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Japanese Journal of Clinical Oncology Pages 58-61

Renal Cell Carcinoma of the Spindle Cell Type with Metastasis to the Pancreas: a Case Report
Introduction
Case Report
Discussion
References

Renal Cell Carcinoma of the Spindle Cell Type with Metastasis to the Pancreas: a Case Report

Renal Cell Carcinoma of the Spindle Cell Type with Metastasis to the Pancreas: a Case Report Bin Zhao1, Wataru Kimura1, Noriaki Futakawa1, Tetsuichiro Muto1 and Kimihiko Haida2

1First Department of Surgery, University of Tokyo,Tokyo and 2Department of Surgery, Hanzomon Hospital, Tokyo, Japan

We report a case of renal cell carcinoma in a 49-year-old man with multiple metastases, including some to the pancreas which were initially diagnosed as primary pancreatic carcinoma. The first clinical manifestation was jaundice caused by a large metastatic lymph node. Computed tomography showed tumors in the body and tail of the pancreas as well as in the left kidney. Angiography showed that all of the lesions were hypervascular. The patient was finally diagnosed as having renal cell carcinoma. Cholecystectomy and choledochojejunostomy were performed. Intraoperative biopsy of the lymph nodes along the common hepatic artery showed spindle cell carcinoma which was compatible with renal cell carcinoma. Since renal cell carcinoma with pancreatic metastasis is rare, special attention should be paid to its differentiation from primary pancreatic carcinoma in patients with tumors in both the pancreas and kidneys.

Key words: renal cell carcinoma - metastasis - pancreas

Introduction

Renal cell carcinoma is a malignant tumor with a high rate of metastasis (more than 25%) (1). The main metastatic sites are the lungs, bones, lymph nodes, adrenal glands, brain, liver and contralateral kidney (1-3). Renal cell carcinoma with metastasis to the pancreas is rare (1-3%), either solitarily or combined with metastases to other organs (3,4). Whereas the overall incidence of tumors metastatic to the pancreas is only 3.7-4.5% (5), the primary tumors are usually located in the lungs, colon, stomach or breast (6), and seldom in the kidney, which accounts for only 1-1.7% of all cases (7).

Here we report a case of renal cell carcinoma with metastases to the pancreas, adrenal gland and retroperitoneal lymph nodes, without any signs of the primary tumor.

Case Report

A 49-year-old man presented at Hanzomon Hospital, Tokyo, in December 1995, complaining of upper abdominal discomfort and generalized jaundice. Physical examination revealed no abnormalities except jaundice. Laboratory studies showed elevated total bilirubin (9.8 mg/dl) and direct bilirubin (6.7 mg/dl) levels in the serum, but carcinoembryonic antigen (CEA) and carbohydrate antigen19-9 (CA19-9) were both within the normal ranges. Computed tomography (CT) showed irregular space-occupying lesions with low density in the head, body and tail of the pancreas (Fig. 1). Lymph node swelling along the common hepatic artery was also detected. A 3 * 3 cm tumor in the left kidney and a small round solitary mass in the right posterior lobe of the liver were also found. Abdominal ultrasonography (US) showed dilatation of the common bile duct (CBD), which was 22 mm in diameter. The findings in the pancreas, the left kidney and the liver were almost the same as those on CT scan. Percutaneous transhepatic cholangiographic drainage (PTCD) was then performed. Cholangiography by way of PTCD showed concordant dilatation of both the intra- and extra-hepatic bile ducts, and apparent stenosis at the end of the CBD. Selective angiography showed hypervascularity in all of the lesions found in the pancreas and the left kidney (Figs 2 and 3), and confirmed that the `hepatic lesion' revealed by CT was actually located in the right adrenal gland. A diagnosis of renal cell carcinoma with metastases to the pancreas, right adrenal gland and lymph nodes along the common hepatic artery was established. No signs of metastasis to the lungs or bones was found.


Figure 1. Computed tomography (CT) shows low-density tumors in both the body and tail of the pancreas and in the left kidney.

An operation was performed in January 1996. No ascites or peritoneal metastasis was found. A 4 cm non-mobile, hard, spherical tumor with an uneven surface was found posterior to the head of the pancreas, and a mass of about the same size and texture was found above the body of the pancreas. These were thought to be metastases to the lymph nodes posterior to the head of the pancreas and along the common hepatic artery respectively. The body and tail of the pancreas were also enlarged and hard, with an uneven surface, suggesting tumors within the pancreas. In the left kidney, a hard tumor about 2 cm in diameter extended from the surface of the upper pole of the kidney. There was no direct invasion between the pancreas and the left kidney. There was also a tumor in the right adrenal gland which directly invaded the liver. Since the tumor had already metastasized extensively, radical resection was abandoned. Cholecystectomy and Roux-en-Y choledochojejunostomy were performed to relieve the jaundice. Biopsy of the swollen lymph nodes along the common hepatic artery was performed.


Figure 2. Selective renal angiography shows a hypervascular lesion in the upper pole of the left kidney.


Figure 3. Angiography of the celiac artery shows hypervascular lesions in the body of the pancreas.

Histological examination showed a carcinoma of the spindle cell type (Fig. 4) which was compatible with renal cell carcinoma. The tumor cells merged with components showing a highly pleomorphic sarcoma-like appearance.

The patient is currently alive six months after surgery, but has metastases to both the lungs and the brain.

Discussion

Renal cell carcinoma shows a high incidence of metastasis on diagnosis (more than 25% of all cases) (1). However, metastasis to the pancreas is rare, either solitarily or combined with metastasis to other organs (3,4). We reviewed previous reports of renal cell carcinoma with metastasis to the pancreas (Table 1) (4,8-33). The patients comprised 15 men and 11 women with an average age of 60.9 yr (range 43 to 84 yr). The period from diagnosis of renal cell carcinoma to that of pancreatic metastasis varied significantly. In five cases the metastases to the pancreas were found at the same time as the primary tumor, (13,14,17,20,25) while in the others they were found as recurrences after resection of the primary.

When renal cell carcinoma metastasizes to the pancreas, the first complaint of the patient is sometimes that of upper gastrointestinal disease (such as jaundice or upper gastrointestinal bleeding) caused by the metastasis (4,10,1512,,17,19) rather than by the primary tumor. In such cases, especially when simultaneous tumors are found in both the pancreas and kidney, but without any urological signs, differentiation may be difficult. Among the five cases in which metastasis to the pancreas occurred at the same time as the primary tumor, four produced various manifestations in the urological system (13,14,20,25), and one patient had only jaundice caused by pancreatic metastasis (17). However, precise preoperative diagnosis was not possible in any of the five cases. In our present case, the first clinical manifestation was obstructive jaundice, which suggested pancreatobiliary disease.

Table 1 Review of previous cases of renal cell carcinoma with metastasis to the pancreas
No. Author, year, (ref.) Age (yr) Sex Other metastasis Time* Histological type
1 Jenssen E, 1952 (8) 64 Male Lungs, brain 14 yr Clear cell
2 Franciosi R, 1969 (9) 61 Male Lung 13 yr Clear cell
3 Marquand J, 1971 (10) 50 Male (-) 1 mo Clear cell
4 Gattman FM, 1972 (11) 66 Male (-) 13 yr Clear cell
5 Hermanutz KD, 1977 (12) 60 Male (-) 13 yr Clear cell
6 Saxon A, 1980 (13) 43 Female (-) Same time Clear cell
7 Yazaki T, 1981 (14) 76 Male (-) Same time Clear cell
8 Weerdenburg JP, 1984 (15) 58 Female Thyroid gland 11 yr Clear cell
9 Scaarap P, 1984 (16) 53 Male Contralateral kidney 13 yr Clear cell
10 Kishimoto H, 1985 (17) 72 Male (-) Same time Clear cell
11 Audisio RA, 1985 (18) 66 Female (-) 20 yr Clear cell
12 Carini M, 1988 (19) 54 Female (-) 12 yr Clear cell
13 Sharma SK, 1988 (20) 60 Female (-) Same time Clear cell
14 Simpson NS, 1989 (22) 53 Female Thyroid gland, contralateral kidney 18 yr Clear cell
15 Temellini F, 1989 (23) 70 Female (-) 25 yr Clear cell
16 Gohji K, 1990 (24) 52 Male (-) 7 yr Spindle cell
17 Oka H, 1991 (25) 56 Male Pituitary gland Same time Clear cell
18 Nishida O, 1991 (26) 84 Female No 16 yr Clear cell
19 Takeuchi H, 1992 (27) 68 Male No 21 yr Clear cell
20 Stankard CE, 1992 (28) 56 Female (-) 5 yr Clear cell
21 Marcote VE, 1993 (29) 66 Male Bone and retroperitoneum 6 yr Clear cell
22 Sauvanet A, 1993 (30) 64 Male (-) 4 yr Clear cell
23 Sauvanet A, 1993 (31) 64 Female (-) 8 yr Clear cell
24 Takeuchi H, 1993 (32) 57 Male No 30 mo Clear cell
25 Dousset B, 1995 (33) 61 Female No 6 yr Clear cell
26[dagger] Zhao B, 1997 49 Male Contralateral adrenal gland Same time Spindle cell
*Time between primary cancer and pancreatic metastasis; [dagger]our present case.

In diagnosing renal cell carcinoma with metastasis to the pancreas, CT and US are often used, but sometimes fail to give precise data. The examination of choice is therefore angiography, which always shows hypervascularity in both the primary and metastatic lesions. In the present case, the patient had typical findings of obstructive jaundice. Since the incidence of renal cell carcinoma with metastasis to the pancreas is low, pancreatic tumors are generally primaries, and even when they are secondary ones, they seldom originate in the kidney (5-7). As our patient had no symptoms related to urinary disease, the diagnosis was initially established as pancreatic carcinoma with lymph node metastases. However, several points made us suspect this diagnosis: (1) the levels of both CEA and CA19-9 were within the normal range, (2) the tumor which caused the obstructive jaundice was not so invasive on CT scan, and (3) there were tumors in both the kidney and contralateral adrenal gland. In pancreatic carcinoma, CEA and CA19-9 levels are often extremely high, the tumor is aggressive, and metastasis to the liver is multiple and seldom affects the pancreas itself. Therefore, abdominal angiography was performed, and it revealed hypervascularity in all of the lesions. This confirmed the diagnosis of renal cell carcinoma with metastases. However, a non-functional endocrine tumor or acinar cell carcinoma of the pancreas could not be excluded.


Figure 4. Histology of the biopsy specimen from the tumor adjacent to the pancreas shows a spindle cell carcinoma.

The postoperative histological examination showed that the tumor was malignant with sarcoma-like cells (spindle cell carcinoma), compatible with renal cell carcinoma. Although sarcoma of the pancreas might also have been possible, this neoplasm is extremely rare. In view of these additional facts, our final diagnosis was renal cell carcinoma.

Spindle cell carcinoma is a rare type of renal cell carcinoma which accounts for only 1% of all renal tumors in adults and is much more aggressive than carcinoma of either the clear or granular cell type. It often shows extrarenal involvement at the time of operation (34). We think that this explains why multiple metastases occurred even when there were no symptoms of the primary tumor in the present case. Moreover, metastases to the lungs and brain also occurred six months after surgery. Among the cases listed in Table 1, only two (including the present case) were renal cell carcinoma of the spindle cell type. Gohji et al. (24) reported another such case where the metastasized tumor was of the sarcomatoid cell type histologically, although the primary carcinoma was the clear cell type. This may have been due to the histological heterogeneity of the tumor cells.

As to the treatment of renal cell carcinoma with metastasis to the pancreas, many surgeons prefer radical nephrectomy with pancreatectomy if the metastasis is solitary and confined to the pancreas. However, in the present case, multiple metastases had already developed, and therefore radical therapy was ruled out. We conclude that special attention should be paid to the possibility of renal cell carcinoma in patients with masses in both the pancreas and kidney, especially when there are no urinary signs, and that surgery may be unnecessary if multiple metastases have occurred, especially in tumors of the sarcomatoid type.

References

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2. DeKernion JB, Rammings KP, Smith RB. The natural history of metastatic renal cell carcinoma: a computer analysis. J Urol 1978;120:148-52. MEDLINE Abstract

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4. Marcote VE, Arlandis FF, Baltasas A. Synchronous pancreatic metastasis of renal carcinoma. Rev Esp Enferm Dig. 1993;83(6):471-3. (in Spanish) MEDLINE Abstract

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8. Jenssen E. A metastasis hypernephroma to the pancreas. Acta Chir Scand 1952;104:177-80.

9. Franciosi RA, Russo JF. Renal cell carcinoma metastasis to the pancreas 13 years following nephrectomy. Mil Med 1969;134:200-3. MEDLINE Abstract

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33. Dousset B, Andant C, Guimbaud R, Roseau G, Tulliez M, Palazzo L et al. Late pancreatic metastasis from renal cell carcinoma diagnosed by endoscope. Surgery 1995;117(5):591-4. MEDLINE Abstract

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Received April 22, 1996; accepted July 10, 1996
For reprints and all correspondence: Wataru Kimura, First Department of Surgery, University of Tokyo, 3-1, Hongo 7-chome, Bunkyo-ku, Tokyo 113
Abbreviations: CEA, carcinoembryonic antigen; CA19-9, carbohydrate antigen 19-9; CT, computed tomography; US, ultrasonography; CBD, common bile duct; PTCD, percutaneous transhepatic cholangiographic drainage.

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