Abstract
In August 2004, a 76-year-old patient was referred to our hospital for progressive loss of appetite, accompanied with mild upper abdominal distention, pain, hiccups and dyspepsia over a recent 3 months period. Reviewing his disease history showed that 16 months before admission (April 2003), he was diagnosed with a recurring left renal clear cell cancer (immunohistochemical staining of tumor cells were positive for CK and Vim, but negative for SMA, HMB-45 and HHF-35, Fig.1) 10 years after a nephrectomy due to a right renal cancer. At that time, he was treated with photodynamic therapy followed by bio-immunotherapy(interleukine-2 plus lymphokine-activated killer cells). Follow-up by an abdominal CT scan every 3 months showed significant regression of the left renal carcinoma. Physical examination on admission showed that his abdomen was flat and soft with no abdominal tenderness or jaundice, and the liver, spleen or masses were not palpable. Routine, serum levels of hepatobiliary enzymes and bilirubin as well as tumor markers including α-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen (CA)50, CA19-9 and CA125 were all normal. An abdominal ultrasonic examination revealed dilatation of the common bile duct due to a mass in the inferior part of the common bile duct as well as a neoplasm in both head and body of the pancreas. A further positron emission tomography (PET-CT) examination revealed a low-malignant pancreatic tumor but no malignant signs in other parts of the body, with a left renal carcinoma remnant lesion present (Fig.2A,B). Endoscopic retrograde cholangiopancreatography (ERCP) showed an ellipse filling defect in the lower common bile duct with dilataton of the upper common duct (Fig.2C). An ultrasound-directed needle biopsy of the pancreas demonstrated infiltration of clear carcinoma cells in the connective tissue, with immunohistochemical staining being positive for CD10 but negative for CA19-9 or CEA. Therefore, diagnosis of pancreatic metastasis from renal clear cell cancer was established, and an intra-bile duct stent was implanted in the inferior part of common bile duct, followed by three-dimensional conformal radiotherapy (3DCRT) and high intensive focused ultrasound (HIFU) directed to the tumorous pancreatic head along with subcutaneous administration of somatostatin. Follow-up abdominal CT showed no sig-
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