Open Access

Renal cell carcinoma metastasizing to duodenum: a rare occurrence

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.
https://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.
https://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.

https://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.

Declarations

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; licensee BioMed Central Ltd. 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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