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CASE REPORT
Year : 2018  |  Volume : 11  |  Issue : 4  |  Page : 335-337  

Late solitary pancreatic metastasis from renal cell carcinoma diagnosed on endoscopic ultrasound-guided fine-needle aspiration biopsy: A rare case report


Department of Pathology, Yashoda Hospital, Hyderabad, Telangana, India

Date of Web Publication2-Aug-2018

Correspondence Address:
Abhijeet Ingle
Consultant Histopathologist, Yashoda Hospital, Malakpet, Nalgonda X.Roads, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/MJDRDYPU.MJDRDYPU_142_17

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  Abstract 


Metastasis of renal cell carcinoma to the pancreas is a rare neoplasm accounting for 0.25%–3% of all pancreatic tumors and most cases arise from renal cell carcinoma. Symptomatic patients usually present with obstructive jaundice, abdominal pain, or gastrointestinal (GI) bleeding . The diagnosis usually occurs in asymptomatic patients during follow-up for renal cell carcinoma. It usually befalls slowly from 2 to 18 years after the onset of the primary tumor of the kidney. We report a case of a 58-year-old male patient who presented to the hospital with weight loss, anorexia, and elevated blood glucose and found to have a large tumor in the head of the pancreas, diagnosed on contrast-enhanced computed tomography. Patient underwent left radical nephrectomy 10 years ago for renal cell carcinoma.

Keywords: Metastasis, pancreas, renal cell carcinoma


How to cite this article:
Ingle A, Gattu V, Reddy R, Khaliq A, Reddy VK. Late solitary pancreatic metastasis from renal cell carcinoma diagnosed on endoscopic ultrasound-guided fine-needle aspiration biopsy: A rare case report. Med J DY Patil Vidyapeeth 2018;11:335-7

How to cite this URL:
Ingle A, Gattu V, Reddy R, Khaliq A, Reddy VK. Late solitary pancreatic metastasis from renal cell carcinoma diagnosed on endoscopic ultrasound-guided fine-needle aspiration biopsy: A rare case report. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2019 Oct 22];11:335-7. Available from: http://www.mjdrdypv.org/text.asp?2018/11/4/335/238158




  Introduction Top


Metastatic cancer of the pancreas from another primary site is rare. Renal cell cancer, along with malignant melanoma, lung, colon, and breast carcinoma, is among the few tumors known to metastasize to the pancreas.[1] It has a late-onset of 2–18 years after the occurrence of the primary tumor. Usually, it coexists with metastases of the lungs, brain, or bones. When it is solitary to the pancreas, it is distributed equally to all parts of it (head, body, and tail).[2]

The metastasis of the kidney occurs through blood or lymph vessels, although no infiltration of the peripancreatic lymph nodes exists. Diagnostic imaging fails to differentiate between primary pancreatic tumors.


  Case Report Top


We report a case of a 58-year-old male patient with weight loss, anorexia, having a pancreatic mass to our outpatient department (Yashoda Hospital, Malakpet). The patient's medical history revealed left nephrectomy for 10 years ago due to renal cell carcinoma; Fuhrman Nuclear Grade 1. The patient did not receive any treatment after left nephrectomy.

Laboratory tests revealed elevated blood glucose. Liver function tests were abnormal. Serum amylase was elevated. Ultrasound examination of the abdomen revealed lobulated hypoechoic to isoechoic mass at the region of the pancreatic head and uncinate process, fatty liver, cholelithiasis, and dilated main pancreatic duct.

Initially, contrast-enhanced computed tomography of the abdomen was performed, which confirmed a lesion at the head and uncinate process of the pancreas measuring 3.6 cm × 3.9 cm × 3.5 cm. Then, positron emission tomography-computed tomography scan of abdomen revealed metabolically active primary disease involving uncinate process of pancreas with standardized uptake value of maximum 7.3 and there was no evidence of distant metastasis. No local recurrence in left renal bed noted.

Endoscopic ultrasound guided-fine needle aspiration cytology performed using a 22-gauge Fine-needle aspiration needle and tissue was obtained and sent for cytology, to allow pathological diagnosis. Cytology reveals round to polygonal cells with cytoplasmic vacuoles [Figure 1]a and [Figure 1]b.
Figure 1: (a and b) Endoscopic ultrasound-guided fine-needle aspiration biopsy (Giemsa) show clusters of round to polygonal cells with round nuclei and small nucleoli and cytoplasmic vacuoles. (c and d) Cell block (H and E) show polygonal cells with clear cytoplasm

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Cell block [Figure 1]c and [Figure 1]d and subsequent immunohistochemistry with diffuse positivity for vimentin, moderately positive for CD10 and weak focal nuclear positivity for PAX-8 confirms the diagnosis of metastatic renal cell carcinoma [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.
Figure 2: Immunohistochemistry ([a] vimentin is diffusely expressed by tumor cells) ([b and c] CD 10 is moderately positive) ([d] weak focal nuclear positivity for PAX-8)

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Patient did not opt for surgery and then he took chemotherapy with sunitinib maleate 37.5 mg, twice a day for 14 days. Follow-up visit after 2 years and magnetic resonance cholangiopancreaticography revealed no significant change in size and morphology of mass in pancreatic head or uncinate process and no evidence of focal lesions in liver and spleen.

The periodic follow-ups of the patient over 2 years have not shown any signs of progression of the disease.


  Discussion Top


Metastasis to the pancreas is very rare. Only 4.5% of all pancreatic tumors are metastatic. Pancreatic metastases from renal cell carcinoma are rare and usually present themselves many years after primary diagnosis.[1],[3] They are accompanied by metastatic lesions in the brain, lungs, or bones. Solitary tumors in the pancreas are extremely rare (0.3% of all pancreatic tumors). They are very difficult to be diagnosed because existing imaging cannot differentiate them from adenocarcinoma of the pancreas.[4] Thus, the patient's history is very important. These patients could be asymptomatic. In a review of 236 cases in the literature, Sellner et al.[5] reported 35% of these patients to be asymptomatic with others presenting with symptoms which included abdominal pain (20%), GI bleeding due to duodenal infiltration (20%), obstructive jaundice (9%), weight loss (9%), and pancreatitis and diabetes (3% each).

The mode of spread of renal cell carcinoma to the pancreas is controversial and can either be hematogenous or through lymphatics with direct spread to the pancreas being unusual. Spread through lymphatics may occur by retrograde lymph flow secondary to tumor infiltration of the retroperitoneal lymph nodes. Hematogenous spread may occur along the draining collateral vein of a hypervascular renal tumor with or without associated renal vein thrombosis.[6]

Surgical resection of primary renal cell carcinoma and metastatic deposits remain the most effective treatment since chemotherapy, radiotherapy, and hormonal therapy have generally proved ineffective. Resection of a pancreatic metastasis may involve a standard pancreaticoduodenectomy or a distal pancreatectomy depending on the location of the secondary deposit. Atypical resection of pancreatic metastasis from renal cell carcinoma, such as duodenum preserving pancreatic head resection, middle pancreatectomy, and enucleation of the tumor, has been adopted by some authors. Atypical resection has been adopted based on the fact that these lesions are well-encapsulated.[1],[6],[7],[8] Five-year survival ranges from 29% to 81%. Multiple metastatic lesions have worse prognosis than solitary ones. The best treatment is R0 resection of the tumor which is curative in most cases of solitary tumors.[9],[10]


  Conclusion Top


Solitary pancreatic metastasis from renal cell carcinoma is a rare pancreatic tumor. It is usually presented years after the primary diagnosis and it is very difficult to differentiate it from pancreatic adenocarcinoma on imaging, and hence, tissue diagnosis is necessary. The only possible curative treatment is R0 resection.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Thompson LD, Heffess CS. Renal cell carcinoma to the pancreas in surgical pathology material: A clinicopathologic study of 21 cases with a review of the literature. Cancer 2000;89:1076-88.  Back to cited text no. 1
    
2.
Sohn TA, Yeo CJ, Cameron JL, Nakeeb A, Lillemoe KD. Renal cell carcinoma metastatic to the pancreas: Results of surgical management. J Gastrointest Surg 2001;5:346-51.  Back to cited text no. 2
    
3.
Crippa S, Angelini C, Mussi C, Bonardi C, Romano F, Sartori P, et al. Surgical treatment of metastatic tumors to the pancreas: A single center experience and review of the literature. World J Surg 2006;30:1536-42.  Back to cited text no. 3
    
4.
Robbins EG 2nd, Franceschi D, Barkin JS. Solitary metastatic tumors to the pancreas: A case report and review of the literature. Am J Gastroenterol 1996;91:2414-7.  Back to cited text no. 4
    
5.
Sellner F, Tykalsky N, De Santis M, Pont J, Klimpfinger M. Solitary and multiple isolated metastases of clear cell renal carcinoma to the pancreas: An indication for pancreatic surgery. Ann Surg Oncol 2006;13:75-85.  Back to cited text no. 5
    
6.
David AW, Samuel R, Eapen A, Vyas F, Joseph P, Sitaram V, et al. Pancreatic metastasis from renal cell carcinoma 16 years after nephrectomy: A case report and review of the literature. Trop Gastroenterol 2006;27:175-6.  Back to cited text no. 6
    
7.
Zerbi A, Ortolano E, Balzano G, Borri A, Beneduce AA, Di Carlo V, et al. Pancreatic metastasis from renal cell carcinoma: Which patients benefit from surgical resection? Ann Surg Oncol 2008;15:1161-8.  Back to cited text no. 7
    
8.
Wente MN, Kleeff J, Esposito I, Hartel M, Müller MW, Fröhlich BE, et al. Renal cancer cell metastasis into the pancreas: A single-center experience and overview of the literature. Pancreas 2005;30:218-22.  Back to cited text no. 8
    
9.
Tuech JJ, Pessaux P, Chautard D, Rouge C, Binelli C, Bergamaschi R, et al. Results of duodenopancreatectomy for solitary pancreatic metastasis from renal cell carcinoma. J Hepatobiliary Pancreat Surg 1999;6:396-8.  Back to cited text no. 9
    
10.
Kavolius JP, Mastorakos DP, Pavlovich C, Russo P, Burt ME, Brady MS, et al. Resection of metastatic renal cell carcinoma. J Clin Oncol 1998;16:2261-6.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2]



 

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