Late focal pancreatic metastasis of renal cell carcinoma

Isolated Pancreatic Metastases of Renal Cell Carcinoma-Clinical Particularities and Seed and Soil Hypothesis

A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed, that, in addition to the unusual exclusive occurrence of pancreatic metastases and the favourable treatment results, the isPMRCC is characterised by further peculiarities of the clinical course: The lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. As an explanation for all these peculiarities, according to today's knowledge, a strong acting seed and soil mechanism can serve, which allows embolized tumour cells to grow to metastases only in the pancreas, and prevents them definitively or for years in all other organs. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. Genetic studies revealed specific changes in cases of PM of RCC: Lack of loss of 9p21.3 and 14q31.2, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, i.e., high genetic stability, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC is still unclear, so only those factors that have been identified as promoting organotropism in other, more frequent tumour entities can be presented: Formation of the pre-metastatic niche, chemokine receptor-ligand mechanism, ability to metabolic adaptation, and immune surveillance.

Isolated Pancreatic Metastases of Renal Cell Cancer: Genetics and Epigenetics of an Unusual Tumour Entity

Isolated pancreatic metastases of renal cell carcinoma (isPMRCC) are a rare manifestation of metastatic renal cell carcinoma (mRCC) characterized by two peculiarities: (1). The definite or at least long-term exclusive occurrence of metastases in the pancreas and (2). an unusual low tumour aggressiveness with slow tumour progression and consecutive, good treatment results. According to current knowledge, the exclusive occurrence of pancreatic metastases is due to a highly specific and highly selective seed and soil mechanism, which does not allow metastases settlement outside the pancreas, and whose detailed genetic/epigenetic causes are not yet elucidated. Recent studies have shed light on some of the pathways involved for the protracted course of the disease and highlighted a special genetic profile (lack of loss of 9p, lower weight genome instability index, low frequency of BAP1 alterations, and a high frequency of PBRM1 loss), which deviates from the conventional mRCC profile. Finally, the question of the reasons for the long-term relative genetic stability of the involved cell clones, which is an essential prerequisite for a favourable prognosis, remains unanswered.

Isolated Pancreatic Metastases of Renal Cell Carcinoma-A Paradigm of a Seed and Soil Mechanism: A Literature Analysis of 1,034 Observations

Previously documented arguments, in favor of the suspected impact of a seed and soil mechanism, in the development and progression of isolated pancreatic metastasis of renal cell carcinomas (isPM) are: (1) uniform and independent from the side of the primary tumor distribution of isPM within the pancreas and, (2) the similar survival rates for singular and multiple isPM. In addition, the present study adds new arguments that further confirm the importance of an seed and soil mechanism in isPM: (1) Within the singular isPM, the size of the metastasis does not affect the overall survival; (2) Within the group of multiple isPMs, the overall survival does not depend on the number of metastases; (3) For synchronous and metachronous isPM, survival rates are also not different, and (4) Within the group of metachronous isPM there is also no correlation between the overall survival and interval until metastases occurs. This unusual ineffectiveness of otherwise known risk factors of solid cancers can be explained plausibly by the hypothesis of a very selective seed and soil mechanism in isPM. It only allows embolized renal carcinoma cells in the pancreas to complete all steps required to grow into clinically manifest metastases. In all other organs, on the other hand, the body is able to eliminate the embolized tumor cells or at least put them into a dormant state for many years. This minimizes the risk of occult micrometastases in distant organs, which could later—after isPM treatment—grow into clinically manifest metastases, so that the prognosis of the isPM is only determined by an adequate therapy of the pancreatic foci, and prognostic factors, such as total tumor burden or interval until the occurrence of the isPM remain ineffective.

Observations on Solitary Versus Multiple Isolated Pancreatic Metastases of Renal Cell Carcinoma: Another Indication of a Seed and Soil Mechanism?

Isolated pancreas metastases are a rare type of metastasis of renal cell carcinoma, characterized by the presence of pancreatic metastases, while all other organs remain unaffected. In a previous study, we determined arguments from the literature which (a) indicate a systemic–haematogenic metastasis route (uniform distribution of the metastases across the pancreas and independence of the metastatic localization in the pancreas of the side of the renal carcinoma); and (b) postulate a high impact of a seed and soil mechanism (SSM) on isolated pancreatic metastasis of renal cell carcinoma (isPM) as an explanation for exclusive pancreatic metastases, despite a systemic haematogenous tumor cell embolization. The objective of the study presented was to search for further arguments in favor of an SSM with isPM. For that purpose, the factor’s histology, grading, and singular/multiple pancreas metastases were analyzed on the basis of 814 observations published up to 2018. While histology and grading allowed for no conclusions regarding the importance of an SSM, the comparison of singular/multiple pancreas metastases produced arguments in favor of an SSM: 1. The multiple pancreas metastases observed in 38.1% prove that multiple tumor cell embolisms occur with isPM, the exclusive “maturation” of which in the pancreas requires an SSM; 2. The survival rates (SVR), which are consistent with singular and multiple pancreas metastases (despite the higher total tumor load with the latter), prove that the metastasized tumor cells are not able to survive in all other organs because of an SSM, which results in identical SVR when the pancreatic foci are treated adequately.

Metachronous pancreatic metastases from renal cell carcinoma: is there a place of Active-Surveillance before deferred deliberately Molecular Target Agent?

Background

Metastatic renal cell cancer is a heterogeneous disease due to its diverse morphological features, the prognostic categories based on clinical criteria. Sometimes indolent course without any significant symptoms can be differentiated before the introduction of novel targeted agents. This observation led to interest in a strategy of deferring systemic therapy in the era of effective systemic therapies.

Case presentation

We report of a 78-year-old Moroccan man with pancreatic metastasis from renal cell carcinoma which occurred 14 years from right nephrectomy. Indolent disease based on body computed tomography imaging with 4 years follow-up was recognized. Active surveillance with deferred antiangiogenic multikinase inhibitor at disease progression was proposed. Nowadays, the patient is under oncological follow-up, he is in a good state of health, and he is disease-free for 48 months from the diagnosis of the tumor and for 20 months from the start of the treatment with Sunitinib

Conclusions

Active surveillance before target therapy may be a suitable approach to ensure long progression-free survival with minimal side-effects and better quality of life in asymptomatic, low-volume, metastatic disease. Further prospective studies with biomarker validation are required to define the patients most likely to benefit from this approach.

Pancreatic metastases from renal cell carcinoma: a case report and literature review of the clinical and radiological characteristics

Metastatic pancreatic cancer is rare, accounting for approximately 2% of all pancreatic malignancies, and most cases arise from renal cell carcinoma. We report the case of a 63-year-old woman, who presented with a pancreatic tumor detected during her annual health examination. She had undergone left nephrectomy 13 years previously for renal cell carcinoma. Computed tomography (CT) revealed two tumors in the head and body of the pancreas, a hypervascular tumor and a hypovascular tumor with an enhanced rim, respectively. She underwent pylorus-preserving pancreaticoduodenectomy, and metastatic pancreatic tumors arising from the kidney with clustered clear cell carcinoma immunohistochemically positive for CD10 were diagnosed. This report presents the different enhancement features of different lesions on CT scans. Because the enhancement features of lesions have been reported to vary according to the size of the metastatic tumor, a knowledge of the history of renal cell carcinoma is crucial for diagnosis.

Resection for secondary malignancy of the pancreas

OBJECTIVES

This study tried to clarify the role of pancreatic resection in the treatment of secondary malignancy with metastasis or local invasion to the pancreas in terms of surgical risk and survival benefit.

METHODS

Data of secondary malignancy of the pancreas from our 19 patients and cases reported in the English literature were pooled together for analysis.

RESULTS

There were 329 cases of resected secondary malignancy of the pancreas, including 241 cases of metastasis and 88 cases of local invasion. The most common primary tumor metastatic to the pancreas and amenable to resection was renal cell carcinoma (RCC) (73.9%). More than half (52.3%) of the primary cancers with local invasion to the pancreas were colon cancer, and nearly half (40.9%) were stomach cancer. The median metastatic interval was 84 months (7 years) for overall primary tumors and 108 months (9 years) for RCC. The 5-year survival for secondary malignancy of the pancreas after resection was 61.1% for metastasis and 58.9% for local invasion, with 72.8% for RCC metastasis, 69.0% for colon cancer, and 43.8% for stomach cancer with local invasion to the pancreas.

CONCLUSIONS

Pancreatic resection should not be precluded for secondary malignancy of the pancreas because long-term survival could be achieved with acceptable surgical risk in selected patients.

Systematic review of pancreatic surgery for metastatic renal cell carcinoma

BACKGROUND

This study examined the clinical outcome of patients with pancreatic metastases from renal cell carcinoma (RCC).

METHODS

A systematic literature search produced individual data for 311 surgically and 73 non-surgically treated patients with pancreatic RCC metastases. A further ten patients underwent resection at the authors' institution.

RESULTS

In the resected group, pancreatic metastases were solitary in 65.3 per cent, symptomatic in 57.4 per cent, and were preceded and/or accompanied by extrapancreatic disease in 22.3 per cent. Respective values in the unresected group were 59, 60 and 58 per cent. Disease-free survival rates were 76.0 and 57.0 per cent respectively at 2 and 5 years after resection, and overall survival rates were 80.6 and 72.6 per cent. The only significant risk factor for disease-free survival after pancreatic resection was extrapancreatic disease (P = 0.001), and that for overall survival was symptomatic RCC metastasis (P = 0.031). Two- and 5-year overall survival rates were 41 and 14 per cent respectively in unresected patients.

CONCLUSION

The actuarial 5-year overall survival rate following pancreatic surgery for RCC metastases was 72.6 per cent, as determined by pooled analysis from published series. Extrapancreatic disease was an independent risk factor for recurrence, but had no significant impact on overall survival.

Value of pancreatic resection for cancer metastatic to the pancreas

BACKGROUND

Cancer metastatic to the pancreas from other primary sites is uncommon, and it has been treated with an aggressive surgical approach in fit patients when the primary tumor is controlled and the pancreas is the only site of metastatic disease. The value of pancreatic resection in this setting is unclear. The purpose of this study was to review cases of cancer metastatic to the pancreas.

METHODS

We reviewed our experience with cancer metastatic to the pancreas and the literature regarding resection of pancreatic metastases. Patient and tumor characteristics were summarized using descriptive statistics.

RESULTS

A total of 220 patients with pancreatic metastasis were analyzed. Three patients were selected from our own experience, and 217 were selected from a literature review. In the 127 patients whose symptoms were recorded at the time of presentation, the most common presenting symptoms were jaundice (n=32, 25.2%) and abdominal pain (n=25, 19.7%). In the 189 patients for whom the location of the metastasis in the pancreas was revealed, the most common location was the head of the pancreas (n=79, 41.8%). The primary tumor site was most commonly kidney (n=155, 70.5%). Surgical resection was attempted in 177 of 220 patients; 135 patients suffering from renal cell carcinoma (RCC) metastasis also underwent pancreatic resection. In the latter group, a median survival of 70 mo was seen, as well as 78% and 65% 2- and 5 y survival rates, respectively.

CONCLUSION

Survival after resection of RCC with isolated metastasis to the pancreas is favorable. However, a more detailed analysis considering outcomes without surgery for each primary tumor site is needed before the value of this aggressive surgical approach can be completely assessed in the general occurrence of pancreatic metastasis.

Pancreatic metastasis from renal cell carcinoma with intraportal tumor thrombus

A 68-year-old woman with a history of renal cell carcinoma (RCC) resected curatively 12 years previously was admitted to our department for scrutiny of pancreatic tumors. Various imaging studies demonstrated heterogeneously well-enhanced masses in the head and tail of the pancreas. The well-enhanced mass in the head of the pancreas was connected with the tumor thrombus in the portal vein. To differentially diagnose the multiple pancreatic lesions, we performed endoscopic ultrasound-guided fine-needle aspiration biopsy (EUS-FNAB). Histopathologic findings of the EUS-FNAB specimens were similar to those of the renal clear cell carcinoma previously resected. The patient underwent a surgical operation with segmental resection of the portal vein with the preoperative diagnosis of RCC metastasis to the pancreas with intraportal growth. Histopathological examination of the resected specimen revealed that the masses in the pancreas were multiple pancreatic metastases with intraportal tumor thrombus of RCC. The pancreas is a rare target for metastasis. This is a rare case of pancreatic metastasis from RCC with intraportal extension, and is the first preoperatively definitely diagnosed case using EUS-FNAB.

Duodenum-preserving pancreatic head resection for pancreatic metastasis from renal cell carcinoma: a case report

INTRODUCTION

We report a case of duodenum-preserving pancreatic head resection (DPPHR) for the treatment of pancreatic head metastasis from renal cell carcinoma (RCC).

CASE REPORT

The patient was a 59-year-old male with a medical history of RCC 18 years ago. Abdominal imaging studies revealed a hypervascular mass localized in the pancreatic head without distant metastasis or tumor invasion into the adjacent organs including the common bile duct and duodenum. Under the preoperative diagnosis of pancreatic metastasis from RCC, the tumor was completely resected by DPPHR. The pathological examination of the resected specimen confirmed the preoperative diagnosis.

CONCLUSION

As lymph node metastasis has been rarely reported in previous cases of pancreatic metastasis from RCC, DPPHR should be considered as a less invasive surgical option to provide a favorable postoperative quality of life (QOL).

Solitary and multiple isolated metastases of clear cell renal carcinoma to the pancreas: an indication for pancreatic surgery

BACKGROUND

Isolated pancreatic metastases (isPMs) of clear cell renal carcinoma are rare. Most of them are solitary; some are multiple. The reported rates and the clinical implications of multiple isPMs from clear cell renal cancer vary. Therefore, the available literature was analyzed to shed light on the clinical significance of these extremely rare metastatic lesions.

METHODS

A literature search brought to light 236 cases of isPMs (both solitary and multiple) from renal cell carcinoma. These were analyzed.

RESULTS

A total of 12% of the metastases were synchronous with the primary tumor, and 88% were metachronous, occurring 10.0 +/- 6.5 years (mean +/- SD) after nephrectomy. A predilection for a specific part of the pancreas was not identifiable. The localization of the renal cell cancer (left or right kidney) did not have any effect on the site of the metastases. Seventy-four (39%) of the metastases to the pancreas were multiple (3.2 +/- 1.5). Their epidemiology did not differ from that of solitary metastatic lesions. Actuarial 3- and 5-year survival rates after radical resection were 78% and 78%, respectively, for multiple versus 75% and 64% for solitary metastases.

CONCLUSIONS

The epidemiological data do not support a direct local lymphogenous or venous spread from the primary tumor to the pancreas. They rather suggest a systemic spread. Because of the positive outcome, radical removal of both solitary and multiple metastases should be attempted in eligible patients.

Renal cancer cell metastasis into the pancreas: a single-center experience and overview of the literature

OBJECTIVES

The pancreas is a rare target for metastasis from other primary cancers, but pancreatic metastasis play a role in the diagnostic workup of patients with pancreatic tumors, especially in patients with a history of renal cell carcinoma (RCC).

METHODS

Between October 2001 and June 2004 data from 601 patients undergoing pancreatic resection were entered prospectively in a database and were analyzed for metastasis into the pancreas from RCC.

RESULTS

Fifteen patients with metastasis to the pancreas from RCC were identified. One patient showed metastatic disease at time of primary diagnosis. In 8 patients, the pancreas was the only site of metastasis, whereas in 7 patients, other organs, such as the thyroid gland, the lung, or the liver, were targets of metastasis, either metachronous or simultaneous at the time of pancreatic metastasis. The median interval between primary treatment of RCC and occurrence of pancreatic metastasis was 86 months (range, 0-258). Most patients were asymptomatic and diagnosed during standard tumor follow-up. So far, 14 patients remain alive with a median follow-up of 10 months.

CONCLUSION

Pancreatic metastasis from RCC is rare but can occur even more than 20 years after primary tumor manifestation. Our results show that pancreatic resections for metastasis can be performed safely with a low rate of complications. Patients with a history of RCC should undergo a long-term follow-up to detect and evaluate for pancreatic metastases as well for metastasis to other organ sites.

Pancreatic metastases: observations of three cases and review of the literature

BACKGROUND

The aim of the study is to analyze pancreatic metastases and their clinical, radiological, therapeutic and prognostic features.

METHODS

Three cases of pancreatic metastases observed and a world literature review of 333 cases were recorded.

RESULTS

Pancreatic metastases are due more frequently to renal cell carcinoma; they are usually metachronous and characterized by a long period of time between the resection of the primary tumor and their detection. The differential diagnosis with other pancreatic masses is difficult, but an accurate anamnesis, some peculiar findings of imaging techniques and percutaneous fine needle aspiration could allow preoperative diagnosis. Pancreatic resections are the treatment of choice allowing the better palliation and improving survival. 150/234 pancreatic metastases underwent pancreatic resections (resectability index = 64.1%); 88/132 patients are alive with a mean follow-up of 27.1 months; of the 44 dead patients the mean survival time was 21.3 months. Among pancreatic metastases the primary tumor with better prognosis is renal cell carcinoma.

CONCLUSION

Pancreatic metastases are rare; their preoperative diagnosis is difficult but useful and possible. Surgical resection is suggested because the patient still may have a prolonged survival.

[Surgical treatment of pancreatic metastases from renal carcinoma]

OBJECTIVES

Pancreatic metastases from renal carcinoma are poorly known. The aim of this study was to report clinical and radiological manifestations, the treatment performed, and the observed survival in 7 patients with this rare entity.

RESULTS

All patients were operated on. One patient had nonresectable tumor. Six patients underwent curative resection. There was one postoperative death. Follow-up after pancreatectomy ranged from 6 months to 3 years. Two patients developed extra-pancreatic metastases one year and 3 years after pancreatectomy respectively.

CONCLUSIONS

Pancreatic metastases from renal carcinoma are rare and often occur several years after nephrectomy. However their resection is often possible and allows a good long-term survival.

PATIENTS AND METHODS

From 1988 to 2000, 7 patients (5 men and 2 women, mean age = 66 years) with pancreatic metastases from a renal cell carcinoma were observed in the same center. One patient had synchronous metastasis; in the 6 others, metastases were diagnosed 4 to 16 years after nephrectomy, and were revealed by pain (n = 2), gastrointestinal bleeding (n = 1), faintness (n = 1) or routine follow-up (n = 2). The diagnosis of metastases was made by contrast-enhanced abdominal CT-scan.

Renal cell carcinoma metastatic to the pancreas: clinical and radiological features

OBJECTIVE

To review the clinical features, computed tomographic (CT) appearance, and treatment outcomes in a case series of patients with renal cell carcinoma (RCC) metastatic to the pancreas.

PATIENTS AND METHODS

We retrospectively reviewed the records of 23 patients (15 men and 8 women) with RCC metastatic to the pancreas, detected by CT examination between 1986 and 1996. All patients had undergone a previous nephrectomy for RCC.

RESULTS

Isolated mild elevation in liver function test results (in 5 patients) or in serum amylase level (in 8 patients) was observed. New-onset diabetes was detected in 3 patients. The CT characteristics of the pancreatic metastases generally resembled those of primary RCC with well-defined margins and greater enhancement than normal pancreas with a central area of low attenuation. The mean interval between resection of the primary RCC and detection of the pancreatic metastases was 116 months (range, 1-295 months). In 18 patients (78%), the pancreatic metastases were diagnosed more than 5 years after nephrectomy. The pancreas was the initial metastatic site in 12 patients (52%). Survival was shortened with higher tumor grade (mean survival time of 41 months and 10 months in patients with grade 2 and 3, respectively). Surgical resection was carried out in 11 patients (7 distal and 3 total pancreatectomies and 1 distal pancreatectomy followed 4 years later by total pancreatectomy), with 8 patients alive at a mean follow-up of 4 years, 6 of whom remained free of recurrence. Overall, 12 patients (52%) were alive at a mean of 42 months after diagnosis of metastatic disease.

CONCLUSIONS

The appearance of metastatic RCC lesions in the pancreas closely resembles the appearance of primary RCC on CT images. Pancreatic metastases from RCC are frequently detected many years after nephrectomy. Patient survival correlates with tumor grade. Histologic analysis of pancreatic masses in patients with a history of resected primary RCC is important since the prognosis for RCC metastatic to the pancreas is much better than that for primary pancreatic adenocarcinoma.