75: Unveiling the Enigmatic: An Encounter of Advanced Renal Cell Carcinoma Disguised as Recurrent Epistaxis

Background: The most common sinonasal tumor is primary nasopharyngeal carcinoma, however metastatic deposits to this region are possible, albeit rare. Here we present a 74-year-old female initially presenting with recurrent epistaxis later discovered as oligometastatic renal cell carcinoma (RCC) to the maxillary sinus.

Methods: A 74-year-old female presented to an emergency department with a 3-week history of intermittent epistaxis. Medical history included diabetes, hypertension, and atrial-fibrillation (on coumadin). Following spontaneous resolution and an unremarkable workup, patient was discharged with Otolaryngology follow-up. Pre-visit cranial CT scan imaging showed opacification of the right frontal, ethmoid, and maxillary sinuses (Figure 1A). Follow-up MRI brain showed an enhancing right maxillary sinus mass with extension into the nasoethmoidal cavity (Figure 1B). The patient underwent endoscopic resection of the right maxillary sinus mass.

Results: Intraoperative findings included a friable pulsatile mass with histology showing metastatic clear cell renal cell carcinoma (ccRCC). Whole-body CT imaging revealed a 4.9-cm left renal mass with bilateral adrenal nodules and a solitary right lung nodule (Figure 1C). Patient received Nivolumab/Ipilimumab on trial and switched to Nivolumab/Cabozantinib to minimize continued epistaxis through this regimen’s anti-VEGF mechanism. In addition, she received concurrent radiation therapy to the head and neck. Ten months into treatment, repeat scans revealed regression of metastatic lesions and primary renal mass (Figure 1D). The decision was made to proceed with cytoreductive nephrectomy one year from discovery of maxillary sinus mass, (Figure 1E). A 3.5-cm left renal mass was surgically removed. Post-operative 2-month imaging showed recurrence of the maxillary sinus mass (Figure 1F). Repeat endoscopic mass resection was again performed. The patient continues to follow with our multidisciplinary cancer care team.

Conclusions: Metastatic renal cell carcinoma may be considered in patients presenting with nasal and paranasal sinus masses. Timely workup, diagnosis, and treatment can help contribute to improve survival outcomes in these patients.