Dr Sarma's Dermpath: Possible Implantation Carcinoma Of The Scalp Following Craniotomy For Metastatic Renal Cell Carcinoma. Dermatology Online Journal 14 (6): 20 1.

Volume 14 Number 6

DOJ Contents

Possible implantation carcinoma of the scalp following craniotomy for metastatic renal cell carcinoma Deba P Sarma1, Jeff F Wang1, Michael V McAllister1, Bo Wang1, 2 James M Shehan Dermatology Online Journal 14 (6): 20 1. Department of Pathology, Creighton University Medical Center, Omaha, Nebraska. [email protected] 2. Department of Medicine, Division of Dermatology, Creighton University Medical Center, Omaha, Nebraska

Abstract We report a case of a 50-year-old man who developed a possible implantation carcinoma of the scalp within the craniotomy scar 19 months after a metastatic renal cell tumor nodule was removed from the brain. The English literature on the implantation carcinoma is briefly reviewed.

Introduction Craniotomy for biopsy or resection of a metastatic tumor nodule from the brain is not an uncommon procedure. However, contamination of the incision site by the tumor cells with subsequent growth of an implantation carcinoma at the craniotomy site is a very rare event. Our patient presented with a partially cystic scalp mass within an old scar 19 months after craniotomy for resection of a single nodule of metastatic renal cell carcinoma in the brain. There was no other evidence of recurrent systemic tumor from a previously resected renal cell carcinoma five years earlier. This led to the clinical diagnosis of a benign cyst of the scalp. We believe that this case report will alert the clinician to consider a possible implantation tumor in the differential diagnosis of any new growth in an old biopsy or incision site for malignancy.

Clinical Synopsis

Figure 1

Figure 2

Figure 1. Renal cell carcinoma of the scalp, low magnification Figure 2. Renal cell carcinoma of the scalp, higher magnification A 50-year-old man presented with a nodule on the scalp that had developed over the last few months. A 2 cm partially cystic dermal nodule on the scalp was thought to be a pilar cyst on clinical examination. The lesion was located within an old craniotomy scar. Past Figure 3 history revealed that the patient had renal cell carcinoma with a single Figure 3. Scalp tumor is metastatic nodule in the brain five years earlier. After undergoing a left positive for immunostaining nephrectomy, the brain nodule was with RCC (renal cell initially treated by radiotherapy and carcinoma) antibody. subsequently by surgical resection 2 years later. Nineteen months after

craniotomy the patient developed a scalp nodule within the craniotomy scar. There was no evidence of any other tumor. The excised scalp nodule on microscopic examination showed features of a renal cell carcinoma (Figs. 1 and 2) with polyhedral tumor cells in a glandular configuration with round or oval nuclei, prominent nucleoli, and granular or clear cytoplasm. The tumor cells showed positive immunostaining for vimentin, RCC (renal cell carcinoma) antibody (Fig. 3) and AR (Androgen receptor). The patient remains free of recurrent tumor six months after the resection of the scalp lesion.

Discussion A recent or unusual skin lesion may be the first sign of a primary or a metastatic tumor from another site [1, 2, 3]. Renal cell carcinoma may metastasize to the skin in 3-11 percent of cases, mostly in the head and neck [1] and in other rare locations such as the thumb [3]. Metastatic skin nodule from a renal cell carcinoma may even mimic a pyogenic granuloma [2]. In our patient, the scalp nodule was clinically thought to be a pilar cyst. Cutaneous metastasis usually occurs by hematogenous dissemination from the kidney. In our case, the tumor appears to have developed within the scar at the old craniotomy site through which the metastatic tumor nodule was removed, suggesting the possibility of tumor contamination and implantation. Alternatively, preferential localization of metastasizing cancer cells to a site of injury or scar is also possible. Leukemic cells at previous catheter insertion sites has been observed by other authors [2, 11]. They have hypothesized that the insertion of the intravenous catheters may have damaged the tissue leading to lower resistance (locus minoris resistentiae) and cutaneous metastasis. There are several reports of implantation carcinoma arising within scars, incision sites, and hand port-sites used for laparoscopic nephrectomy for renal cell carcinoma [5, 6], colonic carcinoma [7], and uterine carcinoma [8]. In these cases, the mechanical transport of the tumor fragments in the incision site by the surgical instruments appears to be the cause of the subsequent development of the implantation carcinoma. This type of tumor implantation or altered tissue resistance at previous surgical sites may have led neoplastic cells to seed at needle tract sites from needle biopsies of various tumors [9, 10]. However, in our case the possibility that the renal cell carcinoma has directly metastasized to the craniotomy scar cannot be completely excluded. A new growth developing either within the scar of an old surgical incision site or a previous biopsy site for suspected malignancy, should alert the clinician to the possibility of an implantation tumor.

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