A Rare Cause of Failure to Thrive: A Case of a Primary Gastric Cancer in a Patient with Metastatic Renal Cell Carcinoma and a Review of the Literature on Management

Abstract

Purpose: Renal cell carcinoma(RCC) accounts for approximately 3% of all adult malignancies. Papillary carcinoma, which is the second most common type of RCC, accounts for approximately 15% of RCC. RCC has a metastasis rate of approximately 25%, which is most commonly to the lungs (>50%). On the contrary, RCC metastasis to the GI (Gastrointestinal) tract (excluding liver) is very uncommon and ranges from 0.2-0.7%. Thus, a gastric cancer in a patient with known metastatic RCC would most likely secondary to metastasis. We present the first reported case of a metastatic RCC coexisting with a new onset primary gastric cancer and a review of management. A 82-year-old male with Papillary RCC status post left nephrectomy with recurrence of liver metastasis presented with failure to thrive shortly after his third cycle of chemotherapy despite stable disease by imaging studies. He had received 7 chemotherapy cycles of Gemzar®, Nexavar®, and Avastin® prior to admission. Catheter related infection was suspected due to a leukocytosis of 19,000. However, he had no evidence of infection. He subsequently dropped his Hct and was found to have Hemoccult positive stool in the setting of having received Avastin®. Endoscopic evaluation of his anemia showed a 3 cm ulcerated mass in the cardia, which was subsequently biopsied. The biopsy showed invasive and poorly differentiated gastric adenocarcinoma unrelated to his RCC. H. pylori was considered negative. The patient subsequently underwent partial gastrectomy with loop gastrojejunostomy for resection of his Stage 1 primary gastric adenocarcioma. The patient did not receive adjuvant chemoradiation for his Gastric cancer due to his comorbidities at the time and did well at a 1 month follow-up. There are no guidelines to manage a primary gastric cancer coexisting with a metastatic RCC. Review of the literature shows that the management of a solitary gastric cancer secondary to RCC metastasis without adjacent organ involvement is ideally surgical (gastrectomy) if the tumor is greater than 2 cm. There is a role of endoscopic resection for non-surgical candidates and for early gastric cancer with differentiated tumors that are slightly raised and less than 2 cm in diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter. In our patient, the gastric cancer was 3 cm in size without nodal involvement, thus, not a candidate for endoscopic mucosal resection. Surgical management was the therapy of choice due to the patient's clinical presentation as well as future consideration of RCC chemotherapy. Conclusion: Metastatic RCC and primary gastric cancer can coexist and surgical management can still be considered for the primary gastric carcinoma.