Images of Memorable Cases: Case 77 This 62-year-old woman presented with diffuse, debilitating skeletal pain and a 2x3x4 cm painless, firm nodule on her forehead. She also had several smaller nodules of similar nature on her scalp. All of these lesions pulsated. 77. Metastatic renal cell carcinoma The primary tumor arose in the left kidney and quickly spread throughout the skeletal system. As this case illustrates, pulsatile metastases characteristically involve adjacent bones (images below). The point to remember, however, is this: If a metastasis pulsates, the primary tumor is carcinoma of the kidney or thyroid gland. There are no other considerations, unless the sternum is the site of a pulsating metastasis. In that instance alone, multiple myeloma is another diagnostic possibility.