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Renal cell carcinoma: an unusual case of sclerotic metastasis Kaouther Ben Abdelghani, Maroua Slouma, Leila Souabni, Leith Zakraoui Department of Rheumatology, Mongi Slim Hospital, La Marsa, Tunisia Correspondence to Dr Kaouther Ben Abdelghani, [email protected] Accepted 26 August 2014

DESCRIPTION A 44-year-old man presented with a 3-month history of low back pain affecting mainly the left lumbar and gluteal regions. Physical examination revealed restricted back movement with tenderness over lumbar spinal processes. Straight leg raising test was negative. Laboratory examinations showed an elevated erythrocyte sedimentation rate (ESR;

Figure 2 Transversal reformats of the abdominal CT scan showing the existence of a 3 cm heterogenous complex tumour at the lower pole of the right kidney. 116 mm) and a high level of alkaline phosphatase (1000 IU/L). Serum levels of calcium, albumin and phosphorus were within the normal range. The pelvis and lumbar spine X-ray showed diffuse and heterogenous osteosclerotic lesions (figure 1). The chest X-ray was normal. Blood parathyroid hormone and prostate-specific antigen levels were normal. Pelvic ultrasound showed a regular and homogenous prostate with no enlargement and no postmictional residue. An abdominal contrastenhanced CT showed the existence of a 3 cm heterogenous tumour at the lower pole of the right kidney (figure 2). Osteomedullary biopsy was then performed. Histopathology showed cells with copious clear cytoplasm and nuclei with prominent, eosinophilic nucleoli. Immunohistochemistry revealed positivity for Vimentin, cytokeratin (CAM 5.2) and epithelial membrane antigen. The diagnosis of osteoblastic bone metastases from renal cell carcinoma (RCC) was established. Palliative radiation therapy was indicated. Bone metastases in RCC occur in 20–25% of cases and are mainly osteolytic.1 Rare cases of sclerotic metastases revealing an RCC have been reported.2 3 Sclerosis is very common in Paget’s disease. The diagnosis of bone metastases should be considered when elevation of ESR is found. In such cases, osteomedullary biopsy is necessary to differentiate among these various entities.

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To cite: Ben Abdelghani K, Slouma M, Souabni L, et al. BMJ Case Rep Published online: [ please include Day Month Year] doi:10.1136/ bcr-2014-204126

Figure 1 Pelvis X-ray (A) and spine X-ray (B) showing diffuse and heterogenous osteosclerotic lesion.

▸ The diagnosis of bone metastases should be considered when sclerotic lesions and an increase in erythrocyte sedimentation rate are found. ▸ Renal cell carcinoma should be kept in mind in front of sclerotic bone metastasis especially when no other primary tumour is found.

Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204126

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Images in… Contributors KBA and MS contributed to the conception, and LS and LZ drafted the manuscript. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; externally peer reviewed.

REFERENCES 1 2 3

Santini D, Procopio G, Porta C, et al. Natural history of malignant bone disease in renal cancer: final results of an italian bone metastasis survey. PLoS ONE 2013;8:e83026. Sneag DB, Krajewski KM, Howard S, et al. Sclerotic osseous metastases from renal cell. Skeletal Radiol 2012;41:1169–75. Salapura V, Zupan I, Seruga B, et al. Osteoblastic bone metastases from renal cell carcinoma. Radiol Oncol 2014;48:243–6.

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Ben Abdelghani K, et al. BMJ Case Rep 2014. doi:10.1136/bcr-2014-204126

Renal cell carcinoma: an unusual case of sclerotic metastasis.

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