Renal Cell Carcinoma Presenting as an Isolated Eyelid Metastasis

Abstract

Background: Renal cell carcinoma (RCC) has a propensity to metastasize with the most common sites of metastasis being the lungs and bones. Cutaneous metastasis of RCC to the eyelid is exceedingly rare, with only six cases reported in the past decade. We are reporting a case of metastatic renal cell carcinoma (mRCC) that presented with a painless eyelid mass.

Case Presentation: We describe a case of a 66-year-old man with a history of chronic kidney disease stage III presenting with a rapidly growing left lower eyelid lesion thought to be a capillary hemangioma. Biopsy revealed polygonal clear cells with small central nuclei with thin-walled vasculature and strong immunostaining with PAX8 consistent with mRCC, clear cell type. Subsequent abdominal CT scan revealed a 5.1 × 4.7 × 4.3 cm heterogeneously enhancing mass with central necrosis in the upper pole of the left kidney. The patient was treated with excision of the eyelid lesion followed by robotic partial nephrectomy of the primary tumor. Follow-up CT scan at 3 and 6 months showed no evidence of recurrence.

Conclusion: Isolated eyelid metastasis is an extremely rare form of presentation of mRCC. Interestingly, that patient did not have any other site of metastasis. Cytoreductive partial nephrectomy has been previously reported to be oncologically safe in selected patients.

Introduction and Background

Renal cell carcinoma (RCC) accounts for 4.2% of new cases of adult cancers and is the most common neoplasm of the kidney. RCC has a propensity to metastasize, with ∼16% of RCC patient with metastasis at initial presentation. The most common sites of metastasis are the lungs and bones. Cutaneous manifestations of metastatic renal cell carcinoma (mRCC) are rare, favoring the head and neck areas. We present a case report of a patient presenting with solitary eyelid metastasis of RCC, treated with excision of the eyelid lesion and resection of the primary tumor with robotic partial nephrectomy (RPN).

Presentation of Case

A 66-year-old man initially presented to ophthalmology with a left lower eyelid lesion, thought to be a capillary hemangioma, which was present for 3 months and growing rapidly (Fig. 1). His past medical history includes chronic kidney disease (CKD) stage III. Shave biopsy of the lesion showed cells with clear cytoplasm (from lipid/glycogen), distinct but delicate cell boundaries, and thin walled, “chicken wire” vasculature consistent with clear cell RCC (Fig. 2). The eyelid lesion was excised with negative margins. CT with contrast revealed a 5.1 × 4.7 × 4.3 cm heterogeneously enhancing lesion with central necrosis involving the upper pole of the left kidney, consistent with RCC (Fig. 3). CT showed no evidence of metastasis or vascular invasion, and MRI of the brain showed no intracranial metastasis.

FIG. 1.

Eyelid lesion at initial presentation.

FIG. 2.

Polygonal cells with clear cytoplasm and delicate vasculature called “chicken wire like” vasculature in the presence eyelid squamous epithelial lining.

FIG. 3.

CT with contrast showing a 5.1 cm enhancing left renal tumor.

The patient was urgently referred to urology and underwent left RPN. Surgery was uneventful with warm ischemia time of 24 minutes. Grossly the tumor was a well-circumscribed solid golden yellow mass with hemorrhage. Microscopically the tumor consisted of round/polygonal cells with central nuclei and eosinophilic cytoplasm with delicate branching vasculature. Surgical pathology report demonstrated Fuhrman grade IV T1b clear cell RCC with negative margins. The patient had an uneventful postoperative course and discharged the next day. The patient did not receive any postoperative systemic therapy. At the last follow-up visit 6 months after partial nephrectomy (PN), the patient was doing well and had no complaints. Follow-up CT-PET scan at 3 and 6 months showed no evidence of metastasis.

Discussion and Literature Review

This patient had mRCC with a solitary metastatic lesion to the eyelid and no further evidence of metastasis, vascular invasion, or pathologic lymph nodes. Given our patient's history of CKD stage III, PN was chosen as the optimal treatment that would also preserve maximal renal function. Although most mRCC is treated with radical nephrectomy (RN), there has been an increased trend toward the use of PN. In a large study charting trends and overall survival of PN versus RN in treating mRCC, the use of PN increased from 1.8% to 4.3% within the period of 2006 to 2013, whereas also conferring an improved overall survival for primary tumors <4 cm.¹ Another large study demonstrated that PN had lower other-cause mortality rate and no difference in cancer-specific mortality rate compared with RN in the treatment of mRCC.²

The robotic approach to cytoreductive PN has been rarely reported. We believe that in carefully selected patient, the robotic approach offers comparable oncologic results to the open 1.

Cutaneous metastasis of RCC to the eyelid is exceedingly rare, with only six cases reported in the past decade.³ Eyelid metastasis was the initial presentation in three of those cases, and in one of the three cases it was the sole metastatic lesion, as with this case report. In Ramez et al.³ the patient underwent total nephrectomy, excision of the eyelid lesion, and routine surveillance with no evidence of recurrence after 2 years.

Routine surveillance without postoperative targeted therapy was chosen after complete metastasectomy of mRCC for this patient. There are no large studies that demonstrate the need for systemic or targeted therapy after complete metastasectomy of mRCC. One smaller study examining 53 patients with mRCC status post-complete metastasectomy found that there was 26.3% recurrence in the 19 patients on postoperative targeted therapy versus 79.4% recurrence in the 34 patients not on postoperative targeted therapy.⁴ However, this study did not separate patients on the number of metastases, and our patient with only a solitary metastatic lesion and without vascular invasion or pathologic lymph nodes was deemed to have favorable odds of remission without the need for targeted therapy. More investigation is needed to determine the role of systemic or targeted therapy in mRCC status post-complete metastasectomy.

Conclusion

This article describes an extremely rare metastasis of RCC to the eyelid. Excision of the eyelid tumor followed by cytoreductive RPN were performed with no evidence of recurrence at an intermediate-term follow-up.

Abbreviations Used

CKD

chronic kidney disease

CT

computed tomography

mRCC

metastatic renal cell carcinoma

MRI

magnetic resonance imaging

PET

positron emission tomography

PN

partial nephrectomy

RCC

renal cell carcinoma

RN

radical nephrectomy

RPN

robotic partial nephrectomy

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Cite this article as: Mikail N, Belew D, Ullah A, Payne-Jamaeu Y, Patel N, Kavuri S, White J, Rabii M (2020) Renal cell carcinoma presenting an isolated eyelid metastasis, Journal of Endourology Case Reports 6:4, 322–324, DOI: 10.1089/cren.2020.0107.