Disorders of the Pleura |

An Atypical Presentation of Renal Cell Carcinoma: Isolated Pleural Metastases With Large Volume Effusion FREE TO VIEW

Laura Clark, DO; Moises Cossio, DO; Fnu Kelash, MD
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Carilion Clinic, Roanoke, VA

Chest. 2015;148(4_MeetingAbstracts):445A. doi:10.1378/chest.2281488
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SESSION TITLE: Disorders of the Pleura Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Pleural effusions are associated with numerous malignancies, but often there is lung parenchyma involved. In cases of isolated pleural metastatic disease, Batson’s plexus should be considered as a route of metastasis.

CASE PRESENTATION: A 62 year-old man presented with several weeks of worsening fatigue and dyspnea when laying on his side without fevers, chills, weight loss, reduced appetite, chest pain, nausea, or vomiting. His medical history included smoking 40 pack-years, and family history was significant for ovarian cancer in his mother and Non-Hodgkin’s Lymphoma in his brother. Chest XRay demonstrated a pleural effusion filling most of the left hemithorax with associated near-complete lower lobe atelectasis. Multiple pleural plaques were visible on chest CT as well as a large mass in the right kidney and superior pole of the left kidney without hilar lymphadenopathy. Pleural fluid analysis revealed an exudative effusion and cytology demonstrated atypical reactive mesothelial cells, but no malignant cells. Open biopsy was consistent with renal cell carcinoma (RCC).

DISCUSSION: Direct hematogenous spread of RCC through Batson’s plexus has been described as a potential source of metastases of genitourinary malignancies. RCC most commonly metastasizes to the respiratory system, but often through the renal vein, IVC, and infiltration of the mediastinal lymph nodes and lung parenchyma. Pleural involvement most often results from direct extension of parenchymal lesions. Similar cases have been described in the literature where isolated pleural disease with exudative effusions were found to be RCC on biopsy after pleural fluid cytology was nondiagnostic. Batson’s plexus has been described as a likely route of such hematogenous metastases. The valveless veins of Batson’s plexus form an anastomosis between the veins of the pelvis, intercostal veins, and vertebral veins. The physiologic pressure variations of the thorax with normal respiration could encourage flow from the abdomen into this region; the venous plexus explains how metastatic cells could easily spread from the kidney directly to the pleura.

CONCLUSIONS: Batson’s plexus is a potential route of hematogenous spread of RCC and other malignancies and poses a challenge to making the primary diagnosis. There are currently no methods to assess hematogenous dissemination of RCC through Batson’s plexus, making it difficult to give a prognosis for future metastases to patients with early stage RCC.

Reference #1: Sun XF, Huang H, Xu ZJ, Li J, Xu K. Renal cell carcinoma presents as pleural metastasis without pulmonary involvement. Chinese Medical Journal. 2012;125(17):3193-3194.

Reference #2: Ohnishi h, Abe M, Hamada H, Yokoyama A, Hirayama T, Ito R, Nishimura K, Higaki J. Case Report: Metastatic renal cell carcinoma presenting as multiple pleural tumors. Respirology. 2005;10:128-131.

Reference #3: Batson OV. The function of the vertebral veins and their role in the spread of metastases. Annals of Surgery. 1940;112:138-149.

DISCLOSURE: The following authors have nothing to disclose: Laura Clark, Moises Cossio, Fnu Kelash

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