S3528 A Rare Presentation of Small Bowel Metastasis From Renal Cell Carcinoma: A Case Report and Review

Abstract

Introduction: At the time of diagnosis, around 25–30% of patients with renal cell carcinoma (RCC) had metastatic disease. The most common locations for metastasis of renal cancer in order of frequency include lung, bone, liver, lymph nodes and brain. RCC metastases to the small intestine are extremely rare, with limited reports in the literature (Table). Case Description/Methods: A 20-year-old male presented with a 3-week history of dull epigastric pain, nausea, and vomiting. Past medical history was significant for iron deficiency anemia, and metastatic RCC was diagnosed in 2021 status post right open radical nephrectomy. The biopsy showed Xp11.2 translocation associated renal cell carcinoma WHO grade 4. The patient had lost follow-up previously. His laboratory workup this admission showed persistent iron deficiency anemia with mild leukocytosis and thrombocytosis and elevated liver enzymes. CT chest/abdomen/pelvis showed concern for intussusception in the distal jejunum causing an obstruction. Surgery team was consulted who took patient for diagnostic laparoscopy. Intraoperatively intussusception was partially reduced laparoscopically but could not be completely reduced since there was a big mass acting as a lead point. The decision was then made to convert to a mini-laparotomy. Small bowel resection with primary anastomosis was performed. Pathology from the specimen confirmed metastatic RCC. Oncology was consulted who plan to start pembrolizumab plus axitinib for systemic therapy. (Figure) Discussion: RCC intraluminal metastases in the small intestine are unusual reported as 2-4% incidence. Bowel metastases from RCC can manifest in several different forms including intussusception, bowel perforation, gastrointestinal bleeding and symptoms of intestinal obstruction due to the presence of a mass within the intestinal wall. This case presented a young male with metastatic RCC to small bowel which has not been reported so far. Clinicians should be aware that, in patients presenting with anemia, clinical symptoms of bowel obstruction and a history of RCC, intestinal tumor involvement should be considered. Metastasectomy may extend patient survival and surgical resection of the involved intestinal segment has been recommended as the treatment of choice.Figure 1.: A: Axial-enhanced CT scan of the abdomen showing Intussusception in the distal jejunum causing the obstruction. B: Intraoperative pictures of intussusception. C: A resected segment of the small intestine with a mass found at the lead point. Table 1. - Published reports of intussusception from renal cell carcinoma No. Author, Year No. of pts Stage of RCC (TNM) Gender Age (years) Histological subtype Outcome 1 Vani et al., 2017 2 NA M, F 65, 68 NA Pt. 1: Death 3 months after surgery. Pt. 2: Death 6 months after surgery. 2 Mishra et al., 2015 1 NA M 57 Clear cell NA 3 Wan Kyu Eo et al., 2008 1 pT1aN0M1 M 47 Clear cell NA 4 Venugopal et al.,2017 1 NA NA NA NA NA 5 Ekbote et al., 2015 1 NA M 52 Clear cell Alive after ten months 6 Bellio et al., 2016 1 pT1bN0 M 75 Clear cell NA 7 Deguchi et al., 2000 1 NA M 58 NA NA 8 Ogiso et al., 2005 1 pT1aN0M1 F 57 NA NA 9 Hegde R J et al., 2014 1 NA M 52 Clear cell NA 10 Budmiger et al., 2015 1 NA M 61 NA NA 11 Kerkeni B et al., 2013 1 pT2bNxM1 F 32 Clear cell Not interpretable 12 Khan AB et al., 1991 1 NA NA NA NA NA 13 Trojaneillo et al., 2017 1 NA M 75 NA Pt. died 9 months after surgery. 14 Tutar et al., 2008 1 NA M 59 Clear cell NA 15 Aissa et al., 2012 1 NA M 64 Tubulo- Papillary NA 16 Longo et al., 2013 1 NA F 52 Clear cell NA 17 Budmiger et al., 2015 1 NA M 61 Clear cell NA 18 Sasaki et al., 2006 1 NA M 64 Clear cell Pt died after few months after jejunal resection 19 Roviello et al., 2006 1 NA M 48 Clear cell Alive at follow up. 20 Rampersad et al., 2006 1 NA F 69 NA NA 21 Collet et al., 2001 1 NA F 77 NA NA Abbreviations: NA, not applicable; F, Female; M, Male.