Dyspepsia: A Rare Presentation of Pancreatic Metastases

Abstract

Pancreatic metastases are uncommon and can present in a variable clinical manner. We hereby present a case of pancreatic metastases from renal cell carcinoma (RCC) 10 years after initial surgery who presented with dyspepsia and was a diagnostic dilemma. A 70-year-old female presented with a 1 year history of worsening dyspepsia without any weight loss, relieved incosistently with protonpump inhibitors. She had undergone a partial left sided nephrectomy 10 years prior to presentation for unclear causes. Physical exam was unremarkable. Patient underwent an EGD which revealed a normal esophagus, stomach and duodenum with biopsies negative for H. Pylori. Abdomen ultrasound revealed a 1.2 cm hypo-echoic mass in the pancreatic body. Contrast enhanced CT revealed hyper-enhancing masses in the pancreatic uncinate process, head and tail respectively. Patient underwent an EUS which revealed complex cystic hypo-echoic masses in the pancreatic head and tail. FNA results came back as non-diagnostic and the patient underwent two successive EUS which revealed the lesions to be stable. A decision was made to proceed with open biopsy with final histopathology revealing the pancreatic masses to be renal cell carcinoma, clear type. Pancreatic metastases are considered rare in general; however, one of the most common malignancies to spread to the pancreas is RCC, which can be seen anywhere between 10 and 32 years after diagnosis of the primary malignancy. Very few reports of the condition exist, and only 96 cases have been reported in literature. Clinical manifestations of of pancreatic metastasis include symptoms such as abdominal pain, anemia, jaundice and bleeding diathesis although most patients have silent disease detected at follow-up. A multi-pronged approach is required to diagnose the condition including imaging (CT scan or MRI), EUS and FNA. Open biopsy has also been undertaken especially in cases where diagnosis is unclear and suspicion for metastatic disease is considered high. Management includes surgical resection (partial or complete with or without adjacent organ resection) depending on various patient factors. Our patient presented 10 years after her partial nephrectomy. What sets her apart is her presentation in an outpatient GI clinic for evaluation of dyspepsia without knowing why she underwent the initial surgery. Interestingly, she was also noted to have multiple lesions in the pancreas of mixed character on EUS, an unusual finding in RCC.