Unusual gastric and pancreatic metastatic renal cell carcinoma presentation 10 years after surgery and immunotherapy: A case report and a review of literature

A Resected Case of Simultaneous Gastric and Multiple Pancreatic Metastases of Renal Cell Carcinoma 11 Years After Nephrectomy

A 50-year-old man with a history of nephrectomy for renal cell carcinoma (RCC) 11 years prior was diagnosed with gastric and multiple pancreatic metastases of RCC. He underwent a pyloric gastrectomy and total pancreatic resection. RCC metastases to the pancreas are rare, and gastric metastases are even rarer. This case represents a rare instance of simultaneous RCC metastases to both the stomach and pancreas. Although there is no difference in prognosis between solitary and multiple pancreatic metastases, surgical resection is recommended even for multiple lesions. However, preoperative imaging often fails to identify all pancreatic metastatic lesions, making total pancreatectomy a consideration for ensuring complete resection, especially when preoperative detection is challenging.

Metastasis to the stomach: a systematic review

Background: This study reviews the literature on gastric metastases (GM) in terms of diagnosis, treatment, and outcomes. The goal of this study was to provide clinicians with a reliable and beneficial source to understand gastric metastases arising from various primary tumors and to present the growing literature in an easily accessible form. Methods: Articles published in English language from implementation of MEDLINE and Cochrane databases until May 2022 were considered for the systematic review. Articles other than English language, letters to the editor, posters, and clinical images were excluded. Hematogenous and lymphogenic metastases were included whereas direct tumoral invasion and seeding were excluded. Articles and abstracts were analyzed and last selection was done after cross-referencing and by use of defined eligibility criteria. Results: In total 1,521 publications were identified and 170 articles were finally included totaling 186 patients with GM. The median age of patients was 62 years. Gynecologic cancer was the most common cancer type causing GM (67 patients), followed by lung cancer (33 patients), renal cancer (20 patients), and melanoma (19 patients). One of the main treatment methods performed for metastasis was resection surgery (n=62), sometimes combined with chemotherapy (ChT) or immunotherapy. ChT was the other most used treatment method (n=78). Also, immunotherapy was amongst the most preferred treatment options after surgery and ChT (n=10). Conclusions: As 172 case reports were screened in the systematic review from different journals, heterogeneity was inevitable. Some articles missed important information such as complete follow-up or clinical information. Moreover, since all of the included articles were case reports quality assessment could not be performed. Among 172 case reports reviewed, resection surgery was performed the most and was sometimes combined with ChT and immunotherapy. Further research about what type of treatment has the best outcomes for patients with gastric metastases is needed.

Gastric metastasis presenting as submucosa tumors from renal cell carcinoma: A case report

BACKGROUND

Gastric metastasis from renal cell carcinoma (RCC) is an extremely rare clinical entity. Due to an easily neglected RCC history, nonspecific symptoms and under-recognized endoscopic presentation may lead to a potential diagnostic pitfall in daily clinical practice.

CASE SUMMARY

We present a case of metastatic gastric tumors arising from RCC 5 years after radical nephrectomy. Simultaneous, multifocal metastases to the gallbladder, pancreas and soft tissue were observed. One year previously, a solitary submucosal discoid tumor with a central depression was detected in the gastric fundus in a 65-year-old man. Endoscopic ultrasonography (EUS) showed a 1.12 x 0.38 cm lesion originating from the deeper mucosal layers with partially discontinuous submucosa. One year later, the endoscopic findings of the lesion showed various changes. A large lesion of the protruding type (2.5 cm × 2 cm) was found in the fundus at the same location. EUS showed a heterogeneous mass that involved the mucosa and submucosal layer. In addition, two small similar submucosal lesions 0.4-0.6 cm in size were detected. These lesions had a central depression, surface mucosal congestion and thickened vessels. The two adjacent lesions in the fundus were resected by endoscopic submucosal dissection. Based on the postoperative pathological analysis, the patient was diagnosed with gastric metastasis from RCC.

CONCLUSION

Gastric metastasis from RCC should be considered in patients with a history of RCC irrespective of the time interval involved.

Application of 18F Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography in Monitoring Gastric Metastasis and Cancer Thrombi from Renal Cell Carcinoma

Background. Renal cell carcinoma (RCC) with gastric metastasis is rare, particularly accompanied by multiple cancer thrombi. Methods. We reported a 66-year-old man with a history of a right radical nephrectomy because of RCC. The patient underwent 18F prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) scanning after 6 months of targeted therapy because of gastric metastasis and cancer thrombi. We conducted a systematic review of the literature and identified 73 cases of RCC with gastric metastasis. We analyzed the clinicopathological characteristics, therapies, and outcomes of patients. Results. 18F-PSMA PET/CT showed a large mass in the gastric fundus and cancer thrombi in the right atrium, inferior vena cava, and splenic vein with intense tracer uptake. Other metastases with increased tracer uptake included multiple bones and abdominal lymph nodes. The majority of gastric metastasis of RCC were men (53/73, 72.6%), with a median age at presentation of 67 (from 48 to 87) years. Gastric metastasis of RCC was mainly metachronous, and presented with small polyps or mass appearance and often accompanied by multiple-site metastases and gastrointestinal symptoms. An overall median interval between nephrectomy and diagnosis of gastric metastasis was 6 (from 0.1 to 23) years, and an overall median survival time was 14 (from 0.25 to 72) months. The median interval time of solitary gastric metastasis was longer than gastric metastasis with multiple-site metastases (7 vs.5 years; $P=0.034$ ). Patients with gastric and multiple-site metastases had higher mortality than patients with solitary metastasis (17 vs.1; $P=0.028$ ). The patients with synchronous gastric metastasis had a shorter survival time than metachronous gastric metastasis (6 vs.17 months; $P=0.018$ ). Conclusions. Postoperative follow-up of multiple imaging modalities to monitor recurrence and metastasis is necessary and important. PSMA PET/CT can improve the detection sensitivity of RCC, especially in metastatic clear cell renal cell carcinoma (ccRCC), and could provide a basis for disease staging, restaging, and therapeutic efficacy evaluation.

Gastrointestinal Metastases From Primary Renal Cell Cancer: A Single Center Review

Introduction: Digestive metastases (DMs) from renal cell cancer (RCC) are rare. Over the past decade, the overall survival of metastatic RCC (mRCC) has been improved by tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors. The main objective of this study was to assess the incidence of metastases of the digestive tract in this new field of treatment. The secondary objectives were to evaluate the clinical characteristics, prognosis, treatments used for DMs, and median time between the diagnosis of RCC or mRCC and DMs. Materials and Methods: A retrospective analysis of data collected from all patients with mRCC between 2007 (the time of TKI was a standard of care) and 2019 was carried out at the Paoli-Calmettes Institute (Marseille, France). Computer research software using artificial intelligence (ConSoRe®) was used to identify patients and assess their characteristics. Results: Between January 2007 and December 2019, 11 out of 660 (1.6%) mRCC patients had metastases of the gastrointestinal tract. The median age was 62 years. Of the 11 patients, 81.8% experienced digestive bleeding or anemia. Only 2 patients were asymptomatic. The metastases were mainly duodenal (50%) and gastric (41.6%). The median time from cancer diagnosis and from metastatic disease to gastrointestinal metastasis was 4.3 years (3 months-19.2 years) and 2.25 years (0 days-10.2 years), respectively. Local treatment was performed in 38.5% of cases by endoscopy (60%), surgery (20%) and radiotherapy (40%) with success rates of 33, 100, and 50%, respectively. Etiological treatment was modified following the discovery of DM in 84.6% of the cases. The median survival was 1 year from the diagnosis of DM (13 days-9.4 years). Two patients were still alive 2.9 and 9.4 years after the diagnosis of DM. Conclusion: This is the largest monocentric retrospective analysis of DM in patients with RCC. It seems to be a rare and late event in the course of the disease. Local treatment combined with systemic treatment could improve survival. In the context of prolonged survival with the new based immunotherapy treatments in mRCC, we suggest that unexplained anemia or persistent digestive symptoms could be explored by endoscopy.

Current Challenges in Diagnosis and Assessment of the Response of Locally Advanced and Metastatic Renal Cell Carcinoma

Locally advanced and metastatic renal cell carcinoma (RCC) present a specific set of challenges to the radiologist. The detection of metastatic disease is confounded by the ability of RCC to metastasize to virtually any part of the human body long after surgical resection of the primary tumor. This includes sites not commonly included in routine surveillance, which come to light after the patient becomes symptomatic. In the assessment of treatment response, the phenomenon of tumor heterogeneity, where clone selection through systemic therapy drives the growth of potentially more aggressive phenotypes, can result in oligoprogression despite overall disease control. Finally, advances in therapy have resulted in the development of immuno-oncologic agents that may result in changes that are not adequately evaluated with conventional size-based response criteria and may even be misinterpreted as progression. This article reviews the common challenges a radiologist may encounter in the evaluation of patients with locally advanced and metastatic RCC. ^©RSNA, 2019.

Simultaneous resection of gastric and gallbladder metastasis from renal cell carcinoma treated by laparoscopic and endoscopic cooperative surgery: a case report

Background

Metastases to the stomach or gallbladder from any malignancy is rarely noted, and simultaneous metastases to both organs are atypical. We present a unique case of simultaneous multifocal metastases of the stomach and gallbladder from renal cell carcinoma (RCC).

Case presentation

The case involved a 60-year-old man, with a past history of RCC (clear cell type, G2, T1b N0 M0 Stage I) treated by a right nephrectomy. Three years after the nephrectomy, a routine gastrointestinal endoscopy found an ulcerative lesion in the greater curvature of the gastric body. The gastric tumor was pathologically proven to be a metastasis from RCC. Furthermore, computed tomography incidentally revealed a mass lesion in the fundus of the gallbladder, which was also diagnosed as a potential metastasis from RCC. As endoscopic ultrasonography of the gastric tumor suggested the tumor potentially invaded to the submucosal layer, gastric wedge resection via a laparoscopic and endoscopic cooperative surgery (LECS) technique was applied to the gastric tumor, and laparoscopic cholecystectomy to the gallbladder tumor was simultaneously performed. Histological examination confirmed that the tumors of the stomach and gallbladder were both metastatic RCC. The hospitalization period after surgery was not eventful, and the patient was discharged on postoperative day 7. Thereafter, the patient required examination every 3 months, did not use anticancer agents, and has survived without relapse to 9 months after the surgery.

Conclusions

For patients with locally resectable RCC metastases, complete metastasectomy may bring long-term tumor control. Moreover, LECS for gastric metastasis is a reasonable approach for minimal invasiveness and an oncologically feasible outcome.

Gastric Metastasis from Renal Cell Carcinoma, Clear Cell Type, Presenting with Gastrointestinal Bleeding

Renal cell carcinoma (RCC) accounts for 80-85% of all primary renal neoplasms. Although RCC can metastasize to any organ, gastric metastases from RCC are exceedingly rare. A 67-year-old male presented with melena and acute blood loss anemia. The patient had a history of RCC that had been treated with a radical nephrectomy. He had a recent myocardial infarction and was receiving double antiplatelet therapy. After hemodynamic stabilization, esophagogastroduodenoscopy showed a polypoid mass in the gastric fundus. The mass was excised. Histological and immunohistochemical evaluation were consistent with clear cell RCC. The polypoid lesion is consistent with a late solitary metastasis.

Metastatic renal clear cell carcinoma to the rectum, lungs, ilium, and lymph nodes: A case report

BACKGROUND

Renal cell carcinoma metastasizing to rectum is very rare, and the unusual metastatic sites should be paid attention to during the follow-up of renal cell carcinoma.

CASE SUMMARY

We describe a case of a 65-year-old male who was diagnosed with metastatic renal cell carcinoma to rectum 10 years after the right radical nephrectomy. Histopathology and immunohistochemical examinations contribute to making differential diagnosis between rectal metastasis of renal cell carcinoma and primary rectal clear cell carcinoma. Positron emission tomography-computed tomography with fluorodeoxyglucose shows hypermetabolic activity in upper rectum and other sites of metastasis at the same time.

CONCLUSION

Possibility of unusual metastatic sites of renal cell carcinoma such as rectum indeed exists, which should not be ignored in the surveillance after resection of the primary tumor.

Renal cell cancer diagnosed at endoscopy

A 59-year-old lady was referred for an open-access endoscopy with a history of dyspepsia. The endoscopy showed a 5 mm sessile nodule in the fundus of the stomach. The histology report suggested that this represented a metastatic deposit from renal cell carcinoma (RCC). Following this, a computerised tomography (CT) of the abdomen showed an 18 × 15 cm RCC. Here we provide a short review on gastric metastases.

Metastatic renal cell carcinoma presenting as gastric polyps: A case report and review of the literature

INTRODUCTION

Renal cell carcinoma (RCC) accounts for approximately 3% of adult malignancies and is responsible for over 13,000 deaths in the U.S. annually. The fatalities are largely due to distant metastasis, with lung, liver, bone and brain being most commonly affected organs. Gastric metastasis from RCC is a rare event (less than 20 cases reported in the English language literature) and usually presents as a large, solitary mass or ulcer (average size of 4.8cm) resembling primary gastric cancer. Here we report the first case of metastatic RCC presenting as small gastric polyps.

PRESENTATION OF CASE

The patient was a 60-year-old African American woman with a history of clear cell RCC (pT1bNX). She underwent esophagogastroduodenoscopy and colonoscopy 5months after nephrectomy due to anemia. Two non-ulcerated, 0.6-cm benign-appearing polyps were found at the greater curvature of the gastric body, which were subsequently removed endoscopically. Unexpectedly, histopathologic examination of the gastric polyps revealed nested collections of vacuolated epithelioid cells in a background of delicate, arborizing vasculature, immediately beneath the congested and hyperplastic foveolar epithelium. A diagnosis of metastatic RCC was rendered after confirming the renal epithelial origin by immunohistochemical stains.

DISCUSSION

Gastric metastasis from RCC usually presents as a large, solitary mass or ulcer, but it can be subtle and present as multiple, small benign-appearing polyps.

CONCLUSION

A careful follow up and thorough endoscopic and histopathologic examinations should be conducted in patients with a history of RCC who present with gastrointestinal manifestations.

Metastatic gastric tumors arising from renal cell carcinoma: Clinical characteristics and outcomes of this uncommon disease

We analyzed the clinicopathological characteristics and therapeutic outcomes of patients with metastatic gastric tumors arising from renal cell carcinoma (RCC) to identify post-therapy prognostic factors. A total of 22 patients who were treated for metastatic gastric tumors arising from RCC were included in the study. A retrospective review was performed on the clinical characteristics of this disease. The median time interval from radical excision of the primary tumor to the detection of gastric metastasis (IGM) was 6.3 years. The overall 1- and 3-year survival rates were 52.6 and 21.0%, respectively, and the median survival time was 19 months. Compared with patients with an IGM of <6.3 years, patients with an IGM of ≥6.3 years showed a significantly longer median survival time (5 vs. 24 months; P=0.017). The median tumor size was significantly greater in patients with multiple metastases compared with those with solitary metastasis (4 vs. 2 cm; P=0.036). The incidence of patients who had undergone therapeutic tumor resection was significantly higher in patients with solitary metastasis compared with those with multiple metastases (100.0 vs. 35.7%; P=0.019). The appearance of gastric tumors in patients with a history of RCC should prompt the clinician to investigate the possibility of metastasis even several years after detection of the original renal cancer. A longer interval from nephrectomy to the diagnosis of gastric metastasis is generally indicative of a better prognosis, most likely the result of less aggressive tumor growth.

Solitary synchronous metastatic gastric cancer arising from t1b renal cell carcinoma: a case report and systematic review

Metastasis to the stomach from renal cell carcinoma (RCC) is extremely rare. Usually, gastric metastasis seems to be a late event in patients with RCC and is accompanied by disseminated tumor spread to other organs. Solitary synchronous gastric metastasis from small, localized RCC has rarely been reported. We report a case of 79-year-old man with synchronous gastric metastasis presenting with a single erosive lesion from pT1 RCC. The patient underwent radical nephrectomy and endoscopic resection for metastatic gastric cancer. The resected specimen showed an ill-defined tumor, approximately 0.6 cm long, with a clear resection margin. The morphologic features of the tumor cells were consistent with those of metastatic RCC of the clear cell type. At 6 months's follow-up, the patient did not show local recurrence or additional metastasis on upper endoscopy and computed tomography scan.

Gastric metastasis from a primary renal leiomyosarcoma

Primary leiomyosarcoma of the kidney is rare. Here we report a case of metastasis of this tumor to the stomach. A 73-year-old man visited our hospital suffering from general weakness and intermittent tarry stools. He had undergone right nephrectomy for renal leiomyosarcoma 2 years previously. There had been no local recurrence or distant metastasis in the 2-year follow-up period. Endoscopy revealed two submucosal tumors in the stomach. These tumors were diagnosed histologically as leiomyosarcoma and distal gastrectomy was performed. Subsequent histochemical staining confirmed the diagnosis of gastric metastasis from renal leiomyosarcoma. The patient died due to metastases to the liver and bone 9 months after the operation. To the best of our knowledge, this is the first report of gastric metastasis from primary renal leiomyosarcoma.

Recurrent renal cell cancer: 10 years or more after nephrectomy

Localized renal cell carcinoma (RCC) responds well to surgery. Patients often question how long they have to be on surveillance after their surgery. Several follow-up patterns have been described in the literature. Until 2009, no published established Canadian guidelines existed to assist Canadian health-care practitioners in the surveillance of these patients. We present 3 cases of RCC that recurred 10 years or longer after the initial nephrectomy. These cases emphasize the need for careful long-term follow-up, as recommended in the Canadian Urological Association guidelines. We also discuss the optimism of prolonged disease survival in the era of novel therapeutic agents that target angiogenesis.

Metastatic gastric tumor from renal cell carcinoma

Metastatic tumors of the stomach are rare, with an incidence of 0.2%-0.7%, and they have been reported to result mainly from primary breast cancers, lung cancers, and melanoma. Further, among such metastatic tumors, the metastasis of renal cell carcinoma (RCC) to the stomach is an extremely rare disease, and it is usually reported in autopsy series. We report a rare case of metastatic gastric tumor derived from right renal carcinoma. Gastric endoscopy confirmed a large, polypoid, friable mass (type 1 tumor, about 7 cm in diameter) in the middle part of the stomach body. The mass was surgically excised and pathological examination showed that the gastric tumor was derived from a metastasis from the right kidney, because it was composed of malignant cells that were identical to those from the removed RCC. In addition, the tumor cells were immunoreactive for CD10, CD15, Ecadherin, early membrane antigen (EMA), and vimentin, but no reactivity was observed for cytokeratins 7 and 20 or c-KIT. Although gastric metastatic tumor derived from renal carcinoma is rare, the precise pre- and postoperative diagnosis may be important; thus, investigation for such metastatic tumors should be performed routinely in the follow up of patients who have been treated for RCC.