J] 1
i
CLINICAL REPORTS
0
Renal adenocarcinoma of the kidney with metastasis to the tongue A rthur H. Friedlander, D D S R ichard Singer, M D , N o rth p o rt, N Y
R enal adenocarcinom a metastasizes to distant sites. In this case, an 84-year-old m an h a d a hem orrhagic lesion on the tip o f his tongue.
alignant tum ors of the oral cavity m ake up about 5% of all forms of can cer in the hum an body. The A m erican Cancer Society estim ates that 8 ,0 0 0 A m ericans w ill die from oral and oropharyngeal cancer in 1 9 7 9 .1 It is the responsibility of the dental profession to conduct a care fu l, m ethodic exam ination of the m ucous m em branes and tissues of the oral cavity at regular intervals. For th is exam ination to be com plete, it m ust inclu d e a visual search, pal pation, and, w hen required, a radiographic survey. There is a m uch higher survival rate w ith early d etec tion, esp ecially of a prim ary oral m alignancy.
On rare occasions, there are metastases from carcinom as in the lungs, breast, prostate glands, or kidneys to the jaw s or to oral soft tissues. The m etastatic fo ci may be the first c lin i cal m anifestation of the disease. Thus, a routine but properly per form ed dental exam ination m ay dis close the presence of an occult cancer. T h is report show s that the dentist can aid the physician in the diag n osis and m anagem ent of advanced m alignant disease.
Report of case The patient w as an 84-year-old, welldeveloped but cach ectic w hite m an ad m itted to the m edical service of the N orthport V eterans A dm inistration Med ical Center in a confused and dehydrated condition. The family informed the ad mitting p hysician that six m onths before, the patient had been admitted to another institution after several episodes of syn cope. A review of the hospital chart from the
previous adm ission described a physical exam ination that show ed no abnor m alities excep t for persistent hypoten sion (80/60 m m Hg) and pale conjunctiva, w hich are con sisten t w ith anem ia. He had a hemoglobin level of 7.4 gm /100 ml and a hem atocrit reading of 22% . Other labora tory tests perform ed at that tim e included an electrocard iogram (norm al), a urin alysis, SM A-6 and SM A -12, a biopsy of the bone m arrow , and radionuclide scans of the bony skeleton, liver, and spleen. Results from a stool guaiac test for occu lt blood, sigm oidoscopy, upper and low er gastrointestinal series, and intravenous pyelogram w ere all norm al. The only other significant finding for this nonsm oker w as a radiograph of the chest that show ed m ultinodular densities in all lung fields (Fig 1). The radiographs were considered to be con sisten t w ith m etasta tic carcin om a. T he patient received three units of w hole blood and his hemoglobin level stabilized at 12.1 g m /100 m l and his hem atocrit reading at 37% . In view of the patient’s age, the physician and the fam ily agreed to forgo any invasive diagnos tic procedures. T he patient w as dis charged on the 12th hospital day w ith a diagnosis of m etastatic carcin om a to the lungs from an o ccu lt prim ary carcinom a. On adm ission to our institution, a re view of system s cou ld not be obtained from the patient. His m edical and social histories w ere obtained from close family mem bers and w ere noncontributory. On p hysical exam in ation, the m an ap peared to be ch ro n ically ill and was dis oriented and confused, but in no obvious acu te distress. His blood pressure in a supine position w as 60/40 m m Hg in the right arm and 90 /5 0 m m Hg in the left arm . The patient’s pulse rate w as 80 beats per m inute and regular. His respiratory rate was 20 breaths per m inute and regular. JADA, Vol. 97, December 1978 ■ 989
C LIN IC A L
REPO RTS
Fig 1 ■ Radiopaque areas in all lung fields.
Fig 2 ■ Lesion at tip of tongue; note lines of excision and traction suture for control of tongue during surgery.
T h e sk in, w h ich had num erous petech ial hem orrh ag es, had a d ecreased turgor. H is m otor stren g th w as u n iform ly weak, and th ere w as a d ecrease in m u scle m ass. T h e h eart rate w as regu lar; th e abdom en was soft w ith no organom egaly. T here w as no ed em a in th e extrem ities, but there w ere d ecreased breath sounds in a ll lung field s. T h e on ly other finding on physical exam in atio n w as a 2-cm ovoid, raised, b lu ish , h em o rrh ag ic lesio n at the tip of th e ton gu e (Fig 2) th at fam ily m em bers said had been th ere for about six w eeks. S ig n ifica n t laboratory resu lts inclu ded a u rin a ly sis th a t show ed gross hem aturia; clu m p s o f bacteria w ere noticed on m i cro sco p ic exam in ation . V alues o f th e co m p lete blo od cell co u n t inclu ded a h em o g lo b in lev el, 7 gm/100 m l; hem ato crit read in g , 22 % ; and w h ite blood cell co u n t, 19,000/cu m m w ith a shift to the left. T h is w as co n sisten t w ith a urine c u l ture o f E sch e rich ia coli w ith a co lo n y co u n t of 7 x 1 0 s per m l of urine. Results of th e SM A -6 and SM A -12 w ere norm al. R adiograp hs o f the ch est show ed no ch a n g e from th at observed on the pa 990 ■ JADA, Vol. 97, December 1978
tie n t’s ad m issio n to a h o sp ital six m onths previously. In itial therapy in clu d ed h yd ration and ad m inistration o f the appropriate an tib io tic s for th e in fectio n of th e urin ary tract. T h e p atien t’s co n d ition stabilized . He b e cam e m ore lu cid by the tenth h o sp ital day and reported pain in the rig h t flank. T h e oral and m axillo facial surgery serv ice was consu lted to evaluate and treat the lesion o f the tongu e that had spontan eously started to ooze blood o n th e fifth h osp ital day. T h e m ed ical staff estim ated th e loss o f blood as 50 m l a day. A d ifferential d iagn osis o f the lesio n inclu d ed m elanom a or m etastatic disease to th e tongue. B ecau se the lesio n did not appear to infiltrate d eeply in to the tongue, it w as thought that an ex cisio n w ith prim ary rep air of the tongu e w ould y ield a satisfactory sp ecim en for h isto p ath o lo g ic evaluation and sim u ltan eou s ly stop the co ntin u ed loss o f blood. In the su rg ical c lin ic for am bulatory pa tien ts, u sing a local an esth etic co n sistin g of 2% lid o cain e w ith 1 :1 0 0 ,0 0 0 ep in ep h rine, the lesio n w as excised . T h e bleed ing edges o f the un involved m uscu latu re o f the tongue w ere cau terized , and the tongue w as closed in layers u sing no. 3-0 p o ly g ly co lic acid sutures. T h e patient lost an estim ated 100 m l of blood. T h e path o lo g ist d escribed th e m ass as a nodu le com posed o f tum or tissu e ar ranged in a solid trabecular gland u lar pat tern. T h e polyh edral tum or c e lls often had clear cytoplasm , large, round v esicu lar n u clei, and p rom in ent n u cleo li. In som e region s, th e tum or cells had in vaded cap illaries (Fig 3). T h e m icro sco p ic fin d in gs w ere co n sisten t w ith renal ad enocarcinom a m etastatic to th e tongue. T h e w ound site healed norm ally w ith in a w eek. On the 30th h osp ital day, th e pa tien t had a card iac arrest that w as refrac tory to resu scitativ e m easures.
Discussion Cancer of the kidney com prises 2% of all m alignan t neoplasm s. Renal adenocarcinom a is the m ost com m on variety and accou nts for 8 0 % o f all renal cancers. Epiderm oid car cinom as o f the renal pelvis account for another 10% . O ther m alignant renal tum ors in clu d e the rare W ilm s tum or (em bryonal adenom yosar com a), usually found in early ch ild hood (6% ),2 and the few reported in cid ences o f a sarcom a that is histopathologically consistent w ith either fibrosarcom a or liposarcom a.3
Fig 3 ■ Polyhedral tumor cells with clear cytoplasm, large vesicular nuclei, and promi nent nucleoli lying within capillary (original magnification x400).
Carcinom a of the kidney alm ost always occurs in persons older than 4 0 years; a peak in cid ence occu rs b e tw een the ages of 60 and 70 years. Renal carcinom a is more than tw ice as frequent in m ales than in fem ales. T h e classic m anifestations of the d is ease inclu d e the triad of hem aturia, flank pain, and an abdom inal mass. V ariations in h istolog ic structure have caused confusion in the ter m inology as the structural pattern w ithin a single tum or may vary greatly. A denocarcinom a, Grawitz tum or, hypernephrom a, clear cell carcinom a, and renal cell carcinom a are currently grouped together as “renal adenocarcinom as of the k id n ey .”4 A w ell-differentiated carcinom a of the kidney has large cells w ith abun dant, pale cytoplasm . In som e re gions, sm aller cells w ith a denser, m ore eosin o p h ilic cytoplasm m ay form a tubular (glandular) structure. Renal adenocarcinom a has a ten dency to m etastasize w idely. T h e m etastasis may precede discovery of the prim ary lesion or may follow it. Carcinom a of the kidney tends to in vade veins and to grow along blood vessels. M etastasis occurs through the blood stream; the lungs, liver, and bones are the m ost com m on sites. Carcinom a of the kidney is also one of the m ost com m on visceral ad enocarcinom as to m etastasize to the head and neck. The m ost com m on m etastatic sites in th e head and neck region are the sinonasal tract, skin, cervical lym phatic channels,
C L IN IC A L
and the mandible. Meyer and Shklar5 have reported that the most frequent sites of metastatic disease from the kidneys to the oral tissues are the jawbones. It is estimated that 1% of all oral malignancies are metastatic foci. Approximately a third of the metasta tic lesions found in the oral cavity are the first evidence of the distant pri mary malignant disease. Ninety per cent of all oral metastatic tumors occur in the jaws, 72% occur in the mandible, and 18% occur in the maxilla. The remaining 10% are found in the oral soft tissues (5% in the tongue, 3% in the cheek, and 2% in other regions). Metastatic lesions that occur in the oral soft tissues grow rapidly and tend to bleed and ulcerate.6 The rarity of orofacial metastases may be exaggerated be cause the jaws and oral tissues are not routinely studied during post mortem examination, and radiog raphs of jaws are not usually in cluded in radiographic surveys of the skeleton. The occurrence of metastatic le sions in the tongue is rare; a review of the literature shows that this is only the sixth case reported. Zegarelli and others7 reviewed almost 7,000 post mortem reports of malignant dis eases and reported a rate of occurr ence of metastatic lesions of the tongue of 0.2%. Ochsner and DeBakey8 reviewed 3,047 instances of primary carcinoma of the lung and reported that lingual metastases oc curred in 1.6% of these cases. Metas
tatic nodules of primary malignant melanoma of the eye and of the ad renal gland have been found in the tongue. Carcinomas of the breast, prostate gland, and uterus have also been reported to have metastasized to the tongue. The most likely route of the spread of the carcinoma is through the lungs, where it can gain access to a pulmonary vein and drain to the left side of the heart and into the systemic circulation. The prognosis for patients with metastatic renal adenocarcinoma to the head and neck is poor. Treatment should be individualized according to the location of the tumor, to the presence of other metastases, and to the general health of the patient. If the lesion is resectable without gross disturbance of function or form, sub stantive palliation and occasional cure can be effected by surgical exci sion. Although historically consid ered radioresistant tumors, they do, in fact, respond to radiation. Irradia tion in tolerable levels is most likely tumorstatic rather than tumoricidal, but it is still a useful palliative treat ment. Short-term alleviation of symptoms has been reported with use of chemotherapy.9
Summary A rare metastatic cancer in the soft tissues of the oral cavity has been discussed. The importance of a good clinical examination and the inter relationship between medicine and dentistry have been emphasized.
REPO RTS
The authors acknowledge the advice of Dr. H. Kolson, formerly of the ch ief of staff’s office, and of Dr. H. Fritts, Jr., ch ief of m edicine, Northport Veterans Adm inistration M edical Center, Northport, NY. 1. Scopp, I.W. Oral m edicine; a clin ical ap proach w ith basic science correlation, ed 2. St. Louis, C. V. M osby Co., 1973, p 345. 2. Ackerman, L. Cancer diagnosis, treatment and prognosis, ed 4. St. Louis, C. V. M osby Co., 1970, p 607. 3. Anderson, W. Textbook of pathology, ed 5. St. Louis, C. V. M osby Co., 1966, p 652. 4. Bennington, J.L., and Beckw ith, J.B. Atlas of tumor pathology. Second series pt 12. Tum ors of the kidney, renal pelvis and ureter. Washington, DC, Armed Forces Institute of Pathology, 1975, p 93. 5. Meyer, I., and Shklar, G. M alignant tumors metastatic to mouth and jaw s. Oral Surg 20:350-362, 1965. 6. Bhaskar, S.N. Oral m anifestations of m etastatic tumors. Postgrad Med 49:155-158, 1971. 7. Zegarelli, D.J., and others. M etastatic tumor to the tongue. Report of twelve cases. Oral Surg 35(2):202-211, 1973. 8. Ochsner, A., and DeBakey, M. Signifi cance o f m etastasis in primary carcinom a o f the lungs, report of two cases with unusual site o f metastasis. Thoracic Surg 11:357-387, 1942. 9. Schantz, J.C.; M iller, S.H.; and Graham, W.P. M etastatic hypernephroma to the head and neck. J Surg Oncol 8(2J:183-190, 1976.
. THE AUTHORS Dr. Friedlander is chief, oral and m axillofacial surgery, and Dr. Singer is acting chief, laboratory service, North port Veterans Adm inistration M edical Center, Northport, NY 11786. Dr. Friedlander is also associate professor of surgery, School of Dental M edicine, and Dr. Singer is associate professor of pathology, Sch ool of M edicine, State University o f New York at Stony Brook. Address requests for reprints to Dr. Friedlander.
Friedlander-Singer: RENAL ADENOCARCINOMA WITH METASTASIS TO THE TONGUE ■ 991
i
CLINICAL REPORTS
0
Renal adenocarcinoma of the kidney with metastasis to the tongue A rthur H. Friedlander, D D S R ichard Singer, M D , N o rth p o rt, N Y
R enal adenocarcinom a metastasizes to distant sites. In this case, an 84-year-old m an h a d a hem orrhagic lesion on the tip o f his tongue.
alignant tum ors of the oral cavity m ake up about 5% of all forms of can cer in the hum an body. The A m erican Cancer Society estim ates that 8 ,0 0 0 A m ericans w ill die from oral and oropharyngeal cancer in 1 9 7 9 .1 It is the responsibility of the dental profession to conduct a care fu l, m ethodic exam ination of the m ucous m em branes and tissues of the oral cavity at regular intervals. For th is exam ination to be com plete, it m ust inclu d e a visual search, pal pation, and, w hen required, a radiographic survey. There is a m uch higher survival rate w ith early d etec tion, esp ecially of a prim ary oral m alignancy.
On rare occasions, there are metastases from carcinom as in the lungs, breast, prostate glands, or kidneys to the jaw s or to oral soft tissues. The m etastatic fo ci may be the first c lin i cal m anifestation of the disease. Thus, a routine but properly per form ed dental exam ination m ay dis close the presence of an occult cancer. T h is report show s that the dentist can aid the physician in the diag n osis and m anagem ent of advanced m alignant disease.
Report of case The patient w as an 84-year-old, welldeveloped but cach ectic w hite m an ad m itted to the m edical service of the N orthport V eterans A dm inistration Med ical Center in a confused and dehydrated condition. The family informed the ad mitting p hysician that six m onths before, the patient had been admitted to another institution after several episodes of syn cope. A review of the hospital chart from the
previous adm ission described a physical exam ination that show ed no abnor m alities excep t for persistent hypoten sion (80/60 m m Hg) and pale conjunctiva, w hich are con sisten t w ith anem ia. He had a hemoglobin level of 7.4 gm /100 ml and a hem atocrit reading of 22% . Other labora tory tests perform ed at that tim e included an electrocard iogram (norm al), a urin alysis, SM A-6 and SM A -12, a biopsy of the bone m arrow , and radionuclide scans of the bony skeleton, liver, and spleen. Results from a stool guaiac test for occu lt blood, sigm oidoscopy, upper and low er gastrointestinal series, and intravenous pyelogram w ere all norm al. The only other significant finding for this nonsm oker w as a radiograph of the chest that show ed m ultinodular densities in all lung fields (Fig 1). The radiographs were considered to be con sisten t w ith m etasta tic carcin om a. T he patient received three units of w hole blood and his hemoglobin level stabilized at 12.1 g m /100 m l and his hem atocrit reading at 37% . In view of the patient’s age, the physician and the fam ily agreed to forgo any invasive diagnos tic procedures. T he patient w as dis charged on the 12th hospital day w ith a diagnosis of m etastatic carcin om a to the lungs from an o ccu lt prim ary carcinom a. On adm ission to our institution, a re view of system s cou ld not be obtained from the patient. His m edical and social histories w ere obtained from close family mem bers and w ere noncontributory. On p hysical exam in ation, the m an ap peared to be ch ro n ically ill and was dis oriented and confused, but in no obvious acu te distress. His blood pressure in a supine position w as 60/40 m m Hg in the right arm and 90 /5 0 m m Hg in the left arm . The patient’s pulse rate w as 80 beats per m inute and regular. His respiratory rate was 20 breaths per m inute and regular. JADA, Vol. 97, December 1978 ■ 989
C LIN IC A L
REPO RTS
Fig 1 ■ Radiopaque areas in all lung fields.
Fig 2 ■ Lesion at tip of tongue; note lines of excision and traction suture for control of tongue during surgery.
T h e sk in, w h ich had num erous petech ial hem orrh ag es, had a d ecreased turgor. H is m otor stren g th w as u n iform ly weak, and th ere w as a d ecrease in m u scle m ass. T h e h eart rate w as regu lar; th e abdom en was soft w ith no organom egaly. T here w as no ed em a in th e extrem ities, but there w ere d ecreased breath sounds in a ll lung field s. T h e on ly other finding on physical exam in atio n w as a 2-cm ovoid, raised, b lu ish , h em o rrh ag ic lesio n at the tip of th e ton gu e (Fig 2) th at fam ily m em bers said had been th ere for about six w eeks. S ig n ifica n t laboratory resu lts inclu ded a u rin a ly sis th a t show ed gross hem aturia; clu m p s o f bacteria w ere noticed on m i cro sco p ic exam in ation . V alues o f th e co m p lete blo od cell co u n t inclu ded a h em o g lo b in lev el, 7 gm/100 m l; hem ato crit read in g , 22 % ; and w h ite blood cell co u n t, 19,000/cu m m w ith a shift to the left. T h is w as co n sisten t w ith a urine c u l ture o f E sch e rich ia coli w ith a co lo n y co u n t of 7 x 1 0 s per m l of urine. Results of th e SM A -6 and SM A -12 w ere norm al. R adiograp hs o f the ch est show ed no ch a n g e from th at observed on the pa 990 ■ JADA, Vol. 97, December 1978
tie n t’s ad m issio n to a h o sp ital six m onths previously. In itial therapy in clu d ed h yd ration and ad m inistration o f the appropriate an tib io tic s for th e in fectio n of th e urin ary tract. T h e p atien t’s co n d ition stabilized . He b e cam e m ore lu cid by the tenth h o sp ital day and reported pain in the rig h t flank. T h e oral and m axillo facial surgery serv ice was consu lted to evaluate and treat the lesion o f the tongu e that had spontan eously started to ooze blood o n th e fifth h osp ital day. T h e m ed ical staff estim ated th e loss o f blood as 50 m l a day. A d ifferential d iagn osis o f the lesio n inclu d ed m elanom a or m etastatic disease to th e tongue. B ecau se the lesio n did not appear to infiltrate d eeply in to the tongue, it w as thought that an ex cisio n w ith prim ary rep air of the tongu e w ould y ield a satisfactory sp ecim en for h isto p ath o lo g ic evaluation and sim u ltan eou s ly stop the co ntin u ed loss o f blood. In the su rg ical c lin ic for am bulatory pa tien ts, u sing a local an esth etic co n sistin g of 2% lid o cain e w ith 1 :1 0 0 ,0 0 0 ep in ep h rine, the lesio n w as excised . T h e bleed ing edges o f the un involved m uscu latu re o f the tongue w ere cau terized , and the tongue w as closed in layers u sing no. 3-0 p o ly g ly co lic acid sutures. T h e patient lost an estim ated 100 m l of blood. T h e path o lo g ist d escribed th e m ass as a nodu le com posed o f tum or tissu e ar ranged in a solid trabecular gland u lar pat tern. T h e polyh edral tum or c e lls often had clear cytoplasm , large, round v esicu lar n u clei, and p rom in ent n u cleo li. In som e region s, th e tum or cells had in vaded cap illaries (Fig 3). T h e m icro sco p ic fin d in gs w ere co n sisten t w ith renal ad enocarcinom a m etastatic to th e tongue. T h e w ound site healed norm ally w ith in a w eek. On the 30th h osp ital day, th e pa tien t had a card iac arrest that w as refrac tory to resu scitativ e m easures.
Discussion Cancer of the kidney com prises 2% of all m alignan t neoplasm s. Renal adenocarcinom a is the m ost com m on variety and accou nts for 8 0 % o f all renal cancers. Epiderm oid car cinom as o f the renal pelvis account for another 10% . O ther m alignant renal tum ors in clu d e the rare W ilm s tum or (em bryonal adenom yosar com a), usually found in early ch ild hood (6% ),2 and the few reported in cid ences o f a sarcom a that is histopathologically consistent w ith either fibrosarcom a or liposarcom a.3
Fig 3 ■ Polyhedral tumor cells with clear cytoplasm, large vesicular nuclei, and promi nent nucleoli lying within capillary (original magnification x400).
Carcinom a of the kidney alm ost always occurs in persons older than 4 0 years; a peak in cid ence occu rs b e tw een the ages of 60 and 70 years. Renal carcinom a is more than tw ice as frequent in m ales than in fem ales. T h e classic m anifestations of the d is ease inclu d e the triad of hem aturia, flank pain, and an abdom inal mass. V ariations in h istolog ic structure have caused confusion in the ter m inology as the structural pattern w ithin a single tum or may vary greatly. A denocarcinom a, Grawitz tum or, hypernephrom a, clear cell carcinom a, and renal cell carcinom a are currently grouped together as “renal adenocarcinom as of the k id n ey .”4 A w ell-differentiated carcinom a of the kidney has large cells w ith abun dant, pale cytoplasm . In som e re gions, sm aller cells w ith a denser, m ore eosin o p h ilic cytoplasm m ay form a tubular (glandular) structure. Renal adenocarcinom a has a ten dency to m etastasize w idely. T h e m etastasis may precede discovery of the prim ary lesion or may follow it. Carcinom a of the kidney tends to in vade veins and to grow along blood vessels. M etastasis occurs through the blood stream; the lungs, liver, and bones are the m ost com m on sites. Carcinom a of the kidney is also one of the m ost com m on visceral ad enocarcinom as to m etastasize to the head and neck. The m ost com m on m etastatic sites in th e head and neck region are the sinonasal tract, skin, cervical lym phatic channels,
C L IN IC A L
and the mandible. Meyer and Shklar5 have reported that the most frequent sites of metastatic disease from the kidneys to the oral tissues are the jawbones. It is estimated that 1% of all oral malignancies are metastatic foci. Approximately a third of the metasta tic lesions found in the oral cavity are the first evidence of the distant pri mary malignant disease. Ninety per cent of all oral metastatic tumors occur in the jaws, 72% occur in the mandible, and 18% occur in the maxilla. The remaining 10% are found in the oral soft tissues (5% in the tongue, 3% in the cheek, and 2% in other regions). Metastatic lesions that occur in the oral soft tissues grow rapidly and tend to bleed and ulcerate.6 The rarity of orofacial metastases may be exaggerated be cause the jaws and oral tissues are not routinely studied during post mortem examination, and radiog raphs of jaws are not usually in cluded in radiographic surveys of the skeleton. The occurrence of metastatic le sions in the tongue is rare; a review of the literature shows that this is only the sixth case reported. Zegarelli and others7 reviewed almost 7,000 post mortem reports of malignant dis eases and reported a rate of occurr ence of metastatic lesions of the tongue of 0.2%. Ochsner and DeBakey8 reviewed 3,047 instances of primary carcinoma of the lung and reported that lingual metastases oc curred in 1.6% of these cases. Metas
tatic nodules of primary malignant melanoma of the eye and of the ad renal gland have been found in the tongue. Carcinomas of the breast, prostate gland, and uterus have also been reported to have metastasized to the tongue. The most likely route of the spread of the carcinoma is through the lungs, where it can gain access to a pulmonary vein and drain to the left side of the heart and into the systemic circulation. The prognosis for patients with metastatic renal adenocarcinoma to the head and neck is poor. Treatment should be individualized according to the location of the tumor, to the presence of other metastases, and to the general health of the patient. If the lesion is resectable without gross disturbance of function or form, sub stantive palliation and occasional cure can be effected by surgical exci sion. Although historically consid ered radioresistant tumors, they do, in fact, respond to radiation. Irradia tion in tolerable levels is most likely tumorstatic rather than tumoricidal, but it is still a useful palliative treat ment. Short-term alleviation of symptoms has been reported with use of chemotherapy.9
Summary A rare metastatic cancer in the soft tissues of the oral cavity has been discussed. The importance of a good clinical examination and the inter relationship between medicine and dentistry have been emphasized.
REPO RTS
The authors acknowledge the advice of Dr. H. Kolson, formerly of the ch ief of staff’s office, and of Dr. H. Fritts, Jr., ch ief of m edicine, Northport Veterans Adm inistration M edical Center, Northport, NY. 1. Scopp, I.W. Oral m edicine; a clin ical ap proach w ith basic science correlation, ed 2. St. Louis, C. V. M osby Co., 1973, p 345. 2. Ackerman, L. Cancer diagnosis, treatment and prognosis, ed 4. St. Louis, C. V. M osby Co., 1970, p 607. 3. Anderson, W. Textbook of pathology, ed 5. St. Louis, C. V. M osby Co., 1966, p 652. 4. Bennington, J.L., and Beckw ith, J.B. Atlas of tumor pathology. Second series pt 12. Tum ors of the kidney, renal pelvis and ureter. Washington, DC, Armed Forces Institute of Pathology, 1975, p 93. 5. Meyer, I., and Shklar, G. M alignant tumors metastatic to mouth and jaw s. Oral Surg 20:350-362, 1965. 6. Bhaskar, S.N. Oral m anifestations of m etastatic tumors. Postgrad Med 49:155-158, 1971. 7. Zegarelli, D.J., and others. M etastatic tumor to the tongue. Report of twelve cases. Oral Surg 35(2):202-211, 1973. 8. Ochsner, A., and DeBakey, M. Signifi cance o f m etastasis in primary carcinom a o f the lungs, report of two cases with unusual site o f metastasis. Thoracic Surg 11:357-387, 1942. 9. Schantz, J.C.; M iller, S.H.; and Graham, W.P. M etastatic hypernephroma to the head and neck. J Surg Oncol 8(2J:183-190, 1976.
. THE AUTHORS Dr. Friedlander is chief, oral and m axillofacial surgery, and Dr. Singer is acting chief, laboratory service, North port Veterans Adm inistration M edical Center, Northport, NY 11786. Dr. Friedlander is also associate professor of surgery, School of Dental M edicine, and Dr. Singer is associate professor of pathology, Sch ool of M edicine, State University o f New York at Stony Brook. Address requests for reprints to Dr. Friedlander.
Friedlander-Singer: RENAL ADENOCARCINOMA WITH METASTASIS TO THE TONGUE ■ 991
