renal cell carcinoma ( rcc ) comprises 23% of all adult malignancies and 85% of malignant renal tumors . the highest incidence is found in individuals in the sixth and seventh decades of life , 66 being the median age at diagnosis [ 1 , 2 , 3 , 4 , 5 ] . rcc has a strong propensity to metastasize ; 25% of patients initially present with distant metastasis and another 50% develop metastasis during follow - up [ 1 , 6 , 7 ] . it is the third most frequent neoplasm to metastasize to the head and neck region , preceded only by breast and lung cancer [ 1 , 3 , 4 , 5 , 8 , 9 , 10 ] . although infrequently reported , head and neck regional metastases may be linked to rcc in up to 815% of cases [ 1 , 2 , 4 , 6 , 7 , 8 , 9 ] . the most affected regions of the head and neck include the paranasal sinuses , larynx , jaws , temporal bones , thyroid gland , and parotid glands . rcc metastases to the nose and paranasal sinuses are the most frequently affected areas , followed by the tongue [ 1 , 3 , 9 , 11 , 12 ] . the most common presenting symptoms to the head and neck region include an enlarging neck mass , epistaxis , anosmia , facial pain , nasal obstruction , and diplopia . rcc is comprised of hypervascular tumors associated with multiple arteriovenous shunts due to the release of vascular endothelial growth factor as well as other angiogenic factors . given the fact that the kidneys receive 25% of the circulating blood volume , rcc has a high spreading potential via the blood [ 12 , 13 ] . rcc has 5 distinct histologic presentations : clear cell / conventional ( 75% ) , papillary ( 15% ) , chromophobe ( 5% ) , collecting duct ( 2% ) , and unclassified ( 3% ) . histopathologically , clear cell rcc typically shows a compact alveolar or solid architecture with varying degrees of cystic changes . rcc characteristically tends to exhibit numerous capillaries and thin - walled blood vessels in the supporting stroma . the cytoplasm is rich in lipids and glycogen ; the latter 2 elements dissolve during processing to provide the characteristic clear cytoplasm [ 2 , 7 ] . immunohistochemical staining helps in this distinction , exhibiting focal cytokeratin positivity ( vs. minor salivary gland cancers that show diffuse positivity ) and a strong reaction for vimentin . radiologic diagnosis is based on the vascular nature of the tumor , which shows moderate to marked signal enhancement on contrast ct . if contrast enhancement indicates destruction and lack of tumor calcification , metastatic rcc should be part of the differential diagnosis . excision is usually performed to control pain and to manage any potential complications from space - occupying masses in the head and neck region , including the brain [ 1 , 10 ] . rcc does not respond well to radiation therapy , and while chemotherapy ( interleukin-2 , interferon- , and 5-fluorouracil ) may be useful in cases of residual disease after resection , a positive response is experienced in less than 25% of patients . radiotherapy can only improve symptomatic relief and increase quality of life for perhaps a few months . the 5-year survival rate for rcc after nephrectomy is 6075% . excision of solitary metastatic lesions of rcc following nephrectomy results in a survival rate of 41% at 2 years and 13% at 5 years . the prognosis for patients with multiple rcc metastases is poor , with a 5-year survival rate of 07% [ 2 , 4 , 9 , 14 ] . we report on a 62-year - old male who presented to the ophthalmology service with vi cranial nerve bilateral paresis , absence of pharyngeal reflex , dysarthria , right tongue deviation , and paralysis to the right side of the face . ct and mri were performed , with ct showing a large expansive process at the cranial base with clivus and right petrous apex osteolysis ( fig . an mri t1 sequence showed a solid isointense expansive process with bilateral internal carotid artery involvement ( fig . 3 ) . an mri t2 sequence revealed small hyperintense areas indicative of being cystic in nature or suggestive of central necrosis ( fig . ipsilateral side secretions coming from the eustachian tube indicated the mastoid region had been compromised . an additional mri t1 sequence following administration of gadolinium contrast material showed moderate enhancement with clear involvement of bilateral internal carotid arteries ( fig . 5 ) and the cavernous sinus , posterior ethmoidal sinus , clivus and both petrous apex infiltration . the head and neck cancer committee recommended ultrasonography , which subsequently revealed a heterogeneous echogenic multilobular mass on the right kidney , with irregular contours ( fig . pelvic and abdominal ct was performed , revealing a large mass on the right kidney with irregular contours and poor definition . further investigations performed following contrast injection revealed a heterogeneous density with a hypodense central area and some calcifications in thickness ( hyperdense deposits in the body of the primary tumor : right kidney ) ( fig . radiotherapy was recommended , but due to the advanced stage of the disease the patient was enrolled in a palliative care and pain control program . metastases of malignances in the head and neck are rare . when present , they tend to be very aggressive due to the advance stage of the disease . multidisciplinary management , clinical experience and high - resolution imaging support are crucial for determining tumor identification , primary tumor localization , and the extent of tumor involvement .
we report on a patient who presented with cranial nerve vi bilateral paresis , absence of pharyngeal reflex , dysarthria , right tongue deviation , and right facial paralysis . 
 imaging studies showed an expansive process in the cranial base with clivus and petrous apex osteolysis . 
 a biopsy confirmed the presence of clear cell adenocarcinoma and suspicion of renal tumor metastases . 
 abdominal imaging studies revealed a mass in the right kidney . 
 consequently , radiotherapy was performed , and the patient was enrolled in a palliative care and pain control program .