A Case of Renal Cell Carcinoma with Small Bowel Metastasis Accompanied by Invagination

Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†.

Renal cell carcinoma (RCC) may metastasize to almost any organ, but metastasis to the small bowel is rare. Small bowel metastasis from RCC can induce obstruction or bleeding, and perforation can also be induced in rare case. Yet RCC metastasis to the small bowel is unlikely to be a direct cause of intussusceptions. A few cases of intussusceptions caused by small intestinal metastasis of RCC have been reported, but multiple small intestinal intussusceptions are extremely rare. We report here on a 47-year-old male patient who presented to the emergency room with acute abdominal pain. He had undergone radical nephrectomy 2 years previously due to left RCC. The abdominal CT scan revealed enhanced masses with the "target" sign that suggested enteric intussusceptions in the jejunum. Eight pedunculated masses within the small intestinal lumen led to intussusceptions at 30 and 150 cm distal to Treitz ligament. Three segmental resections of the small intestine and functional end to end anastomosis were done. The patient recovered uneventfully from this operation. To the best of our knowledge, this is the 1(st) report of metastases from RCC that presented as synchronous intraluminal polypoid tumors, and these tumors served as the lead points for two intussusceptions in the jejunum.

Renal cell carcinoma (RCC) most commonly metastasizes to the lungs, and it is uncommon for RCC to metastasize to the small bowel. Small bowel metastasis commonly presents with gastrointestinal (GI) bleeding. In rare cases, a metastatic small bowel mass can serve as a lead point for intussusception. In this report, we present the case ofa male patient whose chief complaint was melena. The patient denied any abdominal pain or nausea. Investigation with push enteroscopy revealed a jejunal mass, and further evaluation with CT showed small bowel intussusception. The patient subsequently underwent small bowel resection and anastomosis. Histopathology confirmed that the jejunal mass was metastatic RCC. We present this case in order to showcase the utility of push enteroscopy in the diagnosis of small bowel metastasis in RCC.

Diagnostic and Prognostic Molecular Markers in Renal Cell Carcinoma

Renal cell carcinoma (RCC) may metastasize to almost any organ, but metastasis to the small bowel is very rare. Factors responsible for a resistant behavior of small bowel wall are still not clear. Small bowel metastasis from RCC may cause obstruction, bleeding, and perforation. RCC metastasis to the small bowel presenting as intussusception is extremely rare. Only 20 cases of small bowel intussusceptions caused by metastatic RCC have been reported worldwide. Here, we are reporting this rare case of RCC with simultaneous solitary metastasis in jejunum which presented as intussusceptions and which was treated with simultaneous radical nephrectomy, jejunal resection, and anastomosis.

INTRODUCTION: Small bowel malignancies comprise only 0.35% of all malignancies and small bowel metastases only comprise 2% of malignancies, only 7.1% of which are from a primary renal cell carcinoma (RCC).This case demonstrates a rare metastatic RCC of the small bowel diagnosed through video capsule endoscopy (VCE) prompting an antegrade double-balloon enteroscopy (DBE). CASE DESCRIPTION/METHODS: A 53-year old male with hypertension, diabetes mellitus, and anemia presented with a rapidly worsening, necrotic right lower quadrant abdominal wall lesion. Dermatopathology from a wound edge biopsy demonstrated an ulcer with neutrophils and karyorrhectic debris, consistent with pyoderma gangrenosum (PG). He was found to have iron deficiency anemia (IDA) requiring multiple blood transfusions and iron infusions. Colonoscopy and esophagogastroduodenoscopy were unremarkable. VCE demonstrated markedly abnormal mucosa in the proximal jejunum, occupying at least 75% of the lumen with several satellite lesions. Antegrade DBE revealed a large ulcerated jejunal mass with leakage of serosanguinous fluid. Pathology showed poorly-differentiated carcinoma of unknown etiology. Pan-CT revealed a 5.6 × 5.4 cm solid mass in the right kidney with invasion of the right renal vein with thrombus extending into the inferior vena cava, liver masses, and pulmonary nodules consistent with metastatic renal cell carcinoma. DISCUSSION: This is a rare case of RCC metastatic to the small bowel. Only three other case studies report this in the literature. Approximately 25–30% of patients have metastatic disease at time of RCC diagnosis. The most common sites of metastasis for RCC include lymph nodes, lung, bone, liver and brain. Metastasis to the small bowel often originate from cancers of the breast, lung, esophagus, head and neck, and melanoma. While there have been case reports of jejunal metastases many years status-post nephrectomy, there have only been three reported cases of synchronous jejunal metastases from RCC. Metastatic RCC to the small bowel can present as gastrointestinal bleeding and intussusception. VCE and DBE were useful diagnostic tools in our particular case. CT or MR enterography may have also served as an appropriate diagnostic alternative, and in retrospect may have helped to make the diagnosis sooner. Overall, it is important to consider small bowel malignancy on the differential diagnosis in a patient who presents with IDA.

Enteroclysis was first used to diagnose small bowel obstruction in 1996. However, nasojejunal intubation required during enteroclysis causes discomfort to the patient. Triphasic computed tomography (CT) enterography, a noninvasive procedure that does not require intubation, was found to be an efficient method to diagnose small bowel lesions. We describe our experience of using triphasic CT enterography with polyethylene glycol (PEG) for diagnosing renal cell carcinoma (RCC) metastases to the small intestine. RCC can metastasize to many organs and can cause variable clinical presentations. We report the case of a 56-year-old man with RCC who had psoas muscle involvement and lung metastasis. The patient presented with melena and intermittent abdominal pain. Two conventional CT and small bowel series examinations had shown no obstructive lesion in the small intestine. However, triphasic CT enterography with PEG detected two enhanced masses suggestive of small bowel metastasis. The patient underwent laparotomy and segmental resection of the jejunum with primary anastomosis. Histologic examination was compatible with RCC. This is the first report where RCC metastasis to the small bowel was diagnosed using triphasic CT enterography. Our study emphasizes the importance of triphasic CT enterography in cases of obscure gastrointestinal bleeding, especially in patients suspected of having small bowel metastasis.

Focus on kidney cancer

Objective To assess the safety and feasibility of pure laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus. Methods We retrospectively analyzed 6 cases of renal cell carcinoma with inferior vena cava tumor thrombus from December 2010 to October 2014. The patients were all male.Their age ranged from 50 to 69 years and the body mass index ranged from 21.6 to 30.9 kg/m2. Clinical manifestations included painless hematuria in 4 cases, low back pain in 1 cases and physical examination noticing in 1 cases. Imaging suggested the right renal tumor in 4 cases and left renal tumor in 2 cases. The tumor size ranged from 4.0 to 10.6 cm.The inferior vena cava tumor thrombus was found in all patients, including type Ⅰ thrombus in 3 cases and type Ⅱ thrombus in 3 cases. The length of type Ⅱ tumor thrombus ranged from 4.0 to 4.2 cm. We completed pure laparoscopic nephrectomy and inferior vena cava tumor thrombectomy in all patients. We chose retroperitoneal laparoscopic surgery to treat right renal tumor with inferior vena cava thrombus and chose retroperitoneal combined with transperitoneal laparoscopic surgery to treat left renal tumor with inferior vena cava thrombus. Results All surgery were successful. Cancer embolus defluxion didn't occur during the opearation. The operation time was 224–873 min and the intraoperative blood loss was 200–5 000 ml. There were 4 patients get transfusion, which the transfusion volume ranged from 400 to 2 800 ml. For 1 case of left renal cell carcinoma with level Ⅱ inferior vena cava tumor, the operation time was 873 min, the blood loss was 5 000 ml, and the transfusion volume was 2 800 ml. Postoperative hospital stay was 7–14 days. And the pathological results were all renal clear cell carcinoma. In those patients, the Fuhrman grade classification was Ⅱ–Ⅲ. All patients were treated by targeted medicine to control tumor recurrence and metastasis. During the 6–48 months following up, no recurrence and metastasis were reported. Conclusions Pure laparoscopic surgery for right renal cell carcinoma with inferior vena cava tumor thrombus and left renal cell carcinoma with level Ⅰ inferior vena cava tumor thrombus is safe and feasible. However, long learning curve should be necessary for performing the left renal cell carcinoma with level Ⅱ inferior vena cava tumor thrombus. The effect of total laparoscopic surgery for renal cell carcinoma with inferior vena cava tumor thrombus is definite. Key words: Carcinoma, renal cell; Inferior vena cava tumor thrombus; Laparoscopic surgery

Squamous cell carcinoma of kidney is the extremely rare entity of upper urinary tract neoplasm. The most common type of kidney cancer is clear cell renal cell carcinoma followed by papillary and chromophobe renal cell carcinoma. We report a case of renal cell carcinoma who presented with complaints of pain abdomen and hematuria. Radiologic investigation showed a renal mass and calculi in the left kidney. The patient subsequently underwent left radical nephrectomy. Pathological diagnosis of SCC of idney was made.We report a rare case of primary renal squamous cell carcinoma involving whole of the kidney. With the best of our knowledge, only few cases of primary renal squamous cell carcinoma are reported. Keywords: Squamous, Nephrolithiasis, Hydronephrosis, Pelvicalyceal System, Chromophobe.

An elderly man presented with iron deficiency anemia and intermittent rectal bleeding. His past medical history was significant for a renal cell carcinoma resected 9 years earlier. After a colonoscopy and upper endoscopy were unremarkable, he underwent a small bowel capsule endoscopy, which revealed an ulcerated mass in the jejunum (Figure 1 and Video 1). Surgical resection was performed, and the pathology revealed metastatic renal cell carcinoma, clear cell type (Figure 2). The pathology was compared to the tumor from the patient's prior nephrectomy and was found to be identical. While renal cell carcinoma only accounts for 7% of metastases to the small bowel,1 these have occurred even up to 20 years after initial surgery.2 This case highlights the benefits of capsule endoscopy in the diagnosis of small bowel lesions, including metastatic renal cell carcinoma.1,2 Figure 1 An ulcerated mass is seen in the jejunum on small bowel capsule endoscopy. Figure 2 Histology of the jejunal mass confirms a renal cell carcinoma, clear cell type. Video 1 Small bowel video capsule endoscopy shows an ulcerated mass in the jejunum, which proved to be a renal cell carcinoma metastasis. Click here to view.(1.9M, mpg)

Renal cell carcinoma with biphasic morphology: A cohort showing similar morphology but distinct clinicopathological and molecular features.

Rationale:Metastasis to the small intestine from a primary lung cancer is rare, and is associated with a poor prognosis. Early diagnosis of small intestine metastasis is difficult because of the low incidence of clinically apparent symptoms.Patient concerns:Clinical data and treatment of a 59-year-old man with small intestine metastasis from primary solid subtype lung adenocarcinoma are summarized.Diagnoses:A man who was previously diagnosed with stage IIIA (T3N2M0) lung adenocarcinoma (solid subtype) came to our hospital for postoperative radiotherapy. Laboratory tests indicated anemia and melena. The patient was initially believed to have digestive ulcer and was treated with omeprazole, which proved to be ineffective. We conducted an abdominal computed tomography (CT) contrast scan and discovered a mass in the small intestine mass. Further positron emission tomography–computed tomography (PET-CT) imaging indicated the small intestine mass with fluorodeoxyglucose uptake.Interventions:The patient underwent an enterectomy and anastomosis. Pathological analysis confirmed the diagnosis of small intestinal metastasis from lung cancer with concomitant mesenteric lymph node metastasis.Outcomes:One month after the operation, hemoglobin levels became normal, and the patient had good quality of life. However, 3 months after the operation, the patient suffered from anemia again. An abdominal CT scan indicated a new small intestine mass. Progression continued rapidly, and the patient died of hemorrhagic shock 5.5 months after the resection of the small intestine mass.Lessons:Although uncommon, if lung cancer patients present with anemia and melena, enteric metastasis should be part of the differential diagnosis. Abdominal CT scans and PET-CT are effective for early diagnosis. The prognosis of metastatic spread of solid subtype lung adenocarcinoma to the small intestine with mesenteric lymph node metastasis is poor. Subgroups of patients benefitting from metastasectomy and more effective systemic therapy need to be further investigated.

Metachronous metastatic disease may develop in up to 50% of patients with renal cell carcinoma (RCC) who have undergone a presumably curative radical nephrectomy. We describe a case of small...

BackgroundTo observe the diagnostic efficacy of preoperative fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) upon venous tumor thrombus (VTT) in patients with renal cell carcinoma (RCC), and investigate the prognostic value of imaging parameters integrated with clinicopathological characteristics in patients with VTT after nephrectomy with tumor thrombectomy.MethodsPatients with newly diagnosed RCC who underwent 18F-FDG PET/CT were reviewed retrospectively. The diagnostic efficacy of 18F-FDG PET/CT in VTT was analyzed. Logistic regression analysis was carried out to identify the clinical variables and PET/CT variables (including maximum standardized uptake value (SUVmax) of primary tumor, VTT SUVmax and primary tumor size) for differentiating early VTT (Mayo 0-II) from advanced VTT (Mayo III-IV). Cox proportional hazard analyses were used to evaluate clinicopathological factors and PET/CT factors (including distant metastasis, primary tumor SUVmax, VTT SUVmax and primary tumor size) for disease-free survival (DFS) in patients with VTT after operation.ResultsA total of 174 eligible patients were included in this study, including 114 men (65.5%) and 60 women (34.5%), with a median age of 58 years (range, 16–81 years). The distribution of pathological tumor stage (T stage) was 56 (T1), 17 (T2), 95 (T3), and 6 cases (T4), respectively. According to WHO/ISUP grade, except for 4 cases of chromophobe cell RCC, there were 14 patients (8.0%) of grade 1, 59 patients (33.9%) of grade 2, 74 patients (42.5%) of grade 3 and 23 patients (13.2%) of grade 4. The median maximum diameter of the primary tumor on PET/CT was 7.3 cm (5.0–9.5 cm). The distal metastasis was observed in 46 patients (26.4%). Sixty-one cases (35.1%) were confirmed with VTT by pathology. The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 18F-FDG PET/CT imaging were 96.7, 99.1, 98.3, 98.3, and 98.2%, in detecting VTT, respectively, and 70.0, 100.0, 94.9, 100.0, and 94.2%, in evaluating the level of VTT, respectively. Elevated VTT SUVmax (≥5.20) could significantly distinguish the early VTT group and advanced VTT group (P = 0.010). In the prognosis analysis, elevated VTT SUVmax (≥4.30) (P = 0.018, HR 3.123, 95% CI 1.212–8.044) and distant metastasis (P = 0.013, HR 3.344, 95% CI 1.293–8.649) were significantly independent predictors for DFS.ConclusionPreoperative 18F-FDG PET/CT has a high diagnostic efficacy in detecting VTT and evaluating its level in RCC patients. Those patients with elevated VTT SUVmax should be carefully monitored to detect the possibility of disease progression after operation.