Renal cell carcinoma has myriad presentations. Inguinal metastasis at presentation is a rare finding in this tumor. Possible mechanisms of such metastasis may include retrograde lymphatic spread or spread via retrograde spermatic vein flow. Excision of the left inguinal nodal mass was done with a left radical nephrectomy. At a 1-year follow-up, there was no evidence of any locoregional or systemic recurrence, even in the absence of systemic adjuvant immunotherapy.
Amit Attam, Arun Kerketta, Sameer Trivedi, Udai Shankar Dwivedi
Submitted April 9, 2012 - Accepted for Publication May 17, 2012
KEYWORDS: Renal cell carcinoma, inguinal metastasis, varicocele
CITATION: UroToday Int J. 2012 August;5(4):art 41. http://dx.doi.org/10.3834/uij.1944-5784.2012.08.14
Renal cell carcinoma (RCC) is the most lethal of the urologic cancers, and it is known for its protean manifestations and ability to mimic other malignancies or benign conditions. Inguinal lymph nodal metastasis is a rare presentation with only 1 reported case to date . We report a case of a 60-year-old male who presented with inguinal mass and hematuria.
A 60-year-old male presented with swelling in the left inguinal region for 2 months. It was associated with mild, dull aching pain and had increased in size to twice its original size in 2 months. It was non-reducible. He also had intermittent, painless total hematuria with the passage of small clots for 1 month. He had anorexia for 2 months along with weight loss. However, there was no history of bony pain, persistent cough, or jaundice. He never had any lower urinary tract symptoms. He did not report any addictions.
Examination revealed a 6 cm x 8 cm non-tender lump in the left flank that was bimanually palpable and firm in consistency, with well-defined margins. There was a 4 cm x 3 cm left inguinal lymph-node mass that was firm-to-hard, non-tender, and had no fixity to the surrounding structures. Lower limbs were normal on examination. He also had a grade III varicocele on the left side that did not reduce upon lying down (Figure 1). The rectal examination revealed a grade I firm, non-tender prostate that had a non-nodular and smooth surface.
The complete blood count and renal function tests were within normal limits. His alkaline phosphatase was 61 IU/l and his serum calcium was 8.4 mg/dl. His chest X-ray was normal and his serum PSA was 0.8 ng/ml. An abdomen ultrasound revealed an 11.7 cm x 9.2 cm heterogenous, hypoechoic mass in relation to the lower pole of the left kidney, with multiple calcified areas and cystic degeneration. Multiple, enlarged, left inguinal lymph nodes were present. The contrast enhanced computed tomography (CT) scan of the abdomen and pelvis revealed a 7.5 cm x 9.7 cm capsulated enhancing lesion involving the lateral cortical region of the left kidney in the mid and lower poles with areas of necrosis (Figure 2). The mass was reaching up to the anterior abdomen wall with no infiltration of the adjacent bowel. However, renal vein invasion could not be ruled out. There was no evidence of visceral distant metastasis. The Doppler ultrasound of the renal vein revealed thrombus in the renal vein not extending into the inferior vena cava. Fine-needle aspiration cytology (FNAC) of the left inguinal nodes was done, which revealed a metastatic adenocarcinoma, clinical stage T3a N1M1.
A left radical nephrectomy was performed with an excision of the left inguinal mass. There was a 10 cm x 12 cm left renal mass arising from the mid pole of the left kidney with thrombus in the left renal and gonadal vein (Figure 3). Hilar nodes were enlarged and were removed at the time of surgery. The postoperative course was uneventful. The histopathology revealed clear-cell renal cell carcinoma of the left kidney extending into left renal vein with metastatic deposits in the left hilar nodes and left inguinal nodes, pathologic stage T3a N1M1. The patient was advised to undergo systemic therapy as he had a good performance status with no significant comorbidities. However, he defaulted as he did not have sufficient financial resources to undergo systemic therapy. On follow-up at 1 year, he did not have any evidence of locoregional or systemic disease.
In patients with RCC, about 1/3 have metastatic disease at the time of initial diagnosis, and up to 40 to 50% may develop distant metastases after initial diagnosis. RCC has been known to metastasize to unusual sites such as the nasal cavity, oral cavity, larynx, parotid gland, thyroid, heart, bladder, testis, prostate, and pituitary gland . Johnsen and Hellsten, in an autopsy series, reported the occurrence of supraclavicular, cervical, axillary, and inguinal lymph-node metastasis in renal cell carcinoma . Fernandes et al. reported solitary axillary lymph-node metastasis in a case of clear-cell renal cell carcinoma in a 60-year-old patient who underwent left radical nephrectomy along with left axillary clearance .
RCC with inguinal metastasis is a rare presentation of this disease with only 1 reported case to date. Manikandan et al. reported a case of a 70-year-old male presenting with inguinal lymphadenopathy. An excision biopsy of the lymph nodes showed clear-cell adenocarcinoma, probably of genitourinary origin. The radiologic evaluation showed a left renal mass, which, on FNAC, turned out to be clear-cell adenocarcinoma . A likely explanation of its spread to the inguinal lymph node could be either retrograde spread from the hilar nodes  or possibly retrograde spermatic vein flow from the left renal vein, leading to inguinal metastasis .
Resection of the solitary metastasis in patients with renal cell carcinoma has been reported to have a favorable outcome, although the survival benefit has not been proven in a prospective randomized study [6,7]. We resected the inguinal nodes at the time of radical nephrectomy as these were the only site of distant metastasis. No clinical or radiologic evidence of disease at the 1-year follow-up in the absence of any systemic therapy further corroborates the notion that consideration should be given to resection of solitary metastases in RCC.
RCC with left inguinal nodal metastasis is a rare presentation for this disease. Excision of the inguinal nodal mass with the primary tumor offers a reasonable chance for survival, even in the absence of adjuvant systemic immunotherapy.
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