Renal cell carcinoma presenting as solitary foot metastasis

Rajiv Yadav, M.S. Ansari & P.N. DograDepartment of Urology, All India Institute of Medical Science, New Delhi 110029, India

Abstract. Skeletal metastases from genitourinary tract are common, but metastatic tumors involving thehand and foot are rare. We herein present a case of 55-year-old man who presented with painful swelling ofright foot and no urological complaints. Investigations revealed left renal mass and fine needle aspirationcytology from the swelling revealed findings consistent with metastatic clear cell carcinoma.

Key words: Foot, Metastasis, Renal cell carcinoma

Introduction

The literature has shown the overall incidence ofmetastatic tumors in bone as 30% and greater [1].Included among the tumors that commonlymetastasize to bone are those of the kidney, lung,breast, prostate, and colon. Nearly 80% of allmetastatic lesions are found centrally in the skel-eton and approximately 10% are in the long bones[2]. Metastasis to the distal appendicular skeletonis extremely rare. Bloodgood reported the first caseof metastatic disease involving the bones of thefoot in 1920 [3]. However only scattered publishedreports [4–7] have appeared in the literature sincethen.

Renal cell carcinomas are notorious for theirtendency to metastasize early, often before theprimary tumor has become apparent and symp-toms associated with this metastasis may actuallyinitiate the diagnosis. We recently observed a pa-tient whose first clinical presentation of renal cellcarcinoma was that of a metastatic lesion inmetatarsal.

Case report

A 55-year-old male was seen at our outpatientclinic for evaluation of progressive painful swellingof right foot of 1-month duration. The patientdenied all genitourinary symptoms and was

otherwise well. Physical examination revealed dif-fusely tender non-pulsatile swelling on the dorsumof the foot with tense overlying skin (Figure 1a).Laboratory studies showed a normal hemogram,urinalysis, blood urea nitrogen, electrolytes, cal-cium, phosphorus, uric acid, and phosphatase.Roentgenogram of the chest was normal. Aroentgenogram of the foot revealed expansion andextensive destruction of the second metatarsal by ahomogenous soft tissue mass, which had replacedalmost the entire bone (Figure 1b). Subsequentfine needle aspiration cytology from the swellingrevealed findings consistent with metastatic clearcell carcinoma. Further workup of the patient withabdominal ultrasonography confirmed the pres-ence of tumor in left kidney (Figure 2).

Discussion

Renal cell carcinomas account for approximately85% of all malignant renal tumors [4]. It has a highpropensity for early metastasis and evidence ofmetastases is present in about one third of patientsat presentation [8]. Although renal cell carcinomamay metastasize to any organ system, osseousmetastases are common. Nearly one third of thiscarcinoma metastasizes to bone, but only rarely dothey involve the distal extremities [4, 9, 10]. Theinfrequency of metastasis in these parts of theskeleton centers is attributed to the relative paucity

International Urology and Nephrology 36: 329–330, 2004.� 2004 Kluwer Academic Publishers. Printed in the Netherlands.

329

of red marrow in these bones [11], because hema-togenous spread is the most frequent route ofmetastasis. When genitourinary malignancies dometastasize to bones of the feet the tarsal bones areinvolved in about 50% of the cases [6]. The cal-caneus is reported to be the most common site ofinvolvement [1, 12] while metatarsal are involvedin 23% of the cases [6].

After the diagnosis of peripheral metastasis, theaverage survival of a patient with a foot lesion isonly 12 months and thus the goal of therapyshould be palliation of symptoms [10].

References

1. Gall RJ, Sim FH, Pritchard DJ. Metastatic tumors to the

bones of the foot. Cancer 1976; 37: 1492.

2. McNeil BJ. Value of bone scanning in neoplastic disease.

Semin Nucl Med 1984; 14: 277.

3. Bloodgood JC. Bone tumors, benign and malignant: a

brief summary of the salient features, based on a study of

some 370 cases. Am J Surg 1920; 34: 229.

4. Anderson EE, Leitner WA, Boyarsky S et al. Renal cell

carcinoma metastatic to great toe. J Bone Joint Surg 1968;

50A: 997.

5. Wu KK. Metastatic lesion of the foot. J Foot Surg 1987;

26: 164.

6. Zindrick MR, Young MP, Daley RJ, Light TR. Meta-

static tumors of the foot: case report and literature review.

Clin Orthop 1982; 170: 219.

7. Mulvey RB. Peripheral bone metastases. AJR 1964; 91:

155.

8. Middleton RG. Sugery for metastatic renal cell carcinoma.

J Urol 1967; 97: 973.

9. Bhardwaj S, Holland JF. Chemotherapy of metastatic

cancer in bone. Clin Orthop 1982; 169: 28.

l0. Bunkis J, Carter RD. Peripheral bone metastasis from

genitourinary tumors. Urology 1982; 19: 304.

11. Kerin R: The hand in metastatic disease. J Hand Surg

1987; 21 A: 77.

12. Robey EL, Schellhammer PF. Solitary lesions on bone

scan in genitourinary malignancy. J Urol 1980; 132: 1000.

Address for correspondence: M.S. Ansari, Department of

Urology, All India Institute of Medical Science, New Delhi

110 029, India

Phone: 981-054-8618

E-mail: ansarimsa@hotmail.com

Figure 1. (a) Swelling on the dorsum of right foot, (b) Roentgenogram of the right foot showing almost total lysis of the secondmetatarsal bone.

Figure 2. Ultrasonogram showing mass lesion in the left kidney.

330