Renal cell carcinoma with solitary synchronous pancreaticoduodenal and metachronous periprostatic metastases: report of a case

Isolated Pancreatic Metastases of Renal Cell Carcinoma-Clinical Particularities and Seed and Soil Hypothesis

A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed, that, in addition to the unusual exclusive occurrence of pancreatic metastases and the favourable treatment results, the isPMRCC is characterised by further peculiarities of the clinical course: The lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. As an explanation for all these peculiarities, according to today's knowledge, a strong acting seed and soil mechanism can serve, which allows embolized tumour cells to grow to metastases only in the pancreas, and prevents them definitively or for years in all other organs. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. Genetic studies revealed specific changes in cases of PM of RCC: Lack of loss of 9p21.3 and 14q31.2, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, i.e., high genetic stability, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC is still unclear, so only those factors that have been identified as promoting organotropism in other, more frequent tumour entities can be presented: Formation of the pre-metastatic niche, chemokine receptor-ligand mechanism, ability to metabolic adaptation, and immune surveillance.

Diagnostic and therapeutic challenges of synchronous renal mass and pancreatic mass: a review

Objective:

Synchronous renal cell carcinoma (RCC) and pancreatic tumors are rare clinical events and have been described scarcely in the literature. Our institution has recently encountered one case. This review aims to summarize and present the diagnostic and therapeutic approaches that have been presented in the literature for these synchronous solid malignancies.

Methods:

After reviewing the literature using PubMed, 16 papers were collected that showed a total of 21 patients with a synchronous solid renal and pancreatic mass. The diagnostic and treatment data were then evaluated and analyzed.

Results:

Overall, 13 patients (59%) had two independent primary malignancies consisting of RCC and a pancreatic tumor, seven (31%) were diagnosed with primary RCC with synchronous metastasis to pancreas, one (5%) was found to have a primary pancreatic adenocarcinoma with synchronous metastasis to the kidney, and one (5%) was diagnosed with primary RCC with a benign solid pancreatic lesion. Of the 22 patients that were treated, 18 (81%) underwent surgery, one (5%) had no treatment, and three (14%) underwent chemotherapy without surgery. In the cohort of patients with surgical treatment 12 (66%) had no adjuvant therapy, one (6%) had adjuvant chemotherapy, four (22%) had adjuvant immunotherapy, and one (6%) had adjuvant radiation treatment.

Conclusions:

The occurrence of synchronous malignancies of the kidney and pancreas is rare. No clear guidelines have evolved in the literature in regard to diagnostics and treatment of these patients. This review presents recommended diagnostic and treatment guidelines for these rare clinical cases.

Level of evidence:

Not applicable for this multicenter review.

Isolated Pancreatic Metastases of Renal Cell Cancer: Genetics and Epigenetics of an Unusual Tumour Entity

Isolated pancreatic metastases of renal cell carcinoma (isPMRCC) are a rare manifestation of metastatic renal cell carcinoma (mRCC) characterized by two peculiarities: (1). The definite or at least long-term exclusive occurrence of metastases in the pancreas and (2). an unusual low tumour aggressiveness with slow tumour progression and consecutive, good treatment results. According to current knowledge, the exclusive occurrence of pancreatic metastases is due to a highly specific and highly selective seed and soil mechanism, which does not allow metastases settlement outside the pancreas, and whose detailed genetic/epigenetic causes are not yet elucidated. Recent studies have shed light on some of the pathways involved for the protracted course of the disease and highlighted a special genetic profile (lack of loss of 9p, lower weight genome instability index, low frequency of BAP1 alterations, and a high frequency of PBRM1 loss), which deviates from the conventional mRCC profile. Finally, the question of the reasons for the long-term relative genetic stability of the involved cell clones, which is an essential prerequisite for a favourable prognosis, remains unanswered.

Tumour Evolution and Seed and Soil Mechanism in Pancreatic Metastases of Renal Cell Carcinoma

In metastatic renal cell carcinoma, pancreatic metastases can appear in two clinical manifestations: (a) very rarely as isolated pancreatic metastases and (b) in the context with multi-organ metastatic disease. Both courses are characterised by rare, unusual clinical features. For isolated pancreatic metastases, the literature shows no effect on survival in all 11 publications that examined the effect of singular versus multiple pancreatic metastases; a lack of effect on survival time was also present in all 8 studies on pancreatic metastases size, in 7 of 8 studies on the influence of disease-free interval (DFI), and in 6 of 7 studies on the influence of synchronous versus metachronous metastases. In multi-organ site metastases observations, on the other hand, all five available references showed significantly better results in patients with concurrent pancreatic metastases compared to those without pancreatic metastases, although the total number of affected organs in the pancreatic metastases cohort was larger. Tumour volume-dependent risk factors thus remain surprisingly ineffective in both groups, which contradicts the usual behaviour of solid tumours. The reasons for this unusual behaviour and possible relations to tumour evolution and the hypothesis of an influence of a seed and soil mechanism in the occurrence of pancreatic metastases in metastatic renal cell carcinoma are discussed.

Isolated Pancreatic Metastases of Renal Cell Carcinoma-A Paradigm of a Seed and Soil Mechanism: A Literature Analysis of 1,034 Observations

Previously documented arguments, in favor of the suspected impact of a seed and soil mechanism, in the development and progression of isolated pancreatic metastasis of renal cell carcinomas (isPM) are: (1) uniform and independent from the side of the primary tumor distribution of isPM within the pancreas and, (2) the similar survival rates for singular and multiple isPM. In addition, the present study adds new arguments that further confirm the importance of an seed and soil mechanism in isPM: (1) Within the singular isPM, the size of the metastasis does not affect the overall survival; (2) Within the group of multiple isPMs, the overall survival does not depend on the number of metastases; (3) For synchronous and metachronous isPM, survival rates are also not different, and (4) Within the group of metachronous isPM there is also no correlation between the overall survival and interval until metastases occurs. This unusual ineffectiveness of otherwise known risk factors of solid cancers can be explained plausibly by the hypothesis of a very selective seed and soil mechanism in isPM. It only allows embolized renal carcinoma cells in the pancreas to complete all steps required to grow into clinically manifest metastases. In all other organs, on the other hand, the body is able to eliminate the embolized tumor cells or at least put them into a dormant state for many years. This minimizes the risk of occult micrometastases in distant organs, which could later—after isPM treatment—grow into clinically manifest metastases, so that the prognosis of the isPM is only determined by an adequate therapy of the pancreatic foci, and prognostic factors, such as total tumor burden or interval until the occurrence of the isPM remain ineffective.

Observations on Solitary Versus Multiple Isolated Pancreatic Metastases of Renal Cell Carcinoma: Another Indication of a Seed and Soil Mechanism?

Isolated pancreas metastases are a rare type of metastasis of renal cell carcinoma, characterized by the presence of pancreatic metastases, while all other organs remain unaffected. In a previous study, we determined arguments from the literature which (a) indicate a systemic–haematogenic metastasis route (uniform distribution of the metastases across the pancreas and independence of the metastatic localization in the pancreas of the side of the renal carcinoma); and (b) postulate a high impact of a seed and soil mechanism (SSM) on isolated pancreatic metastasis of renal cell carcinoma (isPM) as an explanation for exclusive pancreatic metastases, despite a systemic haematogenous tumor cell embolization. The objective of the study presented was to search for further arguments in favor of an SSM with isPM. For that purpose, the factor’s histology, grading, and singular/multiple pancreas metastases were analyzed on the basis of 814 observations published up to 2018. While histology and grading allowed for no conclusions regarding the importance of an SSM, the comparison of singular/multiple pancreas metastases produced arguments in favor of an SSM: 1. The multiple pancreas metastases observed in 38.1% prove that multiple tumor cell embolisms occur with isPM, the exclusive “maturation” of which in the pancreas requires an SSM; 2. The survival rates (SVR), which are consistent with singular and multiple pancreas metastases (despite the higher total tumor load with the latter), prove that the metastasized tumor cells are not able to survive in all other organs because of an SSM, which results in identical SVR when the pancreatic foci are treated adequately.

Isolated pancreatic metastases from renal cell carcinoma: an outcome of a special metastatic pathway or of specific tumor cell selection?

Isolated pancreatic metastases (isPM) are a rare metastasizing pattern in the natural history of renal cell cancer. Their clinical hallmark is that they are confined to a single organ, the pancreas, while all other organs are unaffected for a long time. Almost all workers in the field suggested that mechanical tumor cell propagation to the pancreas may be the mechanism underlying this metastasizing pattern. In 2006 our group, by contrast, proposed an alternative mechanism, i.e. a special affinity of the tumor cells for the pancreas. In the present study an attempt was made to shed more light on the settlement of isPM by reviewing recent literature data. 666 observations of isPM reported in the literature were reviewed. The analyses showed that local lymphatic spread does not play a major role because the lymphatic system is, in general, rarely involved in isPM. This also applies to a local venous spread, because the site of pancreatic metastases is independent of the side affected by the primary renal cancer. But the results are compatible with a systemic metastatic pathway. That metastases in other organs, which would be expected given a systemic spread, are absent can plausibly be explained by a seed and soil mechanism: only the pancreas offers the tumor cell emboli an environment which is conducive to the growth of clinically manifest metastases, while settlement of metastatic tumor cells is prevented in all other organs.

Solitary jejunal metastasis from renal cell carcinoma presenting as small bowel obstruction 19 years after nephrectomy

Metachronous metastatic disease may develop in up to 50% of patients with renal cell carcinoma (RCC) who have undergone a presumably curative radical nephrectomy. We describe a case of small bowel obstruction secondary to a solitary jejunal RCC metastasis affecting a 66-year-old man with a history of RCC, which was treated 19 years earlier by right radical nephrectomy. The patient underwent successful laparotomy and wide margin resection of the affected small bowel with end-to-end anastomosis. A subsequent staging CT revealed no other metastases. To our knowledge, only eight cases of isolated small bowel metastasis from RCC have been reported. Of these, only one previous report referred to a longer time interval to small bowel metastasis than our case. The case highlights that isolated bowel metastasis should be considered as a possible aetiology of small bowel obstruction, even in patients with a distant history of presumably curative cancer treatment.

Resection for secondary malignancy of the pancreas

OBJECTIVES

This study tried to clarify the role of pancreatic resection in the treatment of secondary malignancy with metastasis or local invasion to the pancreas in terms of surgical risk and survival benefit.

METHODS

Data of secondary malignancy of the pancreas from our 19 patients and cases reported in the English literature were pooled together for analysis.

RESULTS

There were 329 cases of resected secondary malignancy of the pancreas, including 241 cases of metastasis and 88 cases of local invasion. The most common primary tumor metastatic to the pancreas and amenable to resection was renal cell carcinoma (RCC) (73.9%). More than half (52.3%) of the primary cancers with local invasion to the pancreas were colon cancer, and nearly half (40.9%) were stomach cancer. The median metastatic interval was 84 months (7 years) for overall primary tumors and 108 months (9 years) for RCC. The 5-year survival for secondary malignancy of the pancreas after resection was 61.1% for metastasis and 58.9% for local invasion, with 72.8% for RCC metastasis, 69.0% for colon cancer, and 43.8% for stomach cancer with local invasion to the pancreas.

CONCLUSIONS

Pancreatic resection should not be precluded for secondary malignancy of the pancreas because long-term survival could be achieved with acceptable surgical risk in selected patients.

Systematic review of pancreatic surgery for metastatic renal cell carcinoma

BACKGROUND

This study examined the clinical outcome of patients with pancreatic metastases from renal cell carcinoma (RCC).

METHODS

A systematic literature search produced individual data for 311 surgically and 73 non-surgically treated patients with pancreatic RCC metastases. A further ten patients underwent resection at the authors' institution.

RESULTS

In the resected group, pancreatic metastases were solitary in 65.3 per cent, symptomatic in 57.4 per cent, and were preceded and/or accompanied by extrapancreatic disease in 22.3 per cent. Respective values in the unresected group were 59, 60 and 58 per cent. Disease-free survival rates were 76.0 and 57.0 per cent respectively at 2 and 5 years after resection, and overall survival rates were 80.6 and 72.6 per cent. The only significant risk factor for disease-free survival after pancreatic resection was extrapancreatic disease (P = 0.001), and that for overall survival was symptomatic RCC metastasis (P = 0.031). Two- and 5-year overall survival rates were 41 and 14 per cent respectively in unresected patients.

CONCLUSION

The actuarial 5-year overall survival rate following pancreatic surgery for RCC metastases was 72.6 per cent, as determined by pooled analysis from published series. Extrapancreatic disease was an independent risk factor for recurrence, but had no significant impact on overall survival.

A case of small bowel obstruction due to intraluminal metastases from metastatic renal cell cancer

A 71-year-old man, with a history of metastatic renal cell cancer (RCC), presented with symptoms of a small bowel obstruction with nausea, vomiting, cramps, and diarrhea. He underwent surgery and was found to have intraluminal metastases from his metastatic RCC. Intraluminal metastases are rare and usually present with obstruction, bleeding, or perforation. The mainstay of treatment remains complete surgical excision, even in the face of widely metastatic disease. Surgery not only palliates symptoms, but may also extend survival because metastatic RCC can be a very indolent and unpredictable disease. Furthermore, these patients can now be treated with a new class of antiangiogenic agents that are showing impressive response rates, which may also translate into improved overall survival.

Duodenum-preserving pancreatic head resection for pancreatic metastasis from renal cell carcinoma: a case report

INTRODUCTION

We report a case of duodenum-preserving pancreatic head resection (DPPHR) for the treatment of pancreatic head metastasis from renal cell carcinoma (RCC).

CASE REPORT

The patient was a 59-year-old male with a medical history of RCC 18 years ago. Abdominal imaging studies revealed a hypervascular mass localized in the pancreatic head without distant metastasis or tumor invasion into the adjacent organs including the common bile duct and duodenum. Under the preoperative diagnosis of pancreatic metastasis from RCC, the tumor was completely resected by DPPHR. The pathological examination of the resected specimen confirmed the preoperative diagnosis.

CONCLUSION

As lymph node metastasis has been rarely reported in previous cases of pancreatic metastasis from RCC, DPPHR should be considered as a less invasive surgical option to provide a favorable postoperative quality of life (QOL).

Solitary and multiple isolated metastases of clear cell renal carcinoma to the pancreas: an indication for pancreatic surgery

BACKGROUND

Isolated pancreatic metastases (isPMs) of clear cell renal carcinoma are rare. Most of them are solitary; some are multiple. The reported rates and the clinical implications of multiple isPMs from clear cell renal cancer vary. Therefore, the available literature was analyzed to shed light on the clinical significance of these extremely rare metastatic lesions.

METHODS

A literature search brought to light 236 cases of isPMs (both solitary and multiple) from renal cell carcinoma. These were analyzed.

RESULTS

A total of 12% of the metastases were synchronous with the primary tumor, and 88% were metachronous, occurring 10.0 +/- 6.5 years (mean +/- SD) after nephrectomy. A predilection for a specific part of the pancreas was not identifiable. The localization of the renal cell cancer (left or right kidney) did not have any effect on the site of the metastases. Seventy-four (39%) of the metastases to the pancreas were multiple (3.2 +/- 1.5). Their epidemiology did not differ from that of solitary metastatic lesions. Actuarial 3- and 5-year survival rates after radical resection were 78% and 78%, respectively, for multiple versus 75% and 64% for solitary metastases.

CONCLUSIONS

The epidemiological data do not support a direct local lymphogenous or venous spread from the primary tumor to the pancreas. They rather suggest a systemic spread. Because of the positive outcome, radical removal of both solitary and multiple metastases should be attempted in eligible patients.