Endobronchial metastasis (EBM) is rare and has been associated with breast, colon, kidney and pancreatic cancers. It can be asymptomatic or manifest as cough, hemoptysis or dyspnea, and is generally diagnosed during the course of the initial disease. We report the case of a patient with 3 bilateral renal tumors that first manifested as bloody expectoration.
A 76-year-old man with no toxic habits, coal-miner. Clinical history included left pleuritis as a young man, arterial hypertension, and diabetes. No significant family history was reported. He was referred to the respiratory medicine department due to 4–5 daily episodes of expectoration of red blood for some days, after cough. The patient was negative for fever, chest pain, dyspnea, extrathoracic symptoms, loss of weight and hematuria. Physical examination: good general condition, with mildly reduced breath sounds in the left hemithorax, no lymphadenopathies or masses. Clinical laboratory test results showed glucose 125mg/dl and microhematuria. Lung function values were normal. Chest X-ray revealed aortic atheromatosis and left calcified pachypleuritis. Thoracoabdominal computed tomography (CT) revealed an intraluminal nodular lesion measuring 7mm at the entrance of the right main bronchus (RMB), an expansive heterogeneous lesion of 6.6cm in the upper pole of the right kidney, and another measuring 3.7cm in the lower pole. Another lesion (2.6cm) was observed in the upper pole of the left kidney. Fiberoptic bronchoscopy showed 2 vascularized polypoid lesions, one in the anterior aspect of the RMB (Fig. 1) and the other at the entrance of the right lower lobar bronchus. Biopsy results reported metastasis from clear cell carcinoma. Urine cytology testing was negative for malignancy. In view of the extension of the disease, no diagnostic procedures of the renal masses were initiated, and the patient was referred to the oncology department for treatment.
Kidney cancer (KC) represents 3% of all tumors. Renal cell carcinoma is the most common subtype (85%). It often occurs between the ages of 50 and 60, mostly in men (2:1). It appears as hematuria (60%), lower back pain (40%) or masses (30%–40%). Other manifestations include polyglobulia, hypercalemia or Stauffer's syndrome. In 0.4%–6% of cases of KC, presentation is bilateral. Tumors can exist in a hereditary (in younger patients) or sporadic form. The latter account for 2% of bilateral synchronous tumors.1 Between 25% and 30% of KCs present metastasis on diagnosis, and the lung is the second most common site of distant disease (36%). Endobronchial metastases, described in several extrathoracic tumors, are rare (2% in the autopsies of patients who have died from solid organ tumors).2 The clinical manifestation of this type of tumor is no different from that of primary lung tumors (cough, hemoptysis, dyspnea, or asymptomatic, in up to 60% of cases).3 The mean time to diagnosis is generally 41 months.4,5
This case has several unusual features: hemoptysis led to a diagnosis of primary renal cancer, with the peculiarity of presenting in the form of 3 bilateral synchronous tumors. One of the sites of metastasis could be detected with chest computed tomography (which has little sensitivity for distant disease), but the bronchial biopsy obtained by FB was decisive in the final diagnosis. The absence of family history and the patient's age suggest they were sporadic renal tumors.
Please cite this article as: Mateo Lázaro ML, Villanueva Gimeno MdM, Vilar Bonacasa E. Expectoración hemoptoica como primera manifestación de un cáncer renal bilateral. Arch Bronconeumol. 2015;51:529–530.
