CASE REPORT Mandibular Mass as an Only Presentation of Metatatic Renal Cell Carcinoma For Four Years: A Case Report Shahram Gooran1, Alimohammad Fakhr Yasseri1, Negar Behtash1*, Arash karimi1, Masoud Khalili1, Mahboobeh Asadi2 Keywords: mandibular mass; metastasis; oral cavity; renal cell carcinoma. Renal cell carcinoma is one of the most common tumors of the urinary tract. This tumor may appear as Para neo- plastic syndromes or distant metastasis. Metastases in uncommon areas are one of the characteristics of renal tum- ors. One of the uncommon metastatic renal masses areas is the mandible. In different studies, patient survival after metastasis diagnosis is usually one year or less. In this study we introduce a patient with mass of the right mandible which existed four years before his referral, and in examinations it was diagnosed as metastasis with renal origin. INTRODUCTION Renal cell carcinoma is one of the most common tumors of the urinary tract. Metastasis to the oral cavity is very rare and constitutes less than 1% of neoplasms of this area. Extensive metastases to the mandible can be eval- uated by CT and MRI, although in some cases a definitive diagnosis is not possible. However, biopsy is necessary to confirm the diagnosis in all cases(1-3). CASE REPORT The patient was a 74-year old man who complained of swelling in the right side of the face, fever, nausea and vomiting. Patient’s nausea and vomiting and fever had started one month before his referral. But swelling of the right lower jaw started four years before referral and increased gradually. Also, the patient complained of difficult breathing in the past few months (Figure 1). The patient mentioned no history of medical diseases, previous surgeries, occupational exposure and taking med- ications except using 30 packs of cigarettes per year. The patient had been using dentures for almost 10 years. He had referred to physician four years before referral due to pain and swelling of mandible and was diagnosed with inflammation and infections resulting from the dentures and received antibiotic therapy. Since the symp- toms persisted after antibiotic therapy, the patient was advised to perform X-ray and lesion biopsy which the 1Urology Research Center, Sina Hospital, Tehran University of Medical Sciences, Hassan-Abad Sq., Tehran, Iran. 2 Department of Otorhinolaryngology head and neck Surgery, Shahid beheshti University of Medical Sciences, Taleghani hospital,Tehran, Iran. *Correspondence: Department of urology, Tehran University, Sina Hospital, Tehran, Iran. Tel: +98 912 2361 163. Office: +98 21 6312 484 Email: negar_behtash@yahoo.com. Received June 2016 & Accepted January 2017 Figure 1. Gross pathology of tumor Figure 2. Mandibular tumor Case Report 2979 patient did not accept. After a few years, the patient re- ferred to the clinic and mandibular lesion biopsy was performed. Pathology report was highly suggestive of metastatic carcinoma, clear cell type, most probably of renal origin. After IHC the primary source was revealed to be the kidney. CT scan with contrast injection of the head and neck, lungs, abdomen, and pelvis was done for the patient. A large hypervascular mass with thinning of the lateral wall of the right maxillary sinus and also destruction of mandible ramos and trunk were report- ed in the head and neck CT. An enhancing lesion with approximate dimensions of 33 × 33 mm in the lower left kidney bridge and also generalized osteopenia was reported in the abdomen and pelvis CT (Figure 2). In patient’s bone scan, abnormal activity in the right man- dible and right maxillary bones suggesting tumoral in- vasion, was reported. The patient underwent left radical nephrectomy. (Figure 3) The final pathology reported unifocal clear cell RCC with no sarcomatoeid features and no lymphovascular invasion. The patient was referred to Otolaryngology Clinic again for mandible lesion resection. Since the le- sion was extensive and non-respectable, the patient was introduced to oncologists for chemo-radiotherapy. Cur- rently the patient is under chemo-radiotherapy. DISCUSSION RCC bone metastases are osteolytic metastasis and usu- ally observed in axial bones specially T2 to L5. These metastases are often seen on the same side of the pri- mary tumor(4). Jaw invasions are usually detected in ages of 50-70(5). Mandible trunk invasion is 4 to 5 times more common than maxillary bone invasion(2,6). Man- dibular metastasis is from renal origin in 16% of its me- tastasis(7-9) . Metastasis in oral soft tissue is associated with worse prognosis(10,11). The majority of patients die one year after metastasis of head and neck while our patient had the history of lower jaw lesion four years before referral. Most researchers have accepted radi- cal nephrectomy for limited disease and even for kid- ney tumor with distant metastases and believe that this therapeutic approach improves the quality of life and survival of these patients. In different studies with sin- gle metastasis of oral cavity, surgery after nephrectomy improved survival for two years (in 43% of patients) and 5 years (in 13% of patients)(12,13). Although RCC is usually resistant to radiotherapy and chemotherapy, but using these therapies is recommended for the relief of metastatic lesions in the oral cavity. Researchers be- lieve that using local radiotherapy may relieve patients’ local symptoms for a short time(7,8). Using chemother- apy (Interleukin-2, interferon-alpha and 5-fluorouracil) may be helpful in some cases(10). In some studies, using immunotherapy after radical nephrectomy improves survival in patients with distant metastasis. In patients with synchronous metastases, cytoreductive nephrecto- my and systemic immunotherapy has been more effec- tive than immunotherapy alone(7). REFERENCES 1. Pick JB, Wagner RM, Indresano AT. Initial appearance of renal cell carcinoma as a metastatic mass in the mandible. J Am Dent Assoc. 1986;113:759-61. 2. Sastre J, Naval L, Munoz M, Gamallo C, Diaz FJ. Metastatic renal cell carcinoma to the mandible. Otolaryngol Head Neck Surg. 2005;132:663-4. 3. Shibahara T, Nomura T, Cui NH, Noma H. A study of osteoclast-related cytokines in mandibular invasion by squamous cell carcinoma. Int J Oral Maxillofac Surg. 2005;34:789-93. 4. Shetty SC, Gupta S, Nagsubramanium S, Hasan S, Cherry G. Mandibular metastasis from renal cell carcinoma. A case report. Indian J Dent Res. 2001;12:77-80. 5. Vallejo J. Metastases in the mandible: clear cell carcinoma of a horseshoe kidney. International Journal of Oral and Maxillofacial Surgery. 2011;40:1184-5. 6. Quinn JH, Kreller JS, Carr RF. Metastatic renal cell carcinoma to the mandible: report of case. J Oral Surg. 1981;39:130-3. 7. Ahmadnia H, Amirmajdi NM, Mansourian E. Renal cell carcinoma presenting as mandibular metastasis. Saudi J Kidney Dis Transpl. 2013;24:789-92. 8. Will TA, Agarwal N, Petruzzelli GJ. Oral cavity metastasis of renal cell carcinoma: a case report. J Med Case Rep. 2008;2:313. 9. Ebert CS, Jr., Dubin MG, Hart CF, Chalian AA, Shockley WW. Clear cell odontogenic carcinoma: a comprehensive analysis of treatment strategies. Head Neck. 2005;27:536- 42. 10. Maestre-Rodriguez O, Gonzalez-Garcia R, Mateo-Arias J, et al. Metastasis of renal clear- cell carcinoma to the oral mucosa, an atypical location. Med Oral Patol Oral Cir Bucal. 2009;14:e601-4. 11. Ellis GL, Jensen JL, Reingold IM, Barr RJ. Malignant neoplasms metastatic to gingivae. Oral Surg Oral Med Oral Pathol. 1977;44:238- 45. Mandibular mass as an only presentation of metatatic RCC-Gooran et al. Figure 3. Computed tomography of renal tumor Vol 14 No 01 January-February 2017 2980 Case Report 2981 12. Hatziotis JC, Constantinidou H, Papanayotou PH. Metastatic tumors of the oral soft tissues. Review of the literature and report of a case. Oral Surg Oral Med Oral Pathol. 1973;36:544- 50. 13. Makos CP, Psomaderis K. A literature review in renal carcinoma metastasis to the oral mucosa and a new report of an epulis-like metastasis. Journal of Oral and Maxillofacial Surgery. 2009;67:653-60. Mandibular mass as an only presentation of metatatic RCC-Gooran et al.