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Solitary Sternal Metastasis of Papillary Renal Cell Carcinoma FREE TO VIEW

Tukisa Smith, MD
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Internal Medicine, SUNY Downstate Medical Center, Brooklyn, NY

Chest. 2014;146(4_MeetingAbstracts):669A. doi:10.1378/chest.1993852
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SESSION TITLE: Cancer Student/Resident Case Report Posters III

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Nearly 20-30% of patients with renal cell carcinoma (RCC) have distant metastasis at presentation, for which solitary bone metastasis represents 1.6-3.6%. We present a rare case of metastatic RCC involving the sternum.

CASE PRESENTATION: We report a 58 year old African American male with past medical history of obesity, hypertension, hyperlipidemia, chronic kidney disease who presented to outpatient primary care for routine follow up, on exam, noted to have a 6.0cmx5.0cm tender indurated mass of midsternal location present for 4 months. The patient underwent CT chest without contrast which revealed a large soft tissue mass measuring 5.6 x 5. 5 arising from the inferior sternum with erosion of the bone and deep extension into the epicardial fat abutting pericardium, remarkable for left axillary lymphadenopathy without mediastinal involvement. A core biopsy was pursued however, procedure was complicated by sanguineous aspirate, thus Level 1 lymph node FNA was performed revealing metastatic papillary RCC. Completion of staging with further imaging was remarkable for low-attenuation lesions in the liver as well as a 4.7 x 5.6 cm exophytic lesions arising from the middle and lower pole of the left kidney. PET/CT scan was only remarkable for hypermetabolic anterior chest mass (SUV max 5.7). The patient returned for follow up 2 months later, notable for mass progression and dyspnea on exertion, evaluated with repeat CT chest without contrast which showed interval changes, including progression of the now 6.5 x 7.5 cm mass and new 1.0cm x 1.0cm T8 vertebral body lytic lesion. Given bony disease progression, it was decided to initiate therapy with mTOR inhibitor temsirolimus. In evaluation of cardiac status, the patient completed a transthoracic echocardiogram which showed preserved ejection fraction with severe left ventricle dilation. The patient is being followed closely by Cardiothoracic surgery for possible resection if progression of mass demonstrates further compromise to cardiac function.

DISCUSSION: There are several cases reported in the literature regarding metastatic renal cell carcinoma of the sternum, however, none describe the disease progression involving epicardial extension as an impending threat to cardiac function.

CONCLUSIONS: Surgery is indicated as a first-line therapy in individual patients and should be advocated in the case of solitary bone metastasis. This case highlights that beyond solitary bony disease, thoracic resection and reconstruction in the setting of pericardial extension is extremely challenging.

Reference #1: Curti BD. Renal cell carcinoma. JAMA. 2004;292(1):97-100. doi: 10.1001/jama.292.1.97.

Reference #2: Pyle JW, Ash JL, Hussain SM, Reid N, Anderson RC. Sternal resection and reconstruction after renal cell carcinoma metastatic to the sternum. J Thorac Cardiovasc Surg. 2005;129(5):1177-8.

DISCLOSURE: The following authors have nothing to disclose: Tukisa Smith

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