Renal cell carcinoma is the most common renal malignancy. RCC accounts for 2% of all the malignancies in adult population and around 90% of the malignant renal tumors are eventually diagnosed as RCC1. Globally RCC is the 6th most common malignancy in males and 10th most common in females accounting for 5% and 3% of all cancers respectively2.. Typically it is found incidentaly but RCC is known to have notorious presentations. Today, we present a case where a lesion initially thought to be a pyogenic granuloma turned out to be a metastatic RCC.

65-year-old gentleman presented to the surgical OPD of a tertiary care hospital in AJK with complaint of a dark coloured lesion on the skin just below his left ear lobe. The lesion was painless and patient noticed it when it bled while he was combing his hair. He was a known ischemic heart disease patient with ejection fraction of 35 % and was on regular prescription of dual anti-platelet agents. On further inquiry, patient had no other complaints. Systemic examination was unremarkable and on detailed examination of the lesion, it was diagnosed to be a pyogenic granuloma and an excision under local anesthesia was done. Histopathology showed a malignant lesion with clear cell morphology and immunohistochemistry confirmed it as RCC. CT Triphasic Chest Abdomen and Pelvis was done which showed a Right Renal Mass with locoregional advancement and showed metastatic deposits in spine and left humerus. So patient was refered to medical oncology and is currently under palliative care.

The overall incidence of metastasis in patients with an internal malignancy is estimated to be 5-10%. Skin lesions can be the first sign of extra nodal metastasis in 7.6% of patients6. Usual metastatic sites for RCC are lungs, bones and local invasion of IVC. Cutaneous metastatic deposits in RCC can present as red, purple or black colored subcutaneous nodules. These lesions are difficult to clinically distinguish, therefore vigilance and a high clinical suspicion is required.

Renal cell carcinoma is among the common malignancies encountered in daily practice of an oncology and urology center. RCC is known to have atypical presentations such as discussed above. Therefore, while dealing with an un-usual presentation of a skin lesion in an atypical location, metastatic deposit of RCC should be kept in mind while making a pool of differential diagnosis.