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Renal Cell Carcinoma Presenting as a Scalp Cutaneous Metastasis: A Case Report
Apresentação do caso
A 63-year-old female presented with a 4-month history of an enlarging scalp solitary nodule that rapidly grew into a bleeding pedunculated tumor. Reports weight loss of 10 kg during this period. Physical examination showed a 8,5x6,0x3,5 cm polypoid, pedunculated tumor with firm consistency and a violaceous base with hemorrhage spots. An excisional biopsy was performed and the scalp was reconstructed with a skin flap. Histopathology revealed a clear-cell proliferation in dermis and hypodermis, compatible with metastatic Renal Cell Carcinoma (RCC). The surgical margins were negative. Immunohistochemistry was positive for CD10 and PAX8 markers, supporting the diagnosis of Cutaneous Metastases of RCC (CMRCC). The patient was submitted to an Abdomino-Pelvic CT that revealed a 15,0x11,8x11,3 cm lesion with heterogeneous uptake after contrast and involvement of the renal capsule, extending to the pancreas. Thoraco CT showed multiple nodular lesions diffusely affecting the lungs compatible with metastatic implants. Cranial CT did not show any evidence of metastases. The patient was sent home with support measures, where she died two months later.
RCC is a common urological malignancy, representing 85% of all primary renal neoplasms and 2% of all adult malignancies. RCC is twice more common in males compared with females, and the median age at diagnosis is 64 years of age. It is characterized by late and unspecific symptoms like fatigue and weight loss. RCC most frequently metastases to lungs (43-69%), liver (17-39%), bones (27-36%) and brain (2-16%). The incidence of cutaneous metastasis in RCC is around 3,3%. The most common site for CMRCC is the scalp and face, emerging as single lesions that grow rapidly. Macroscopic differential diagnosis includes angioma, cutaneous horn and basal cell carcinoma. The prognosis of disseminated RCC is poor, with a 5-year survival of 0–32% and a mean of 7 months survival after the diagnosis of CMRCC. Surgical removal of the skin lesion is recommended when there are features such as rapid growth, local extension or bleeding. Selected cases of CMRCC have been considered to undergo radiotherapy. Adjuvant therapy for solitary CMRCC has not been described yet.
Although rare, CMRCC should always be an important differential diagnosis in patients who present with rapidly growing and irregular lesions at unusual skin sites. Full skin examination followed by immunohistochemical analysis is essential, as this leads to appropriate diagnosis.
renal cell carcinoma; cutaneous metastasis; scalp metastasis
ANA PAULA STRAZAS, GABRIEL VOLPATO, LUIGGI ANSELMO LEONARDI