© 2004 Foundation for Promotion of Cancer Research
Case Report |
Spontaneous Rupture of Pancreatic Metastasis from Renal Cell Carcinoma
Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, Chiba, Japan
For reprints and all correspondence: Akitoshi Kobayashi, Department of Medicine and Clinical Oncology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuou-ku, Chiba, Chiba 260-8670, Japan. E-mail: konino{at}par.odn.ne.jp
Received May 20, 2004; accepted July 24, 2004
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Abstract |
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 TOP Abstract INTRODUCTIONCASE REPORTDISCUSSIONReferences |
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We report the case of a 53-year-old female who was admitted for sudden abdominal pain. Her right kidney was resected in 1993 due to renal cell carcinoma. Abdominal computed tomography performed in September 2002, while she was placed under observation, revealed a tumor 40 mm in size that extended from the head to the body of the pancreas. Abdominal ultrasonography on admission indicated retention of ascites, and the aspirated ascites was bloody. Based on this result, spontaneous rupture of a pancreatic tumor was strongly suspected. On abdominal contrast-enhanced computed tomography, multiple tumors were clearly visualized in the pancreas. Angiography revealed high-density tumor in the early arterial phase. The results of endocrinological tests were normal. Accordingly, the patient was diagnosed with multiple pancreatic metastases of renal cell carcinoma, and total pancreatectomy was performed. Histopathologically, the tumor resected was clear cell carcinoma and corresponded to the renal cell carcinoma resected in 1993. This is a rare case of pancreatic metastasis of renal cell carcinoma that resulted in spontaneous rupture 9 years after nephrectomy.
Key Words: renal cell carcinoma • pancreatic metastasis • rupture
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INTRODUCTION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONReferences |
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Renal cell carcinoma often recurs and metastasizes a long time after radical treatment. Hematogenous metastasis to lung, bone and liver is frequently noted, but metastasis to the pancreas rarely occurs. Furthermore, no report has been made of spontaneous rupture of a pancreatic tumor resulting from metastasis from renal cell carcinoma. In this report, we describe a rare case of spontaneous rupture of multiple pancreatic metastases that occurred 9 years after surgery for renal cell carcinoma.
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CASE REPORT |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONReferences |
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A 53-year-old female complained of sudden and marked upper abdominal pain, and was urgently admitted to our hospital in October 2002. She had hypertension and had been under treatment with an oral medication. In February 1993, a tumor 80 x 55 mm in size was detected in the right kidney by abdominal computed tomography (CT) and her right kidney was resected. It was diagnosed as renal cell carcinoma (clear cell type, grade 2, pT3pN0pM0) based on the result of nephrectomy. While she was under observation, abdominal CT performed in September 2002 revealed a tumor of 40 mm in size that extended from the head to the body of the pancreas.
At the time of admission, she complained of severe upper abdominal pain and was vomiting. Laboratory findings on admission revealed anemia with a hemoglobin concentration of 9.7 g/dl. Tumor markers and the results of endocrinological tests of the pancreas were normal. On abdominal ultrasonography (US) conducted at the time of admission, a hypoechoic lesion measuring 40 mm was noted in the head of the pancreas. Hemoglobin concentration was 7.3 g/dl on the day after admission. Abdominal ultrasound indicated retention of ascites that had not been detected at the time of admission. Since bloody ascites was observed after percutaneous puncture and aspiration, bleeding from the tumor was suspected. Abdominal contrast-enhanced CT suggested bleeding over the liver surface and tumor flank. The pancreatic tumor exhibited strong contrast in the arterial phase, suggesting the presence of a hypervascular tumor such as an islet cell tumor, acinar cell carcinoma or metastasis of renal cell carcinoma. On celiac arteriography (Fig. 1), hypervascular lesions were noted in the head and tail of the pancreas. On superior mesenteric arteriography, two portions of the hypervascular lesion in the head of the pancreas were detected. A total of five lesions, including two measuring 10 mm and two measuring several millimeters, were detected from the head to the tail by CT during arteriography (Fig. 2a–d). Since endocrinological tests of the pancreas were normal, multiple metastases of renal cell carcinoma were suspected. In addition, systemic examination detected no metastases in other organs. Total pancreatectomy was performed in November 2002.
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The findings obtained at surgery indicated an extrapancreatic hematoma. A dark-red nodular lesion measuring 45 x 40 mm and demonstrating clear margins was noted from the head to the body of the pancreas. A total of five tumors were observed in the resected sample. The number of tumors and their sites corresponded to the results of pre-operative tests. On histopathological examination (Fig. 3), focal proliferation of idioblast having small nuclei and clear sporozoites was noted. The histological image corresponded to that of the renal cell carcinoma resected in 1993. Accordingly, the patient was diagnosed with pancreatic metastasis of renal cell carcinoma.
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For serum blood glucose control, insulin therapy was required after surgery but the systemic condition was favorable and the patient was discharged. At the most recent follow-up the patient has continued to do well and there was no evidence of recurrence, 20 months after total pancreatectomy.
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DISCUSSION |
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TOPAbstractINTRODUCTIONCASE REPORTDISCUSSIONReferences |
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The prevalence of malignant metastasis to the pancreas is low. According to an investigation of 1000 cases of malignant tumor by Abrams et al. (1) it was only 11.6%. Roland and van Heerden (2) reported that metastatic tumors accounted for only 2% of the pancreatic tumors noted in 1350 cases or more, while 98% were primary pancreatic tumors. Lung cancer was the most frequent primary lesion of metastatic pancreatic tumors. The next most common was colorectal carcinoma, followed by breast carcinoma, but the prevalence of metastasis from renal cell carcinoma as the primary lesion was low (2,3). According to the report by Klugo et al. (4), metastasis to the pancreas rarely occurred, and its prevalence was only 2.8%. According to the investigation of autopsy results by Tongio et al. (5), metastasis to the pancreas occurred in only 1.3% of 320 cases of renal cell carcinoma.
Concerning the symptoms of pancreatic metastasis, digestive tract bleeding, abdominal pain, obstructed jaundice, body weight decrease, palpable abdominal tumor, and intrapancreatic and extrapancreatic secretion disorders may also occur, but are not always observed in many cases (5,6).
Spontaneous rupture of primary renal cell carcinoma seldom occurs. Spontaneous rupture occurred in only one case (0.3%) of the 309 cases and in only one case (0.6%) of the 166 cases reported by Skinner et al. (7) and Patel and Lavengood (8), respectively.
Spontaneous rupture of a liver tumor metastasized from renal cell carcinoma has been reported previously (9,10), but no report has been made of rupture of a tumor that metastasized to the pancreas.
Murakami et al. (10) cited tumor necrosis, increased intra-abdominal pressure, local hepatic venous congestion resulting from tumor obstruction, and others as causes of spontaneous rupture. In our patient, angiography revealed a clear high-density image in the flank of the tumor located in the body of the pancreas, which suggested overflow from the vessel supplying the pancreatic tumor. Although she had no history of pancreatitis and trauma of the abdomen during 9 years, she was under treatment for hypertension, which suggests that blood pressure may increase as a factor to rupture the vessel.
The duration from resection of the kidney due to renal cell carcinoma to detection of pancreatic metastasis was long. Recurrence after 10 years or more was noted in many cases (11–13). Growth of renal cell carcinoma occurs in two ways: rapidly or slowly. Many cases are of the slow-growing type, as was ours.
Ng et al. (14) reported that contrast CT is superior in imaging of pancreatic metastasis of renal cell carcinoma because contrast can be clearly observed against the pancreatic parenchyma in the early phase. Using CT during arteriography, it was possible in our case to detect small pancreatic metastases that could not be imaged by contrast CT. Angiography is reported to be useful in diagnosing metastasis of renal cell carcinoma, which is in typical cases imaged as a hypervascular tumor (15). Metastatic lesions are imaged by ultrasonography as hypoechoic lesions against the pancreatic parenchyma. It is possible to image such lesions effectively by power Doppler ultrasonography (16).
Chemotherapy, radiotherapy and hormone therapy are not very effective for primary renal carcinoma and their metastatic lesions. In this regard, the rate of efficacy of immunological treatment using interferon is still only 16% (17). If possible, radical resection including the primary lesion and metastatic lesions is desirable. Considering the multiple metastatic lesions and bleeding from the metastatic lesions in the pancreas, total pancreatectomy was performed in our patient. However, considering the substantial surgical effect and the poor prognosis after pancreatectomy (18), caution is required in the selection of the surgical method.
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Acknowledgments |
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We thank the members of First Department of Surgery, Chiba University, for their surgical technique.
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References |
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