Abstract
Cancer metastases to the oral cavity are reported infrequently. Renal cell carcinoma has a high metastatic potential, with approximately one third of patients presenting with metastatic disease. New lesions in the oral cavity often rely on preoperative biopsy to establish the diagnosis. However, we report an unusual case in a setting of known renal cell carcinoma disease, where initial pathology and culture data were misleading. Appropriate follow-up and a high index of suspicion will remain necessary. Surgical excision is the treatment of choice.
1
Introduction
Only 1% of oral cavity malignancies are metastatic lesions, often originating from primary tumors in the lungs, skin, and breast . Renal cell carcinoma (RCC) is a disease with a variable clinical course, wherein 40% to 50% of patients develop distant metastasis . Resection of metastases from RCC is associated with improved survival, although the selection criteria have been poorly defined. Here, we report a patient with unusual bilateral RCC metastases to the oral cavity.
2
Case report
A 63-year-old white man presented to his medical oncologist with a 3-week history of constipation, intermittent nausea, and vomiting. After identifying significant hypercalcemia (13.7 corrected), he was admitted to our institution for further evaluation. During the admission, the patient described a 2-month history of progressively enlarging bilateral oral lesions. He noted that a similar mass was discovered by his dentist 1 year prior. At that time, the dentist had prescribed nystatin mouth rinse, and the lesions had responded.
The patient’s medical history is significant for clear cell RCC of the left kidney, diagnosed 2 years prior, with computer tomography and bone scan showing extensive disease metastases to brain, bone, lungs, nodes, and adrenals. His treatment history thereafter includes whole brain radiation therapy (total, 3750 cGy), sunitinib, and sorafenib.
Upon hospital admission, the patient complained that the lesions were becoming progressively larger and made eating difficult. He denied any fever, trismus, or pain. Intraoral examination revealed bilateral, friable, fungating masses with a foul odor ( Fig. 1 ). These were located at the superior alveolus bilaterally and covered with a grayish exudate and bled on manipulation. The lesions were cultured for bacteria and fungus, and a biopsy was obtained at the bedside and sent to pathology.
The pathology report indicated granulation tissue with extensive necrosis with no evidence of malignancy. The cultures indicated 4+ mixed Gram-positive and Gram-negative organisms, including Candida albicans . The patient was discharged with fluconazole and Bactrim and scheduled for appropriate follow-up.
The patient presented 5 days later for follow-up and reported an increased difficulty tolerating anything by mouth. The patient was admitted because of failure of conservative measures and for evaluation of possible surgical resection.
On reevaluation, the lesions seemed to have diminished and were without the previously noted exudate. In addition, a pedunculated right tonsillar tag with granulation tissue similar to the alveolar lesions was also appreciated. The patient was taken to the operating room, and the large bilateral masses were removed ( Fig. 2 ) along with the tonsillar tag using electrocautery. The patient tolerated the procedure well and returned to the oncology unit after this procedure. His diet was advanced slowly, and the patient was able to tolerate soft food by the end of his hospital stay. The patient was discharged on postoperative day 4.
