A 72-year-old man was referred to our institution with a 4-month history of a voluminous mass in the upper portion of the nasal pyramid following a nasal trauma. He had been treated a few weeks earlier at a different ENT service for a massive spontaneous epistaxis. The patient also reported a long history of hematuria, previously attributed to renal tuberculosis occurring over 40 years before. At admission, a cranial CT scan showed a large soft tissue ethmoid mass extending to the right and left choanal region, the right orbit, the right frontal sinus, and an initial intracranial extension with partial erosion of the crista galli. MRI confirmed the evidence found at computed tomography (Figure 1). Fine needle aspiration showed typical epithelial tissue and clear-cytoplasm cells interpreted as pericytes. Preoperative local biopsy was not performed due to the history of severe epistaxis and the high risk of massive bleeding during the procedure.
The patient underwent surgery with a trans-sinusal frontal approach using a bicoronal incision combined with an anterior midfacial degloving to excise the mass; however, the right orbital and especially the initial intracranial extension did not allow a complete removal of the neoplasm. Considerable bleeding occurred during surgery. The histological exam revealed a clear cell renal cell carcinoma (Figure 2). Based on these findings, the patient underwent a total body CT scan that showed a solitary 6 cm mass in the upper posterior pole of the left kidney. Bone scintigraphy also revealed increased uptake in the ethmoid and orbital region. Due to the poor general conditions, no surgery was performed to remove the primary tumor; the patient died 4 months later.