Figure 1
Teaching Case
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsValentina Iotti 1, Federica Fiocchi 1, Daniele Rinaldi 1, Mariachiara Ferrari 2, Francesco Rivasi 3, Pietro Torricelli 1
Connected authors
68 years, female
A 68-year-old female patient was admitted to the emergency department with fever of unknown origin and sweating for the past 2 months: physical examination and blood work-up revealed inflammatory state, without signs of hematologic disorder. In 1987 she had undergone right nephrectomy for c-RCC, from which she had fully recovered.
Intra-operatory biopsy lead to final diagnosis of c-RCC localisation.
Metastases of colorectal cancer
Chronic abscess
Metastases of clear-cell renal carcinoma
Ultrasound (US) examination showed two hepatic lesions and a pseudo-kidney mass in epigastric fossa, suspicious for colorectal origin (Fig. 1).
Subsequent Computed Tomography (CT) demonstrated that all lesions were target type, the latter belonging to pancreatic body (Fig. 2). No other lesions were detected, especially in residual kidney.
First diagnostic hypothesis was colorectal metastasis due to CT morphological and contrast enhancement behaviour (Fig. 3).
Colonoscopy was performed but showed no colonic pathologies (Fig. 4).
Neoplastic markers CEA and Ca 19.9 were negative.
US-guided biopsy of all lesions was performed three-time finding only necrotic tissue and chronic active inflammation without evidence of malignant cells.
Considering clinical and histological findings new hypothesis of chronic abscess was proposed, but imaging findings did not support this hypothesis (Fig. 5).
Explorative laparotomy with intra-operatory biopsy lead (Fig. 6) to diagnosis of metastases from RCC in both sites, with round cells and positive to CD10 antigen.
Subsequent Computed Tomography (CT) demonstrated that all lesions were target type, the latter belonging to pancreatic body (Fig. 2). No other lesions were detected, especially in residual kidney.
First diagnostic hypothesis was colorectal metastasis due to CT morphological and contrast enhancement behaviour (Fig. 3).
Colonoscopy was performed but showed no colonic pathologies (Fig. 4).
Neoplastic markers CEA and Ca 19.9 were negative.
US-guided biopsy of all lesions was performed three-time finding only necrotic tissue and chronic active inflammation without evidence of malignant cells.
Considering clinical and histological findings new hypothesis of chronic abscess was proposed, but imaging findings did not support this hypothesis (Fig. 5).
Explorative laparotomy with intra-operatory biopsy lead (Fig. 6) to diagnosis of metastases from RCC in both sites, with round cells and positive to CD10 antigen.
The majority (78%) of recurrent c-RCC occurs within the first 5 years post-operatively, but late recurrence, defined as more than 10 years after nephrectomy [1], is not uncommon and occurs in more than 10% of patients [2]. There is a predominance of women among patients with late recurrence and it occurs also in individuals with well-differentiated tumours [3].
The majority of patients with metastatic renal cell carcinoma have multiple liver metastases and associated involvement of other organs in accordance with the pattern of hematogenous dissemination [4].
RCC tends to metastasise to the lungs in 70-76% of patients, lymph nodes in 50%, skeleton in 40% and to the liver in 20% [2, 4]. Pancreas is an uncommon site for metastasis from renal cell carcinoma and is asymptomatic in about 50% of cases [1, 8].
Patients with this cancer can present with local or systemic symptoms, although most presentations are incidental with the widespread use of abdominal imaging.
Local signs and symptoms include haematuria, flank pain, or a palpable abdominal mass, all of which have negative prognostic implications. Systemic symptoms can be due to metastases or paraneoplastic events largely related to secreted proteins, such as parathyroid-hormone-related protein (causing hyper calcaemia), rennin (causing hypertension), erthyropoietin (causing erythrocytosis), and fever or wasting syndromes. The diversity of paraneoplastic syndromes associated with this cancer is remarkable [9].
Early recurrences may present with rapid progression of disease; on the other hand, tumour-free intervals of more than 20 years have been observed with a slow growth pattern, especially for pancreatic metastasis [10].
Our case report supports this concept, as late recurrence of C-RCC shows slow growth pattern and systemic non specific symptoms.
In conclusion special attention should be paid to potential late recurrence of RCC after apparent curative treatment since it is not a rare event and lifelong follow-up is necessary, considering that RCC is known to be ‘a great mime’.
Imaging techniques such as US and CT are useful non-invasive modalities and should be employed during follow-up to detect asymptomatic metastases at an early stage.
The majority of patients with metastatic renal cell carcinoma have multiple liver metastases and associated involvement of other organs in accordance with the pattern of hematogenous dissemination [4].
RCC tends to metastasise to the lungs in 70-76% of patients, lymph nodes in 50%, skeleton in 40% and to the liver in 20% [2, 4]. Pancreas is an uncommon site for metastasis from renal cell carcinoma and is asymptomatic in about 50% of cases [1, 8].
Patients with this cancer can present with local or systemic symptoms, although most presentations are incidental with the widespread use of abdominal imaging.
Local signs and symptoms include haematuria, flank pain, or a palpable abdominal mass, all of which have negative prognostic implications. Systemic symptoms can be due to metastases or paraneoplastic events largely related to secreted proteins, such as parathyroid-hormone-related protein (causing hyper calcaemia), rennin (causing hypertension), erthyropoietin (causing erythrocytosis), and fever or wasting syndromes. The diversity of paraneoplastic syndromes associated with this cancer is remarkable [9].
Early recurrences may present with rapid progression of disease; on the other hand, tumour-free intervals of more than 20 years have been observed with a slow growth pattern, especially for pancreatic metastasis [10].
Our case report supports this concept, as late recurrence of C-RCC shows slow growth pattern and systemic non specific symptoms.
In conclusion special attention should be paid to potential late recurrence of RCC after apparent curative treatment since it is not a rare event and lifelong follow-up is necessary, considering that RCC is known to be ‘a great mime’.
Imaging techniques such as US and CT are useful non-invasive modalities and should be employed during follow-up to detect asymptomatic metastases at an early stage.
References
[1] Uemura T, Kurita A, Nishimura R, Ishizaki M, Takashima S (2003) Solitary Pancreatic Metastasis from Renal Cell Carcinoma Concomitant with Early Gastric Cancer 17 Years After Nephrectomy: Report of a Case. Surg Today 33: 395–398 (PMID: 12734740)
[2] Tapper H, Klein H, Rubenstein W, Intriere L, Choi Y, Kazam E (1997) Recurrent renal carcinoma after 45 years. Clinical Imaging 21: 273-275 (PMID: 9215475)
[3] Riviello C, Tanini I, Cipriani G, Pantaleo P, Nozzoli C, Poma A, Viligiardi R, Valeri A (2006) Unusual gastric and pancreatic metastatic renal cell carcinoma presentation 10 years after surgery and immunotherapy: A case report and a review of literature. World J Gastroenterol 12: 5234-5236 (PMID: 16937540)
[4] Lordan JT, Fawcett WJ, Karanjia ND (2008) Solitary Liver Metastasis of Chromophobe Renal Cell Carcinoma 20 Years After Nephrectomy Treated by Hepatic Resection. Urology 72: 230.e5–230.e6 (PMID: 18329075)
[5] Miyao N, Naito S, Ozono S, Shinohara N, Masumori N, Igarashi T, Nakao M, Tsushima T, Senga Y, Horie S, Kanayama H, Tokuda N, Kobayashi M (2011) Late Recurrence of Renal Cell Carcinoma: Retrospective and Collaborative Study of the Japanese Society of Renal Cancer. Urology 77: 379-84 (PMID: 20970828)
[6] Jadav AM, Thrumurthy SG, De Sousa BA (2010) Solitary colonic metastasis from renal cell carcinoma presenting as a surgical emergency nine years post-nephrectomy. World Journal of Surgical Oncology 8: 54 (PMID: 20587023)
[7] Feathestone JM, Bass P, Cumming J, Smart CJ (2006) Solitary, late metastatic recurrence of renal cell carcinoma: Two extraordinary cases. International Journal of Urology 13: 1525–1527 (PMID: 17118029)
[8] Wente NM, Kleeff J, Esposito I, Hartel M, Mueller MW, Froehlich BE, Buechler MW, Friess H (2005) Renal Cancer Cell Metastasis Into the Pancreas. A Single-Center Experience and Overview of the Literature. Pancreas 30: 218–222 (PMID: 15782097)
[9] Rini BI, Campbell SC, Escudier B (2009) Renal cell carcinoma. Lancet 373: 1119–32 (PMID: 19269025)
[10] Tanis PJ, van der Gaag NA, Busch ORC, van Gulik TM, Gouma DJ (2009) Systematic review of pancreatic surgery for metastatic renal cell carcinoma. British Journal of Surgery 96: 579–592 (PMID: 19434703)
Case information
| URL: | https://eurorad.org/case/9537 |
| DOI: | 10.1594/EURORAD/CASE.9537 |
| ISSN: | 1563-4086 |
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Figure 1
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena, Italy
Figure 2
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena; Italy
Figure 3
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena; Italy
Figure 4
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena; Italy
Figure 5
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena; Italy
Figure 6
Federica Fiocchi, MD
Dipartimento dei Servizi Diagnostici e per Immagine - Servizio di Radiologia 1
Azienda Ospedaliero-Universitaria Policlinico di Modena; Italy