An Older Woman Presenting with Jaw Pain and a Kidney Mass

Abstract

Case Description

A 91-year-old woman presented with 6 months of worsening jaw pain and increased shortness of breath. She had a medical history significant for rheumatoid arthritis, atrial fibrillation, chronic anemia, and chronic pain for which she took daily oxycodone. The patient never smoked. She presented to the emergency department with dyspnea and hypoxia which was attributed to her oxycodone use. Physical examination revealed a right mandibular jaw mass. No cervical lymphadenopathy, trismus, or parotid gland swelling was found. Laboratory investigation revealed BUN 23 mg/dl and serum creatinine 0.8 mg/dl. Computed tomography of the maxillofacial structures demonstrated a 3.5-cm destructive soft tissue mass extending from the angle of the mandible through the distal mandibular body with a resultant displaced pathologic fracture of the right mandibular body (Figure 1A). A large destructive mass at the level of C3 extending into the spinal cord was also found. There was almost complete destruction of C3 vertebral body (Figure 1B). Biopsy of the mandibular lesion was performed, and a pathologic diagnosis of renal cell carcinoma (RCC) was made. Computed tomography abdomen/pelvis revealed a large 8.5-cm multilobulated mass replacing most of the right kidney (Figure 1C).

Figure 1.

Primary tumor and extrarenal metastases. (A) Maxillofacial CT scan without contrast demonstrating a 3.5-cm destructive soft tissue mass extending from the angle of the mandible through the distal mandibular body with a resultant displaced pathologic fracture of the right mandibular body. (B) Cervical spine CT scan without contrast demonstrating a marked lytic destruction of C3 vertebral body extending into the paraspinal soft tissues, ventral epidural space, and C2–C3 disk space. There is severe central canal narrowing and compression of the cervical cord as well as destruction of the C2 and C4 vertebral bodies. (C) Abdomen/pelvis CT scan (contrast-enhanced) demonstrating a large 8.5-cm multilobulated mass replacing most of the right kidney as well as small cysts on the left kidney. CT, computed tomography.

Discussion

RCC is the most common solid tumor of the kidney, representing 90% of primary kidney tumors. The classic presenting symptoms are the triad of hematuria, flank pain, and a palpable abdominal mass (Grawitz triad)¹; however, this presentation only occurs in 10%–15% of patients with RCC.² This disease often presents at advanced stages with metastases³ to the lung, bone, lymph nodes, adrenal glands, and brain. Metastases are believed to be driven by hematogenous or lymphatic spread.⁴ In total, 25%–30% of patients will have metastatic disease at the time of presentation.² RCC commonly spreads to orofacial soft tissues and sinuses; however, only 1% of patients with RCC demonstrate isolated head and neck metastases.¹ Breast, liver, and thyroid cancers are the most common cause of oral metastases in women.⁴ Mandibular lesions that presented in this case would more commonly raise suspicion for a primary head and neck cancer, such as squamous cell carcinoma, parotitis, or Warthin tumor. Previous studies show several cases of RCC metastasic to the head and neck region with a previously established diagnosis; however, very few had these lesions as the initial presentation of disease.³ Oral metastases convey a worse clinical prognosis.⁵

Teaching Points

• Only 10%–15% of patients with RCC present with the classic symptoms of hematuria, flank pain, and palpable abdominal mass.

• When multiple osteolytic lesions are present in the head and neck, it is strongly recommended that a search for the primary tumor be conducted.

Disclosures

All authors have nothing to disclose.

Funding

None.

Author Contributions

Formal analysis: Matthew McAuliffe.

Investigation: Matthew McAuliffe.

Writing – original draft: Matthew McAuliffe.

Writing – review & editing: Kostas Papamarkakis.