Renal Cell Carcinoma with Metastasis to the Clivus 1Amit A. Patel, MD; 1Arjuna B. Kuperan, MD; 1Chirag R. Patel, MD; 2Leroy R. Sharer, MD; 3,4James K. Liu, MD; 1,4Jean A. Eloy, MD
Introduction
Renal cell carcinoma is a uncommon malignancy
which accounts for approximately 3% of all adult
malignancies diagnosed per year. It has been
known to metastasize to unusual distant locations.
We report a case of a renal cell carcinoma with
metastasis to the clivus causing cranial nerve
neuropathy.
Case Report A 59 year-old female with a medical history
notable for hypertension and mental retardation
presented to an outside hospital with progressive
headaches, acute onset left ptosis, diplopia and left
V2 hypoesthesia. CT and MRI scans revealed a
large clival lesion with skull base destruction with
extension into the sphenoid sinuses and
nasopharynx. There was encasement of the left
carotid artery with narrowing of the lumen of the
artery. Endoscopic endonasal extended approach
of this anterior skull base tumor was successfully
performed with near complete
resection. Intraoperative frozen section was
concerning for sarcoma, however, final pathology
showed renal cell carcinoma. Postoperatively the
patient had complete resolution of her cranial nerve
neuropathies. Follow-up CT of the abdomen
revealed a large left renal mass. The patient
elected to undergo palliative radiation treatment.
References 1. Rini BI, Ward JF, Vogelzang NJ. Ch 128 – Primary Neoplasms of the Kidney and
Renal Pelvis. Diseases of the Kidney & Urinary Tract, Ed. Schrier RW, 2007.
2. Alpers CE. Ch 20 – The Kidney. Pathologic Basis of Disease, 8th edition, Ed. Kumar
V, Abbas AK, Fausto N, Aster JC, 2009
3. Traynelis VC, Menezes AH. Chapter 4 – Differential Diagnosis of Clival Tumors.
Chordomas and Chondrosarcomas of the Skull Base and Spine, Ed. Harsh GR,
2003
4. Sagoh M, Kodaki K, Ichikizaki K, Murakami K, Oizumi T, Kawase T, Toya S, Shiga H.
Skull base metastasis from renal cell carcinoma presenting as abducens nerve
paresis: report of two cases. No Shinkei Geka. 1996 Sep;24(9):829-33.
5. Fumino M, Matsuura H, Hayashi N, Arima K, Yanagawa M, Kawamura J. A case of
renal cell carcinoma with metastasis in clivus presenting as diplopia. Hinyokika
Kiyo. 1998 May;44(5):319-21.
6. Pallini R, Sabatino G, Doglietto F, Lauretti L, Fernandez E, Maira G. Clivus
metastases: report of seven patients and literature review. Acta Neurochir 2009
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Discussion
• Renal cell carcinoma accounts for 3% of all malignancies
diagnosed per year. Clear cell renal carcinoma accounts for 85-
90% of all renal carcinoma diagnosed. It typically affects middle
aged to elderly men with a history of smoking.1
• In the most classic presentation, renal carcinoma causes
hematuria, flank pain, and a palpable mass. However, renal
carcinoma is notorious for its protean manifestations including
multiple paraneoplastic syndromes and unusual locations of
metastasis. 10-50% of patients present with metastasis. There
are case reports of metastasis to the heart, thyroid, and even
skeletal muscle.1
• Clear cell carcinomas most likely arise from proximal tubular
epithelium, and usually occur as solitary unilateral lesions.
Histologically, the show a growth pattern that varies from solid to
trabecular or tubular. The tumor cells have a rounded or polygonal
shape and abundant clear or granular cytoplasm, which contains
glycogen and lipids along with delicate branching vasculature.
Most tumors are well differentiated, but some show marked
nuclear atypia with formation of bizarre nuclei and giant cells.2
• The most common type of clival tumor is a chordoma. Other
common possibilities include chondromas, meningiomas, and
chondrosarcomas. Nasopharyngeal malignancies can invade
posteriorly into the clivus. Clival tumors usually present with pain,
cranial nerve neuropathies, and occasionally, cerebellar
dysfunction.3
• On CT scan, malignant clival lesions show bony destruction
and can encase vital structures such as the carotid artery and
cranial nerves III, IV, V and VI. MRI appearance is dependent on
the pathology of the lesions.3
• There have been three case reports of renal carcinoma
presenting with clival metastasis, all in the Japanese literature.
Each case presented with cranial nerve neuropathies. In addition
to renal carcinoma, metastases from other malignancies to the
clivus have been reported.4,5 Pallini et. al reported a case series
of 46 patients who underwent surgery for clival tumors. Seven of
these tumors were diagnosed as metastatic lesions on final
pathology, which included lung adenocarcinoma (two patients)
prostate carcinoma (two patients), melanoma, hepatocarcinoma,
and squamous cell carcinoma of the lung (one patient each).6
• In this case, we report a rare case of clear cell renal
carcinoma presenting as a clival mass with acute onset cranial
nerve neuropathy. Previous reports on similar casea have
discussed this entity but we call attention to the importance of
recognizing this pathology in the contest of endoscopic skull base
surgery, in particular, the role for endoscopic biopsy and
decompression of malignant masses causing cranial nerve
symptoms.
Abstract
Background: Renal cell carcinoma is an
uncommon malignancy which accounts for
approximately 3% of all adult
malignancies. Metastasis from renal cell
carcinoma generally occurs in locoregional lymph
nodes, lungs, liver, bones, and the brain. Other
sites of spread have been described, but are
increasingly infrequent. We describe a rare
metastasis of renal cell carcinoma to the clivus
causing multiple cranial nerve neuropathies treated
by purely endoscopic resection with complete
resolution of symptoms. This is the first report of
clival metastasis due to renal cell carcinoma in the
English literature.
Methods: Case report and current literature
review.
Results: A 59 year old female presented to our
institution from a long term care facility with
headaches and acute onset cranial nerve
neuropathies. Imaging of the head revealed a
large clival based lesion with extension into the
sphenoid sinus and encasement of the carotid
artery. She underwent a transnasal endoscopic
decompression of the large mass. Intraoperative
pathology was positive for a tumor of
mesenchymal origin. Final pathology revealed
metastatic renal cell carcinoma.
Conclusion: This case aims to increase
awareness of this infrequently encountered
disease of the skull base/clivus and offers insight
into the diagnosis and treatment of this rare
entity.
Figure 2. Histopathologic slides demonstrating architecture consistent with clear cell renal carcinoma. (A) Clear cell carcinoma with cellular and nuclear
pleomorphism, also a nested appearance, H&E, 10X., and (B) at higher magnification, 25X (C) Clear cell carcinoma involving bone. H&E, 10X (D) :
Immunohistochemistry for PAX 8: Tumor cell nuclei are positive (considered to be a marker for renal cell carcinoma). DAB with light hematoxylin
counterstain, 10X.
Figure 1. (A) Preoperative CT scan with contrast, axial image demonstrating an enhancing clival lesion encasing the carotid
artery. (B) Reformatted bone window of Figure 1A demonstrating bony destruction of the skull base. (C) Coronal CT scan
image again demonstrating destruction of the skull base and extension into the nasopharynx. (D) Preoperative axial MRI scan
image, T2 FLAIR sequence demonstrating a heterogeneous lesion of the clivus.
Contact Information:
Jean Anderson Eloy, MD, FACS
1Department of Otolaryngology – Head & Neck Surgery, University of Medicine and Dentistry of New Jersey – New Jersey
Medical School, Newark, NJ 2Department of Pathology, University of Medicine and Dentistry of New Jersey – New Jersey Medical School, Newark, NJ 3Department of Neurological Surgery, University of Medicine and Dentistry of New Jersey – New Jersey Medical School,
Newark, NJ 4Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, University of Medicine and Dentistry of
New Jersey – New Jersey Medical School, Newark, NJ
A B
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