Uncommon Presentation of an Uncommon Condition

Abstract

Purpose: A 66-year-old male who presented with increasing fatigue, weight loss, anorexia, abdominal pain, and confusion. He started having emesis with streaks of blood on day of admission. On physical exam he was only oriented to person and place and had right sided abdominal tenderness. Stool was positive for occult blood. Blood tests were significant for anemia and hypercalcemia. Computed tomography (CT) scan revealed right renal mass extending into the IVC and expanding the duodenum at the junction of the first and second part. Esophagogastroduodenoscopy (EGD) showed a friable infiltrating mass in the lateral wall of the duodenum. Duodenal biopsy was suggestive of renal cell carcinoma, clear cell type. Tumor burden was prohibitive for surgical intervention, and he was started on weekly Temsirolimus. After 4 cycles of chemotherapy he decided to receive only palliative care. Duodenal metastasis from renal cell carcinoma (RCC) origin is very uncommon. This case report demonstrates the variable presentations of metastatic RCC with duodenal involvement. Despite a large mass at the duodenal wall, he did not have classic symptoms of small bowel obstruction. Moreover, bleeding from this mass manifested as blood streaked emesis in contrast to overt hematemesis that has been classically reported. He also lacked lower extremity and scrotal edema despite tumor infiltration of the IVC. This case underscores the importance to apply fundamental principles of disease pathogenesis and gross anatomy to atypical presentations of disease manifestations.Figure: [914] Computed tomography scan showing duodenum being expanded by tumor mass (arrow) and infrahepatic IVC with a tumor thrombus (arrow head). EGD picture showing friable mass that is oozing blood and invading lateral wall of the duodenum.Figure: [914] Histopathology; biopsies from the duodenal mass revealed mucosal ulceration with a submucosal mass rich in vasculature (A) and clear cytoplasm (B). The morphology is suggestive of renal cell carcinoma, clear cell type and it is confirmed by positive immunohistochemical stains for Vimentin (C) and PAX8, a nephritic-lineage transcription factor (D).