Lymphangitic Metastasis of Recurrent Renal Cell Carcinoma to the Contralateral Lung Causing Lymphangitic Carcinomatosis and Respiratory Symptoms

Abstract

3.8 g/dL. Erythrocyte sedimentation rate (esr) and C-reactive protein (crp) were never measured.On current presentation, the patient also complained of fatigue and decreased appetite, and denied fevers, chills, nausea, vomiting, diarrhea, and constipation. Respiratory exam revealed decreased right lower lobe breath sounds and moderate crackles in the right middle lobe. Laboratory studies were consistent with his postoperative baselines: bun 25 mg/dL, scr 1.4 mg/dL, sCa 8.8 mg/dL, wbcs 7300/μL, hemoglobin 9.5 g/dL, platelets 431000/μL, and lfts within normal limits except for albumin 2.8 g/dL, with esr and crp again not measured. Troponin and creatine kinase-mb were negative for 3 consecutive drawings (ruling out a cardiac cause). Chest radiography demonstrated a right-sided pleural effusion, and an electrocardiogram revealed normal sinus rhythm at 58 bpm.Because the patient had presented to a New York City hospital in July 2009 (during an H1N1 swine flu epidemic), he was initially diagnosed with pneumonia (with H1N1 influenza also a consideration), and he was treated with cefepime, vancomycin, and oseltamivir. Although he improved symptomatically, serial chest radiography demonstrated a persistent right pleural effusion. Intravenous (IV)-contrast computed tomography (ct) imaging of the chest revealed diffuse metastatic tissue in the right lung consistent with pulmonary lymphangitic carcinomatosis (Figure 1). The patient subsequently underwent right middle lobe tissue biopsy through bronchoscopy with endobronchial ultrasonography. Cytopathology examination confirmed rcc grade 4/4 metastases with lymphangitic spread (Figure 2).The patient next presented to an outside hospital's cancer center for further evaluation and treatment, where he was started on palliative sunitinib without surgery or radiotherapy. Over the next 4 months, serial chest and abdominal ct imaging revealed growing metastases in both lungs and the right kidney, and a mass in the left posterolateral pelvis. Head ct imaging demonstrated a single brain metastasis, which was treated with stereotactic radiosurgery. In January 2010, the patient was intubated for respiratory compromise and soon died. ABSTRACTRenal cell carcinoma comprises 80%-85% of kidney malignancies. For early presentations, nephrectomy provides a high cure rate, but patients usually present at advanced stages, leading to poor outcomes. Even for patients without metastatic spread who undergo nephrectomy, metastatic recurrence is frequent. We report the case of a patient who underwent nephrectomy for stage iii renal cell carcinoma and who presented 20 months later with respiratory symptoms consistent with pneumonia, influenza, or (less likely) congestive heart failure or a cardiac event. Persistent right pleural effusion on serial chest radiographs despite treatment prompted computed tomography evaluation, which revealed lymphangitic carcinomatosis, a very rare form of renal cell carcinoma metastasis to the lung. This preliminary finding was confirmed by right middle lobe tissue biops...

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