 2013;49:139–40. [12] Ziania Y, Abira B, Chahdib H, Albouzidib A, Abouchadia A, ElKhatiba K. Infratemporal metastasis from a renal cell carcinoma. Rev Stomatol Chir Maxillofac Chir Orale 2014;115:181–4. [13] Tiwari R, Quak J, Egeler, Smeele L, Waal IV, Valk PV, Leemans R. Tumors of the infratemporal fossa. Skull Base Surg 2000;10:1–9. [14] Gupta M, Motwani G, Gupta P. Extranasopharyngeal angiofibroma arising from the infratemporal region. Indian J Otolaryngol Head Neck Surg 2006;58: 312–5. [15] Morita N, Morimoto K, Yonezawa K, Otsuki N, Nibu KI. Infratemporal fossa metastasis of papillary thyroid cancer. Head Neck 2013;35:119–21. [16] Sohns JM, Staab W, Sohns C, Schwarz A, Streit U, Hosseini AS, Spiro JE, Kertész A, Zwaka PA, Lotz J. Current perspective of multidetector computed tomography (MDCT) in patients after midface and craniofacial trauma. Clin Imaging 2013;37: 728–33. [17] Escudier B, Eisen T, Porta C, Patard JJ, Khoo V, Algaba F, Mulders P, Kataja V. Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2012;23:65–71.
