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Renal cell carcinoma is a common malignancy and often presents with metastatic disease. Metastasis to the pedal bones is uncommon and has only been described a few times in the literature. We present a rare case of a patient with metastatic renal cell carcinoma whose initial presenting symptom was a pathologic calcaneal fracture. This case demonstrates the need for full workup and multidisciplinary care when evaluating tumors in the foot and ankle.
Renal cell cancer makes up 2.6% of all cancers. It is the 7th most common cancer in men and the 12th most common cancer in women. 85% of renal cancers are renal cell carcinoma. Treatment of renal cell carcinoma is often delayed due to late diagnosis; 25% of cases are locally invasive or metastatic upon detection.
In this paper, we discuss a unique case of metastatic renal cell carcinoma that presented as a pathologic calcaneal fracture.
In March 2019, 59-year-old male presented to the emergency department with complaints of left heel pain of 3 weeks duration. He stated that he was walking up a ramp loading a trailer when he noticed pain in his left heel. He continued to be weightbearing and continue his normal activities. Approximately 2 weeks later he felt a painful pop in the back of his heel and noticed swelling. He was no longer able to walk. At that time, he presented to the emergency department for evaluation.
Physical exam revealed a well-appearing patient in no distress. He was neurovascularly intact and there were no breaks in the skin of his left foot. Weakness upon plantar flexion was noted, as well as tenderness to palpation of the posterior heel at the insertion site of the Achilles tendon.
Radiographs were taken, and he was noted to have a large, lytic lesion of the posterior calcaneus, which were read as possible osteomyelitis or pathologic fracture. (Fig 1) The patient had no wound or history of wound at this site and therefore made osteomyelitis unlikely. The patient was placed in a Jones compressive cast, made non-weight bearing, and discharged from the emergency department.
The patient was followed up 4 days later in podiatry clinic. Further questioning revealed the patient had unintentionally lost 30 pounds in the past 2 months. He also admitted to smoking 1 pack of cigarettes per day and drinking a 12 pack of beer a week. He endorsed a history of stage 1 Hodgkin's lymphoma, treated 10 years prior with chemotherapy and radiation, and believed to be in remission. An MRI with and without contrast was ordered to further evaluate the area, as well as a chest x-ray and optic screening for metal fragments. Oncology was consulted at this time.
The MRI revealed a large, aggressive, neoplastic calcaneal mass. The largest portion of the mass measured 4 × 6 × 5 with multiple smaller foci and extension to posterior sinus tarsi. (Fig 2, Fig 3) The screening chest x-ray revealed multiple masses consistent with metastatic malignancy. (Fig 4)
Due to the masses noted on the patient's chest x-ray, the oncology service recommended a chest CT and neck CT to rule out further metastasis and to potentially identify the origin of the malignancy.
The CT of the neck revealed multiple metastases in the lungs and lymph nodes. The patient was also noted to have moderately sized pleural effusions in the left and right lungs that were highly dense and partially loculated, which were read as potentially malignant exudates.
The CT of the abdomen and pelvis revealed a large heterogenous soft tissue mass in the mid lower left kidney. Again, masses were noted in the chest suspicious for lung and pleural metastases, as well as mediastinal, subcarinal, and hilar adenopathy. “This constellation of clinical findings and possible lucent metastatic lesion of the left calcaneus are suspicious for metastatic renal cancer.”
The patient was seen and evaluated in the oncology clinic. It was determined that the best biopsy site would be a mediastinal biopsy and biopsy of the lung mass, if possible, by the pulmonologist.Renal cell carcinoma often metastasizes to the lungs and a lung mass biopsy would differentiate metastasis from a second primary malignancy.
The pulmonologist performed the lung biopsy and samples from the left lung were determined to be metastatic renal cell cancer by the pathologist (Fig. 6,7). The pathologist read the right lung aspirate as atypical and suspicious for adenocarcinoma.
Once the initial pathology results were obtained, a repeat bronchoscopy and thoracentesis was planned 8 days after the first procedure to obtain more tissue.
The day of the repeat bronchoscopy, a therapeutic thoracentesis was performed instead. 50 mL of fluid was drained, sent to pathology, and was read as suspicious for metastatic adenocarcinoma. A lymph node biopsy of a lesion on the scalp was also performed and was read as metastatic adenocarcinoma.
On follow up, patient continued to have worsening shortness of breath. Oncology recommended starting immunotherapy vs. supportive care, patient opted for chemotherapy, understanding that chemotherapy was only palliative.
Within one week of follow up, the patient presented to the emergency department of an outside facility due to shortness of breath. He had been saturating in the low 80 s on 4 L of oxygen. He was again noted to have large pleural effusions in his chest. He was also found to be hypercalcemic with a serum calcium of 15.7, increased from original labs. He was admitted to the ICU for management of his hypercalcemia and pleural effusions.
During his admission to the ICU, the patient continued to deteriorate. He passed away in May 2019, 49 days after his original presentation to podiatry.
Renal cell carcinoma is a rare disease that often metastasizes. While this disease often metastasizes to the lungs, it rarely metastasizes to the foot. When it does, the calcaneus is the most common bone involved, due to its rich vascularity. Survival amongst patients with metastases is low, and early detection is key to treatment.