Orthopedic Oncology cases skeletal metastatic renal cell carcinoma
A 71-year-old male with back pain has been referred to your office. His primary care physician ordered x-rays of the thoracic and lumbar spine, which revealed multiple compression fractures. An MRI was subsequently ordered, which was concerning for metastatic processes within the vertebral bodies. He also has had some right thigh pain and left shoulder pain. X-rays done in your office reveal lucencies in the mid-shaft of the right femur, and proximal left humerus. On questioning, he notes that his urine has been pink over the past several months.
Which of the following is not included in workup for this patient?
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Urinalysis, urine protein electrophoresis
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CT of chest, abdomen, and pelvis
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Thyroid studies
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MRI of the shoulder
Discussion
The correct answer is (D). The patient has several lytic lesions in the left humerus, right femur, and vertebral bodies causing symptomatic compression fractures. In a 71-year-old male, these are concerning for metastatic disease. He reports urinary symptoms, which are concerning for renal cell carcinoma, although he must be worked up for all common primary malignancies that metastasize to bone. These include breast, lung, prostate, thyroid, and renal cell. The workup includes a thorough history and physical examination, electrolyte panel (with calcium), alkaline phosphatase, CBC, PSA, serum and urine protein electrophoresis, CT scan of the chest/abdomen/pelvis, and total body bone scan.
His urinalysis is positive for gross blood, and CT scan of the abdomen reveals a
fungating mass in his right kidney. Image-guided needle biopsy of the left humeral lesion is performed, which results in a diagnosis of metastatic renal cell carcinoma. What is the next step in management of the shoulder?
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An open biopsy of the left humeral lesion should be obtained, because needle biopsy is generally unreliable
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Preoperative radiation to the right humerus, followed by fixation
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Preoperative embolization of the humeral lesion
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Total shoulder replacement
Discussion
The correct answer is (C). Embolization of the feeding vessels should be performed prior to prophylactic fixation of all renal cell metastases. Thyroid metastases and hepatocellular also tend to be highly vascular, and preoperative embolization should be considered in these cases as well to avoid catastrophic hemorrhage at the time of fixation.
Objectives: Did you learn...?
Clinical features and workup of skeletal metastatic renal cell carcinoma? Management of renal cell carcinoma metastases to bone?