LETTERS TO THE EDITOR

 

Subtotal distal pancreatectomy for metachronous metastatic renal clear cell carcinoma

Pancreatectomía subtotal distal por metástasis metacronas de carcinoma de células claras

 

 

---

Key words: Renal cell carcinoma. Pancreas metastasis.

---

 

 

Dear Editor,

A 61-year-old man with a history of hypertension and diabetes mellitus had undergone left radical nephrectomy for renal clear cell carcinoma 10 years previously. The pathological staging was T3 N0 M0. He was monitored by oncology service and he maintained good health until he developed fatigue and had a significant weight loss. Evaluation with the computed tomography (CT) of abdomen revealed two lesions in the tail and body of the pancreas (Fig. 1A). No other lesions was detected in the PET-CT. The endoscopy ultrasound-guide biopsy did not contribute to further findings.

The suspected diagnosis was multifocal metastatic renal cell carcinoma (RCC) in the tail and body of pancreas.

Thus, he underwent an exploratory subcostal laparotomy and a subtotal distal pancreatectomy and splenectomy were performed (Fig. 1B). Histology was reported as a metastatic renal clear cell carcinoma. The margins of the resected pancreas and lymph nodes were clear of tumor.

 

 

In the postoperative course, the patient developed a low debit pancreatic fistula, it resolved with octreotide ambulatory treatment.

 

Discussion

The hypernephroma or renal clear cell renal carcinoma (CCRC) is the most common renal tumor in adults. Up to 30% of cases, metastases often present at the time of diagnosing, resulting principally affects the lungs and the liver, bones and brain and rarely the pancreas (3%) and it usually is metachronous (1-3).

Metastases cancer to the pancreas from another primary site is rare, representing 1-3% of the total pancreatic tumors. The way of spread of renal cell carcinoma to the pancreas is controversial and can either be hematogenous or via lymphatics. There is an indolent affinity of pancreatic parenchyma by clear cell (1).

Renal cell carcinoma metastasis to the pancreas typically occur long after nephrectomy and, thus, should be looked for during the follow-up or in patients with upper abdominal symptoms. The median duration of presentation was 10 years following a nephrectomy. The CT scan usually reveals the presence of mass or masses (in one third of cases are multifocal metastases). CT or endoscopic ultrasonography-assisted fine needle aspiration cytology could confirm the presumptive diagnosis preoperatively. The PET- CT is used to detect the neoplastic dissemination in other place and so it is possible to name the case as "isolated pancreatic metastases CRCC" (1,4).

A high resectability rate (80%) is characteristic of metastasis from renal cell carcinoma as compared to primary pancreatic cancer. When possible, complete surgical resection offers the best chance of cure (1).

It is necessary an individual surgical approach with optimal resection strategy which achieves adequate disease-free resection margins and maximal tissue preservation of the pancreas (1,2,5,6).

In inoperable or unresectable cases, there are biological therapies may be effective. Thus, the immunomodulators interferon-alpha (INFα) and IL-2, antiangiogenetic agents, such as bevacizumab, and the tyrosine kinase inhibitor erlotinib have been in use for some time, and the current standard in the treatment of metastatic disease (1,6).

 

Sources of funding: Article funded in part by the FFIS (Foundation for Health Research and Training in the Region of Murcia, Spain, Group FFIS-008).

 

José Luis Aguayo-Albasini, María Luisa García-García, Juan Gervasio Martín-Lorenzo,
María José Cases-Baldó, Álvaro Campillo-Soto and Mónica Mengual-Ballester
Department of General Surgery. Hospital General Universitario "Morales Meseguer". Murcia, Spain

 

References

1. Machado NO, Chopra P. Pancreatic metastasis from renal carcinoma managed by Whipple resection. A case report and literature review of metastatic pattern, surgical management and outcome. JOP 2009;10:413-8.         [ Links ]

2. Machado NO, Chopra P, Al Hamdani A. Pancreatic metastasis from colon carcinoma nine years after a hemicolectomy managed by distal pancreatectomy. A review of the literature regarding the role and outcome of pancreatic resection for colorectal metastasis. JOP 2010;11:377-81.         [ Links ]

3. Ohzato H, Yamamoto T, Fukunaga M, Imamura H, Furukawa. Middle-preserving pancreatectomy for multifocal metastatic renal cell carcinoma located in the head, body and tail of the pancreas. A case report. JOP 2010;11:633-7.         [ Links ]

4. Hijioka S, Hifumi M, Mekkey MA, Takekuma Y, Kawaguchi T, Yokomizo H, et al. Total pancreatectomy for metastatic renal cell carcinoma with marked extension into the main pancreatic duct. Intern Med 2010;49:557-62.         [ Links ]

5. Coelho JC, Valle CL, Ribas BM. Andriguetto LD, Claus CM. Surgical treatment of cystic neoplasms of the pancreas. Arq gastroenterol 2010;47:135-40.         [ Links ]

6. Demirjian AN, Vollmer CM, McDermott DF, Mullen JT, Atkins MB, Callery MP. Refining indications for contemporary surgical treatment of renal cell carcinoma metastatic to the pancreas. J Hepatobiliary Pancreat Surg 2009;11:150-3.         [ Links ]