Renal cell carcinoma metastasizing to duodenum: a rare occurrence

  • Alka Bhatia1Email author,

    Affiliated with

    • Ashim Das1,

      Affiliated with

      • Yashwant Kumar1 and

        Affiliated with

        • Rakesh Kochhar2

          Affiliated with

          Diagnostic Pathology20061:29

          DOI: 10.1186/1746-1596-1-29

          Received: 28 August 2006

          Accepted: 14 September 2006

          Published: 14 September 2006

          Abstract

          Background

          Duodenal metastasis is rare in renal cell carcinoma (RCC) and early detection, especially in case of a solitary mass, helps in planning further therapy.

          Case presentation

          We present the case report of a 55 year old male with duodenal metastasis of RCC. This patient presented with jaundice and abdominal lump one year after nephrectomy. On upper gastrointestinal endoscopy a submucosal mass lesion was noted in the duodenum, the biopsy of which revealed metastasis.

          Conclusion

          In a nephrectomized patient presenting with jaundice and an abdominal mass, the possibility of metastasis should be suspected and a complete evaluation, especially endoscopic examination followed by biopsy, should be carried out.

          Background

          Renal cell carcinoma (RCC) has a potential to metastasize to almost any site. In descending order of frequency, the most common sites of metastasis are the lung, lymph nodes, liver, bone, adrenal glands, kidney, brain, heart, spleen, intestine, and skin [1]. It can involve any part of the bowel and accounts for 7.1% of all metastatic tumours to small intestine [2]. Duodenal metastasis from RCC is very uncommon and only few cases have been described in the English literature (table 1) [318]. Also duodenal metastasis generally occurs when there is widespread nodal and visceral involvement and evidence of metastatic disease elsewhere in the body. Here we present the case report of a patient with duodenal and liver metastasis who presented with jaundice and right sided abdominal lump one year after nephrectomy. Duodenal biopsy performed revealed metastasis in the duodenum.
          Table 1

          Previously reported examples of duodenal metastasis in patients with renal cell carcinoma

          Author

          Year

          Age/Sex

          Duration post-nephrectomy

          Presenting symptoms

          Other organs involved

          Treatment

          Patient outcome

          Lawson et al [3]

          1966

          69/F

          0 years

          Bleeding anemia

          -

          Pancreatico-duodenectomy

          Alive (8 months FU)

          Tolia et al [4]

          1975

          -/M

          16 years

          -

          -

          -

          5 months

          Heymann et al [5]

          1978

          64/M

          8 years

          Bleeding

          Colon

          Complex procedure

          3 weeks

          McNichols et al [6]

          1981

          52/M

          10 years

          Malabsorption

          -

          Diagnostic only

          -

          Lynch et al [7]

          1987

          16/M

          1 year

          Bleeding

          -

          Embolization

          Alive (6 months FU)

            

          61/M

          6 years

          Jaundice

          -

          Embolization

          6 months

            

          67/M

          2 years

          Bleeding

          Lungs

          -

          Lost to FU

          Robertson et [8]

          1990

          70/M

          13 years

          Bleeding

          Pancreas

          Whipple procedure

          -

          Gastaca et al [9]

          1996

          -

          8 years

          -

          -

          Duodenectomy

          -

          Toh et al [10]

          1996

          59/F

          10 years

          Obstruction anemia

          -

          Metastatectomy

          Alive (6 months FU)

          Ohmura et al [11]

          2000

          62/M

          5 years

          Obstruction

          -

          Embolization- local resection

          -

          Hashimoto et al [12]

          2001

          57/M

          11 years

          Bleeding

          Pancreas

          PPPD

          -

          Nabi et al [13]

          2001

          40/M

          4 years

          Obstruction

          -

          Gastrojujenostomy

          7 days

          Sawh et al [14]

          2002

          53/M

          6 years

          Bleeding

          Brain Anal canal

          Duodenectomy

          Alive (4 years FU)

          Loualidi et al [15]

          2004

          76/M

          5 years

          Anemia

          -

          Radiotherapy

          Alive

          Chang et al [16]

          2004

          63/F

          9 years

          Bleeding

          -

          Metastatectomy

          -

          George et al [16]

          2004

          65/M

          2 years

          Obstruction

          Omentum ileum

          Intestinal Resection

          9 months

          Arroyo [17]

          2005

          -

          -

          -

          -

          -

          -

          Bhatia et al (current)

          2006

          50/M

          1 year

          Jaundice

          Liver

          Diagnostic only

          Lost to FU

          PPPD = Pylorus preserving pancreatico-duodenectomy, FU = Follow up

          Report of a case

          The patient was a 55 years old male who came to gastroenterology out patient department with complaints of jaundice and an abdominal mass. He had a history of RCC in the left kidney and had undergone left radical nephrectomy one year ago in our institute. The tumour was present in the lower pole and measured 7 × 5 × 6 cm. Microscopically, it was a conventional clear cell carcinoma (Furhman grade III) involving the renal sinus with tumour emboli in the renal vein. The adrenal gland and ureter were free. This time the patient had jaundice and an abdominal lump. An upper gastrointestinal endoscopy (UGIE) followed by duodenal biopsy was performed. Endoscopy showed a 4 × 4 cm submucosal mass lesion (Fig. 1) in the second part of duodenum. A biopsy was taken from the mass and sent for histopathology.
          http://static-content.springer.com/image/art%3A10.1186%2F1746-1596-1-29/MediaObjects/13000_2006_Article_29_Fig1_HTML.jpg
          Figure 1

          Endoscopic view of submucosal mass lesion in second part of duodenum, with normal glistening mucosa.

          The biopsy consisted of three fragments which revealed duodenal mucosa with normal villi, however many of the vascular channels in the lamina propria showed tumour emboli. The tumour cells were mildly pleomorphic, had abundant pink cytoplasm and low nuclear:cytoplasmic ratio (Fig. 2). These were positive for cytokeratin (CK), vimentin (Vim) and epithelial membrane antigen immunostaining and negative for chromogranin (Fig. 3). The surrounding lamina propria, villi and crypts were normal. Considering these features, a diagnosis of metastatic renal cell carcinoma was offered on the biopsy. This was followed by abdominal Ultrasonography (USG), CT scan, liver function tests and other investigations to know the extent of illness. Liver enzymes were raised significantly with serum alkaline phosphatase levels of > 1000 IU/L. Both USG and CT scan showed multiple tumour deposits in the liver. Other visceral organs and peritoneum were normal. Radiotherapy as a part of palliative treatment was planned but could not be performed as the patient was lost to follow up.
          http://static-content.springer.com/image/art%3A10.1186%2F1746-1596-1-29/MediaObjects/13000_2006_Article_29_Fig2_HTML.jpg
          Figure 2

          Tumour emboli of renal cell carcinoma in lymphatics of lamina propria.

          http://static-content.springer.com/image/art%3A10.1186%2F1746-1596-1-29/MediaObjects/13000_2006_Article_29_Fig3_HTML.jpg
          Figure 3

          Strong positivity of tumour cells for vimentin and cytokeratin immunostaining.

          Discussion

          Small bowel involvement by metastatic tumors is rare and has been reported in only 2% of autopsy cases [2]. Common metastatic malignancies known to involve the small bowel are melanomas, lung cancer, carcinoma of the cervix, RCC, thyroid carcinoma, hepatoma and merkel cell carcinoma. Males are more commonly affected (male: female = 1.5:1) and the incidence of metastasis increases with age [17]. Metastatic lesions of the duodenum are most frequently located in the periampullary region or the duodenal bulb [17]. On endoscopy the lesion can be seen as a submucosal mass with ulceration of the tip, multiple nodules of varying sizes or raised plaques [19]. In the present case the metastatic lesion was seen as a 4 × 4 cm submucosal mass in the 2nd part of duodenum. The patients commonly present with gastrointestinal bleeding or intestinal obstruction [10, 17], however our patient presented with jaundice and abdominal lump. On investigation he was found to have liver metastasis also.

          The majority of patients are found to have metastasis within a year after nephrectomy though it can be seen even after several years [16]. The routes of spread can be (i) peritoneal dissemination, (ii) direct spread from an intra-abdominal malignancy, (iii) hematogenous and (iv) lymphatic spread [17]. The last two mechanisms can be responsible for metastases in the case reported.

          Treatment options in a case of RCC metastasis depend upon the extent and location of the lesion. In the majority of reported cases of duodenal metastasis, metastatectomy was done. However for disseminated malignancy like in our case treatment is in the form of palliative (non-curative) surgery, radiotherapy, chemotherapy (Sunitinib) or immune stimulating agents (Interleukin-2). However even after treatment the patients with metastatic disease have poor survival. The average survival is about 4 months and only 10% of these survive for one year [20].

          The report therefore highlights the importance of investigating patients of RCC presenting with any gastro-intestinal tract manifestations for metastasis. A complete evaluation, especially endoscopic examination and biopsy, should be carried out in such patients. Awareness of this entity and a high index of suspicion on the part of the treating physician and pathologist would help in proper diagnosis and treatment.

          Authors’ Affiliations

          (1)
          Department of Histopathology, Postgraduate Institute of Medical Education and Research
          (2)
          Department of Gastroenterology, Postgraduate Institute of Medical Education and Research

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          Copyright

          © Bhatia et al. 2006

          This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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