Japanese Journal of Clinical Oncology 32:315-317 (2002)
© 2002 Foundation for Promotion of Cancer Research
Pancreatic Metastasis from Renal Cell Carcinoma Extending into the Main Pancreatic Duct: a Case Report
1 Clinical Laboratory Division, National Cancer Center Hospital, Tokyo, 2 Pathology Division, National Cancer Center Research Institute, Tokyo and 3 Hepatobiliary and Pancreatic Surgery Division, National Cancer Center Hospital, Tokyo, Japan
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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While metastasis to the pancreas is uncommon, it may occur from renal cell carcinomas (RCCs). We here present a case of pancreatic metastasis from RCC extending into the main pancreatic duct (MPD) in a 66-year-old Japanese man. The patient had a history of RCC treated with a radical nephrectomy 17 years previously and was found to have a mass ~2 cm in diameter in the body of the pancreas on radiological images. The patient was suspected of having pancreatic metastasis from RCC and underwent a distal pancreatectomy with splenectomy. Histologically, the tumor consisted of cells arranged in trabecular and alveolar structures with clear or eosinophilic granular cytoplasm, compatible with a metastatic RCC. The pancreatic tumor extended into the MPD with the stream of pancreatic juice. This condition is similar to RCC extension into the renal vein and the inferior vena cava. In conclusion, although extension into the MPD may be rare, such a growth pattern may be characteristic of metastases from RCCs.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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Although the pancreas is not a common site of metastasis from renal cell carcinomas (RCCs) (1), it is one of the few primaries from which metastatic pancreatic tumors, accounting for 2% of pancreatic tumors removed in sizable series of operations (2,3), can occur (4). There are more than 50 reports concerning pancreatic metastases from RCCs, mostly treated with aggressive surgical resection (3,5–8). In general, RCCs have several distinct features, including direct extension into the renal vein and the appearance of metastases many years after nephrectomy. During the period 1962–2001, five patients with pancreatic metachronous metastases from RCCs underwent pancreatectomy in the National Cancer Center Hospital, Tokyo (Table 1). Among these, three patients had intraductal extension into the main pancreatic duct (MPD). Here we report a typical case of pancreatic metastasis from RCC extending into the MPD and discuss such a growth pattern that may be characteristic of RCC metastases to the pancreas.
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CASE REPORT |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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A 66-year-old Japanese man underwent a right radical nephrectomy and radiation therapy (35 Gy) for an RCC at another hospital in October 1983. The patient underwent dissection of metastatic tumors in the mediastinal lymph nodes from the RCC 11 years after nephrectomy and had been subsequently treated with
-interferon until February 1996. In August 2000, diabetes mellitus was found on routine health check-up. He was re-admitted to the hospital for further evaluation of worsening diabetes mellitus (hemoglobin A1C, 9.8%) and weight loss (7 kg) in November 2000. Abdominal ultrasonography and computed tomography showed a mass ~2 cm in diameter in the body of the pancreas and marked MPD dilation (Fig. 1a). Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed an MPD obstruction and marked dilation of the distal MPD and its branches (Fig. 1b). A pancreatic metastatic tumor from RCC was suspected and the patient was referred to our hospital in February 2001. The patient underwent a distal pancreatectomy with splenectomy.
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Macroscopically, a 2.5 x 1.5 x 1.5 cm tumor occupied the body of the pancreas. The cut surface showed a well-defined, yellow tumor with foci of necrosis and hemorrhage, extending into the MPD via its ductal branch as a free floating mass (Fig. 2a). No metastases were found in the regional lymph nodes. Histologically, the tumor was surrounded by a fibrous capsule distorting the normal pancreatic tissue and consisted of cells arranged in trabecular and alveolar structures with clear or eosinophilic granular cytoplasm, compatible with a metastatic RCC (Fig. 2b). The tumor extended into the MPD, the lining epithelium showing no cellular atypia (Fig. 2c). The pancreatic parenchyma distal to the lesion had been entirely replaced by fibrous tissue and fat (secondary obstructive pancreatitis), which was probably associated with worsening diabetes mellitus.
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The postoperative course was good and to date he has survived for 12 months without further treatment or any evidence of recurrence or metastasis.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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RCC is well known for its unique biological behavior, e.g., spreading by direct extension into the renal vein and from these via the inferior vena cava to the chambers of the heart and pulmonary artery up to the lung. Such intrarenal vein involvement is observed in ~16% of cases while involvement of the main extrarenal vein and propagation into the vena cava have been noted in 8 and 7% of cases, respectively (9). Interestingly, in our three cases, the pancreatic metastatic tumors from RCCs extended into the MPD as free floating masses with the stream of pancreatic juice (Table 1). This condition is similar to the extension into the renal vein of primary RCCs. It is known that this tumor tends to grow as a tissue chain, with connection to the primary focus maintained (10). In the literature, to our knowledge, two cases featuring MPD extension have been described (6,8) and one of the tumors extended not only into the MPD but also the common bile duct (6). Although extension of the tumor into the MPD may be rare, such a growth pattern could be characteristic to metastatic tumors from RCCs. In contrast, primary pancreatic ductal adenocarcinomas and neuroendocrine tumors (the latter are hypervascular like RCCs) do not give rise to MPD extension.
The appearance of metastases many years after nephrectomy is also one distinctive feature of the RCC. In our cases, the intervals between primary tumor resection and recognition of metastasis to the pancreas were 3–24 years (Table 1). In a recent comprehensive review of the world literature, Thompson and Heffess (7) examined the clinicopathological features and prognosis for 109 patients and reported that the interval between the initial nephrectomy and presentation of the metastases averaged 14.6 years (range, 1 month to 32.7 years). As a result of such a long interval, the initial diagnosis of pancreatic tumor may be overlooked in the cases of prolonged disease-free interval. When a patient with a history of RCC presents clinically with symptoms and/or laboratory data suggestive of exocrine and/or endocrine functional disturbance, as in our cases, pancreatic metastasis from RCC should be considered. Additionally, on radiological images, the complication of MPD extension may provide useful information to differentiate primary pancreatic tumors from RCC pancreatic metastases. An aggressive surgical approach may contribute to prolonged survival.
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Acknowledgment |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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This work was supported in part by a Grant-in-Aid for the Second Term Comprehensive 10-Year Strategy for Cancer Control from the Ministry of Health, Labour and Welfare, Japan.
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FOOTNOTES |
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+ For reprints and all correspondence: Michiie Sakamoto, Pathology Division, National Cancer Center Research Institute, 1–1, Tsukiji 5-chome, Chuo-ku, Tokyo 104–0045, Japan. E-mail: msakamot@gan2.ncc.go.jp
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REFERENCES |
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TOPABSTRACTINTRODUCTIONCASE REPORTDISCUSSIONAcknowledgmentREFERENCES |
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6 Fabre JM, Rouanet P, Dagues F, Blanc F, Baumel H, Domergue J. Various features and surgical approach of solitary pancreatic metastasis from renal cell carcinoma. Eur J Surg Oncol 1995;21:683–92.[Medline]
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8 Abbas MA, Collins JM, Mulligan DC. Renal cell carcinoma metastatic to pancreas. Am J Surg 2001;182:183–4.[Medline]
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Received February 21, 2002; accepted May 14, 2002
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