The correct answer is D: Perform a urinalysis.
Discussion: The lesion depicted could be interpreted as a benign cherry (or “senile”) angioma, but such lesions are rarely solitary, are much more common on the trunk, and are typically dome-shaped and sessile (rather than exophytic and pedunculated). There is nothing in his history to suggest HIV–AIDS, characteristically associated with bacillary angiomatosis. Rather, this clearly vascular-appearing lesion in an elderly patient should suggest a cutaneous metastasis, specifically due to renal cell carcinoma (RCC). One of the classic presentations of cutaneous metastases of RCC is a red-purple papulonodule that clinically resembles an angioma or pyogenic granuloma. A urinalysis demonstrated substantial microscopic hematuria, and a biopsy of the skin lesion, including cell surface marker staining, was highly suggestive of RCC. The patient was ultimately found to have an RCC (clear cell variant) located in the right kidney.
Overall, cutaneous metastases of visceral neoplasms are uncommon. A recent large-scale meta-analysis of American journal articles suggests that about 5% of all internal malignancies (excluding lymphoma) will metastasize to the skin. Of all these cutaneous metastases, only 10% arise from primary urological tumors. While many RCCs demonstrate metastases, skin involvement is most often encountered in conjunction with widespread multi-organ visceral metastases. Cutaneous metastasis as the sole manifestation of primary RCC, as demonstrated in this case, is a relatively rare phenomenon.
Renal cell carcinoma comprises only about 3% of all adult visceral neoplasia. Unfortunately, about one in three RCCs have metastases at the time of presentation, and the general prognosis is not favorable; median survival is under one year, and the five-year survival is 10%. In previous decades, the prognosis for metastatic RCC was especially grim. Things have improved somewhat in that, combined with nephrectomy, a variety of maneuvers can be considered. Immunotherapy (eg interleukin-2 or interferon alfa-2a(Drug information on interferon alfa-2a)) or traditional chemotherapy (eg, vinblastine(Drug information on vinblastine) and 5-fluorouracil) may be utilized. Moreover, mTOR kinase inhibitors (eg, everolimus [Afinitor], temsirolimus [Torisel]), multikinase inhibitors (eg, sunitinib [Sutent], sorafenib [Nexavar]), and anti-angiogenic monoclonal antibodies (eg, bevacizumab(Drug information on bevacizumab) [Avastin]) have had a positive impact on survival and quality of life in advanced RCC.
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