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CASE REPORT |
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Year : 2014 | Volume
: 7
| Issue : 2 | Page : 195-197 |
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Thigh metastasis of renal cell carcinoma masquerading as soft tissue sarcoma: A role of MRI
Parag S Bhirud1, Rohit Singh1, Priti Bhirud2, Sharad Kankalia1
1 Department of Urology, Dr. D.Y. Patil Medical College, Hospital and Researh Centre, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India 2 Department of Radiology, Bhirud Hospital, Bhusawal, Maharashtra, India
Date of Web Publication | 4-Feb-2014 |
Correspondence Address: Parag S Bhirud Department of Urology, Dr D.Y. Patil Medical College, Hospital and Researh Centre, Pune India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.126339
Distant metastasis of renal cell carcinoma (RCC) to the sartorius muscle is extremely rare, particularly as an initial presentation. In the present study, we report a rare case of sartorius muscle metastasis from RCC as an initial presentation in a 48-year-old male who presented with a hard painless lump in the right thigh region. Investigation revealed RCC in the right kidney. A radical nephrectomy with wide excision of metastasis was performed. Unusual features on MRI helped in suspecting and further evaluating the metastatic RCC. Keywords: Metastasis, renal cell carcinoma, Sartorius
How to cite this article: Bhirud PS, Singh R, Bhirud P, Kankalia S. Thigh metastasis of renal cell carcinoma masquerading as soft tissue sarcoma: A role of MRI. Med J DY Patil Univ 2014;7:195-7 |
Introduction | | |
Renal cell carcinoma (RCC) has widespread and unpredictable metastatic potential, [1] even after curative nephrectomy is performed. [2],[3] RCC is able to metastasize to virtually any site. The most common sites of metastatic RCC are the lungs, lymph nodes, bones, liver, and brain. [4] In several autopsy series, about 0.4% of cases with RCC had skeletal muscle metastases. [2] Making a diagnosis of metastatic RCC to the skeletal muscle is challenging, because the site is unpredictable, in addition to it being rare. Furthermore, cases of metastasis arising long after nephrectomy have been reported. [2],[5] The differential diagnosis is primary soft-tissue tumor. It is particularly important that benign soft-tissue tumor should be differentiated, because aggressive surgical resection is necessary for metastasized RCC, but not for benign soft-tissue tumor. [6]
Case Report | | |
We present a case of a 48-year-old man presented with right thigh swelling since 6 month which was hard, painless with restricted mobility. He underwent sonography of the lesion which showed solid mass with heterogeneous echo texture. We performed magnetic resonance imaging (MRI) which showed a well defined 13 × 3 × 3 cm, lesion, heterogeneous in signal intensity and isointense to muscle on T1W and heterogeneously hyperintense on T2W [Figure 1], [Figure 2]. Primary soft-tissue tumor was a differential diagnosis. The MRI features were unusual for most soft-tissue tumors having low-signal intensity on T1-WI and high-signal intensity on T2-W. He was planned for biopsy for confirmation of diagnosis. The histology was suggestive of RCC [Figure 3]. Therefore, a diagnosis of metastatic RCC was suspected rather than primary soft-tissue tumor. Contrast CT scan of abdomen and chest was performed, which revealed right renal cell carcinoma. He underwent right radical nephrectomy with wide excision of thigh metastasis. Histopathology confirmed the diagnosis. To our knowledge, it is very rare to have such presentation of metastatic RCC to sartorius muscle.
Discussion | | |
Surgical resection of metastatic RCC reportedly improves the outcome of patients with metastatic RCC, and 5 year survival rates are between 35% and 50% after surgical therapy for solitary metastasis. [3],[7] In the our case, metastatic RCC to the skeletal muscle was detected retrogadely due to special features of swelling on MRI. To our knowledge, this first case report of RCC presenting as thigh swelling. It is difficult to detect metastases to the skeletal muscle on CT, because the area of skeletal muscle to be metastasized can vary. Moreover, the tumors may be painless, and they may go unnoticed when they are small. Also, metastatic RCC to the skeletal muscle must be differentiated from primary soft-tissue tumors. Primary soft-tissue tumors are more common than metastatic tumors to the skeletal muscle. [8] Generally, either open or needle biopsy is necessary in order to make a diagnosis in cases of soft-tissue tumor. In cases where malignancy is proven by a biopsy, the puncture tract should be excised in order to avoid tumor seeding. Dissemination due to a needle biopsy is rare. However, this may not be true for possible hypervascular tumors as in the current case. Furthermore, a needle biopsy has the risk that the tip of the needle may not penetrate the tumor, when the tumor is small. MRI features of metastatic RCC to the skeletal muscle may show high-signal intensity on T1- and T2-weighted MRI. [7],[9] These signal intensities seem to be characteristic for metastatic RCC to the skeletal muscle, even in other previous reports where such points were not emphasized by the authors. [8],[10] In the current case, the characteristic features of MRI for metastatic RCC were beneficial in differentiating it from primary soft-tissue tumor and suspecting the RCC retrospectively, because most cases of primary soft-tissue tumor have low- to iso-signal intensity relative to the skeletal muscle on T1-weighted images and high signal intensity on T2-weighted images. Although lipoma, hemangioma, [11] clear cell sarcoma (malignant melanoma of the soft parts), [12] and alveolar soft-part sarcoma [13] are all known to have high signal intensity on T1-weighted images, fat-suppression MRI is useful to differentiate lipoma. It has been reported that hemangioma can be differentiated from other malignant soft-tissue tumors by the existence of lobulation, septation, and central low signal intensity. [11] On the other hand, clear cell sarcoma (malignant melanoma of the soft parts) and alveolar soft-part sarcoma may be difficult to differentiate from metastatic RCC on MRI. It has been reported that angiography shows that RCC metastatic to the skeletal muscle usually appears as hypervascular lesions. [7],[8] However, MRI may still be beneficial in excluding benign tumors of lipoma and hemangioma from malignant tumors of metastasis RCC, clear cell sarcoma, or alveolar soft-part sarcoma.
Conclusion | | |
Metastatic RCC can present soft tissue swelling, which should be kept in mind while dealing with them. MRI helps in differentiating and suspecting the RCC metastasis from soft tissue tumor.
Aknowledgement | | |
Dr. Surendra Bhirud. Dr. Amarjit Singh, Dean, Padm. Dr. D.Y. Patil Medical College, Pune.
References | | |
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[Figure 1], [Figure 2], [Figure 3]
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