SECONDARY CARCINOMA PAROTID GLAND TUMOR

MARK HOROWITZ, M.D. PRAMOD SOGANI, M.D.

OF KIDNEY FROM

From the Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, and the State University of New York Health Science Center at Brooklyn, New York

ABSTRACT-Secondary tumors of the kidney are rarely diagnosed during life. However they should be suspected in a patient with a primary malignancy of nonrenal origin and a renal mass. A case of parotid cancer metastatic to the kidney is presented. This case is unique because of its rarity, clinical presenta- tion, hnd pathologic findings.

Secondary neoplasms of the kidneys have been reported in autopsy series, with an incidence of 7.6 to 20 percent. l-3 In 1951 Klinger3 reviewed 5,000 autopsies performed at The Henry Ford Hospital to the year 1948. He reviewed the cases of urinary involvement by metastatic dis- ease. Only those cases were included in which there was actual invasion of the urinary or geni- tal structures. A total of 142 cases were found; most of the primary lesions were from lympho- mas (33%), lung (13%), stomach (ll%), and breast (8 %). Willis in 1952l discovered only 38 cases of secondary renal tumors in a series of 500 postmortem examinations. Abrams, Spiro, and Goldstein2 performed 1,000 autopsies on subjects who died of cancer and found 21 cases (12.6%) with renal metastases. There were no reported primary tumors of the parotid gland in each of these large series.

Case Report

A twenty-five-year-old white woman pre- sented in March 1989 with a mass on left side of neck. Aspiration cytology was positive for ma- lignant cells; she subsequently underwent surgi- cal excision of the mass. Pathologic study of the mass revealed a malignant mixed tumor of parotid origin with lymphatic invasion. She re- ceived adjuvant external beam radiation.

Eight months later severe and continuous left flank pain developed. Physical examination re- vealed a febrile patient (38.9O C) with marked

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left costovertebral angle tenderness. Her blood pressure was 130/77 mm Hg and she had a pulse rate of 84. Laboratory evaluation revealed mi- croscopic hematuria without pyuria or casts. Urine cytology was negative for malignant

FIGURE 1. Excretory urogram.

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FIGURE 2. Renal ultrasound.

FIGURE 4. Left retrograde pyelogram.

FIGURE 3. Computerized tomography.

cells. Complete blood count (CBC) and serum chemistry values were within normal limits. Multiple sets of blood and urine cultures re- vealed no growth.

Excretory urogram (IVP) showed a faint nephrogram of the left kidney without visual- ization of the collecting system (Fig. 1). Renal ultrasound revealed a large mass replacing the left kidney with a patent vena cava (Fig. 2). Computerized tomography showed a bulky left renal mass distorting the calices and resulting in a dense cortical stain in the upper pole (Fig. 3).

Cystoscopic examination revealed a normal bladder; left retrograde pyelogram showed a normal left ureter without any opacification of the renal pelvis or calices (Fig. 4). Percutaneous aspiration of the subcapsular renal collection revealed old blood, and findings on cytology were negative.

FIGURE 5. Specimen.

The patient then underwent exploration and radical nephrectomy. Pathologic study revealed metastatic poorly differentiated epidermoid cancer consistent with the primary salivary gland tumor. The tumor did not invade the re- nal capsule (Fig. 5).

Comment Salivary gland tumors comprise less than 3

percent of all neoplasms of the head and neck.4

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Eveson and Cawson5 examined 2,410 primary epithelial salivary gland tumors and found that 73 percent were from the parotid gland. Epi- dermoid carcinoma was the histologic finding in only 1.1 percent of parotid gland tumors. The peak incidence of malignant tumors was in the seventh decade, with very few cases occur- ring before the third decade.

The classic features of secondary tumors of the kidney have been described by Willis1 and by Bracken et ~1.~ Multiple nodules of varying sizes are usually scattered throughout the kid- ney, particularly in the cortex. One-third are smaller than 1 cm and only 10 percent are larger than 3 cm. Lesions are bilateral in about half the cases.

In contrast to autopsy findings, clinical de- tection of secondary carcinoma to the kidney is rare. There are several reports of isolated cases in which the kidney is the site of a metastatic malignant neoplasm. No secondary tumors were found in 2,314 cases of renal tumors re- viewed by Riches, Griffiths, and Thackraya7 Two hundred ninety-five kidney tumors were examined by Foot, Humphreys, and Whit- more8 and only 5 cases were found to be meta- static. Newsam and Tullochg reported 13 cases of secondary tumor involvement of the kidney from cancer of the lung.

Metastatic tumors in the kidney are consid- ered of little clinical interest because they rarely produce symptoms and therefore are found

only at postmortem examination. Clinically, this case is of interest not only because it is the first reported case of a metastatic tumor to kid- ney from the parotid gland, but also because the clinical presentation was suggestive of an in- fectious process. Also, pathologically this case deviated from the norm in that the secondary tumor was a large solitary lesion. We again em- phasize the need for concern in a patient with a nonrenal malignancy and symptoms suggestive of a renal mass.

3822 42nd Avenue NE Seattle, Washington 98105

(DR. HOROWITZ)

References

1. Willis RA: The Spread of Tumors in the Human Body, 2nd ed., London, Butterworth & Co., 1952.

2. Abrams HL, Spiro R, and Goldstein N: Metastases in car- cinoma: analysis of 1,000 autopsied cases, Cancer 3: 74 (1950).

3. Klinger ME: Secondary tumors of the genito-urinary tract, J Urol 65: 144 (1951).

4. Leegaard T, and Lindeman H: Salivary gland tumors. Clinical picture and treatment, Acta Otolaryngo1263: 155 (1970).

5. Eveson JW, and Cawson RA: Salivary gland tumours. A re- view of 2,410 cases with particular reference to histological types, site, age, and sex distribution, Pathology 146: 51 (1985).

6. Bracken B, Chica G, Johnson D, and Luna M: Secondary renal neoplasms: an autopsy study, South Med J 72: 806 (1979).

7. Riches EW, Griffiths IH, and Thackray AC: New growths of the kidney and ureter, Br J Uro123: 297 (1951).

8. Foot NC, Humphreys GA, and Whitmore WF: Renal tu- mors: pathology and prognosis in 295 cases, J Urol66: 190 (1951).

9. Newsam JE, and Tulloch WS: Metastatic tumors in the kid- ney, Br J Urol 38: 1 (1966).

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