The Journal of Laryngology and Otology

August 1987. Vol. 101. pp.'843-850

Metastasis to the larynx revealing a renal cell

carcinoma
by
ALFIO FERLITO, M.D.,* GASTONE PESAVENTO, M.D.,t SALVATORE MELI, M.D.,t
GIANFRANCO RECHER, M.D.t and ALFONSO VISONA, M.D4 (Padua and Vicenza, Italy)

Introduction
Secondary tumours of the larynx are rare and usually occur in the advanced stages of the
disease. A metastatic tumour in the larynx revealing a primary lesion situated elsewhere in
the body is extremely rare (Loughead, 1952; Shaheen, 1960; Bergstedt and Herberts, 1962;
Glanz and Kleinsasser, 1978).
We report a case of a laryngeal polyp, which proved to be the first small metastic deposit
from an unrecognized renal cell carcinoma.

Case report
A 73 year-old male patient, a heavy smoker, was
admitted to hospital in October 1984 with hoarse-
ness. Indirect laryngoscopy disclosed a smooth
polypoid lesion, 1 cm. in diameter, involving the
anterior subglottic region (Fig. 1). Laboratory find-
ings, including routine blood chemistry,
urinanalysis, and X-ray films of the chest were
within normal limits. The polypoid lesion was
resected at direct microlaryngoscopy. Histological
examination of the surgical specimen showed that
the mucosa was infiltrated by sheets of polygonal
and oval clear cells forming a solid pattern (Fig. 2)
interrupted only by thin-walled vessels and fibrous
septae. There was scanty nuclear atypia and
mitoses were rare. The overlying epithelium was
not involved (Fig. 3). Focal stromal hemorrhage
was present. Histochemistry (PAS and DPAS)
showed the clear cells to be PAS positive and sensi-
tive to diastase digestion, confirming their glycogen
content. The possibility of a metastatic origin from
a renal cell carcinoma was suggested. The kidneys
were therefore carefully investigated through FIG. 1
abdominal ultrasonography (Fig. 4), and a large, Endoscopic photography showing the metastatic
prevalently hyperechogenous, mass was detected laryngeal lesion presenting as a laryngeal 'polyp'.

* Department of Otolaryngology. University of Padua. Padua. Italy

t Division of Otolaryngology, St. Bortolo Hospital. Vicenza, Italy
| Department of Pathology, St. Bortolo Hospital, Vicenza, Italy

843
844 A. FERLITO, G. PESAVENTO, S. MEL1, G. RECHER AND A. VISONA

FIG. 2
Microscopy of renal cell carcinoma metastasis in the subglottic region showing the clear cell' pattern formed by
typical polygonal cells with a clear cytoplasm. Note binucleated cells (hematoxylin-eosin; original magnification.
xlOO).

FIG. 3
Metastatic renal cell carcinoma of the larynx. Note the intact squamous epithelium (hematoxylin-eosin; original
magnification, x40).
CLINICAL RECORDS 845

FIG. 4
Abdominal ultrasonography showing a large, prevalently hyperechogenous mass in
the right lumbar area.

in the right lumbar area. CT scan (Fig. 5) confirmed
the involvement of the lower two-thirds of the right
kidney by a voluminous mass. The inferior vena
cava was easily injected with contrast medium and
was apparently free of neoplastic thrombi. The
other abdominal viscera, the lungs and the medias-
tinum were negative. The high vascularity of the
tumour was confirmed by transfemoral arterio-
graphy (Fig. 6). Total right nephrectomy (Fig. 7)
was performed. Histological examination of the
surgical specimen confirmed the diagnosis of renal
cell carcinoma grade I (Fig. 8) with focal vascular
invasion. In November 1984 the patient was dis-
charged in good general condition, but a few
months later he started to complain about pain in
his right hemithorax. An X-ray of the chest showed
multiple nodular opacities related to pulmonary
metastatic deposits (Fig. 9). Osteolytic areas were
846 A. EERUTO-, G. PESAVENTO, S. MELI, G. RECHER AND A. VISONA
CT scan showing a large mass in the right kidney.
also detected in the 8th and 9th right ribs. At the
same time, indirect laryngoscopy failed to reveal
any metastatic recurrence in the larynx. In April
1985 a course of palliative radiotherapy of the bony
lesions was performed. The patient died two
months later. Autopsy was not obtained.
Discussion
The involvement of the larynx by metastatic
deposits is a rare event. In the material of the ENT
Department of Padua University there have been
seven cases of laryngeal metastases during the last
20 years in a series of 3,377 malignant laryngeal
neoplasms. Six of the seven patients had primary
cutaneous malignant melanomas. A review of the
literature made in 1984 by Ferlito and Caruso
revealed 81 laryngeal secondary cancers. Other
reports concerning single cases have been detected
(Stepanov et al., 1968; Abemayor et al., 1983;
Coakley and Ranson, 1984; Ritchie et al., 1985).
Some cases have been only mentioned (Rosai,
1981; Mancuso and Hanafee, 1983). Recently Bat-
sakisera/. (1985) reported 11 cases of metastases to
the larynx, but all without clinical data and histo-
logical documentation. At the same time it must be
pointed out that laryngeal involvement during
systemic diseases must be excluded (as in acute and
chronic leukemia, Hodgkin's disease, lymphomas
and multiple myeloma) together with the second-
ary spread to the larynx by paralaryngeal and thy-
roid tumours.
Malignant melanoma of the skin is the neoplasm
most frequently metastasizing to the larynx. In this
connection we should like to stress that a melanoma
presenting in the larynx is more likely to be second-
ary rather than primary, even in the absence of a
detectable cutaneous primary tumour, although
primary malignant melanoma of the larynx may
occur. Other sites of origin of metastatic tumours of
the larynx in order of frequency are the kidney.
lung, breast and prostate. Occasional cases of met-
astasis from the colon, stomach, testis. nose,
nasopharynx, trachea, oesophagus, gall bladder,
pancreas, uterine cervix and ovary have been
reported (Ferlito and Caruso, 1984).
CLINICAL RECORDS
FIG. 6
Arteriography showing abnormality of the distribution of the renal vessels.
Renal cell carcinoma has long been labelled 'the
great imitator' on account of its frequent initial
presentation as a metastatic disease, producing
symptoms unrelated to the kidney (Silverberg,
1983; Robbins el al., 1984). In fact, almost all
organs and tissues of the body may be the site of
metastases, either as a first sign of the tumour or as
a widespread extension of it. Since the classical
clinical symptoms—such as hematuria, lumbar pain
and abdominal mass—tend to be of relatively late
847
occurrence in the course of the disease, the initial
clinical signs can erroneously lead to diagnostic
confusion with benign processes or with other
primary tumours. Our experience is totally in
agreement with this observation: in fact the patient
made no complaint about the renal mass when he
first decided to consult a physician because of per-
sistent hoarseness.
The symptoms of metastatic tumours to the
larynx do not differ from those of primary malig-
 FIG. 7
Gross appearance of the renal cell carcinoma.

FIG. 8
Histological features of the primary renal cell carcinoma (hematoxylin-eosin; original magnification, x40).
CLINICAL RECORDS
FIG. 9
Chest X-ray showing multiple lung metastases of the renal cell carcinoma.
nancies and vary accordingly to the site affected.
Some Authors (Bergstedt and Herberts. 1962;
Stankiewicz and Mostowski. 1979). nevertheless,
refer to hemophtysis as a typical sign of metastatic
involvement of the larynx by a renal cell carcinoma
because of the high vascularity of the tumour.
Laryngeal metastases can be completely asympto-
matic and are occasionally detected at autopsy.
According to Freeland et al. (19"7''). the predomi-
nance of 'silent' metastases suggests that meta-
stases to the larynx are more common than
previously held. Clinically, secondary involvement
of the larynx may be suspected only in cases of a
well recognized primary tumour. However, when
the primary tumour is occult, a metastatic deposit
will only be suspected on histological grounds.
From the pathological point of view, it must
nevertheless be pointed out that some important
differential diagnoses have to be considered. The
clear cell or hypernephroid areas may be present in
squamous cell carcinoma, in mucoepidermoid,
adenosquamous and acinic cell carcinomas and in
849
the extremely rare primary clear cell carcinoma of
the larynx (Pesavento et al.. 1980). Stains for
glycogen and lipids are usually positive in the cells
of renal cell carcinoma, and histochemical stains
with PAS, DP AS. Best's carmine, oil red and sudan
black may therefore assist in reaching the correct
diagnosis.
Treatment of a secondary lesion of the larynx is
justified only when other organs have not yet been
affected. Long survival has been reported in two
other cases (Chamberlain, 1966; Glanz and
Kleinsasser. 1978) and the patient of Glanz and
Kleinsasser (1978) was alive and well at 12 years
(Glanz, 1985) The palliative nephrectomy in meta-
stasizing renal cell carcinoma can prolong life
expectancy up to 3 years after operation (Jonas et al
., 1984). Regression of pulmonary metastases fol-
lowing nephrectomy has been reported (Garfield
and Kennedy, 1972; Fairlamb, 1981). These data
from the literature seem to confirm the validity of
surgical removal of the primary renal cell car-
cinoma and of a solitary distant metastasis. Surgical
850 A. FERLITO, G. PESAVENTO, S. MEL1, G. RECHER AND A. VISONA

excision by direct laryngoscopy of the metastasis F. (1979) Metastases to the larynx. The Journal of
and subsequent nephrectomy was performed in our Otolaryngology, 8: 448-456.
case, but 5 months later lung and bony metastases Garfield, D. H. and Kennedy, B. J. (1972) Regression
appeared. Similar treatment was applied by of metastatic renal cell carcinoma following
nephrectomy. Cancer 30: 190-196.
Bergstedt and Herberts (1962). The patient was Glanz, H. (1986) Personal communication.
alive and free from disease 2 years and 9 months Glanz, H. and Kleinsasser, O. (1978) Metastasen im
after the surgical removal. Kehlkopf. HNO, 26: 163-167.
In general the short-term prognosis is poor if Jonas, D., Weber, W.,Beckert,H.,Thoma,B.,Dorn,
laryngeal metastases are present. B., Miiller, H. and Stutte, H. J. (1984) Surgery of
the primary tumor of metastasizing renal car-
cinoma. Urologia Internationalis, 39: 110-113.
Summary Loughead, J. R. (1952) Malignant melanoma of the
larynx. Annals of Otology, Rhinology and Laryngol-
A rare case of laryngeal metastasis as the first ogy, 61: 154-158.
sign of an unrecognized renal cell carcinoma, occur- Mancuso, A. A. and Hanafee, W. N. (1983) Elusive
ring in a 73-year-old man, is reported. The clinical head and neck carcinoma beneath intact mucosa.
picture, pathology, diagnosis, differential diagnosis Laryngoscope, 93: 133-139.
and prognosis are discussed. Pesavento, G., Ferlito, A. and Recher, G. (1980)
Primary clear cell carcinoma of the larynx. Journal
of Clinical Pathology, 33: 1160-1164.
Ritchie, W. W., Messmer, J. M., Whitley. D. P. and
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