Survival outcomes and risk factors for liver and pancreatic metastases in renal cell carcinoma after curative nephrectomy

BACKGROUND

Renal cell carcinoma (RCC) has a high recurrence risk, with 20-40% of patients developing metastatic disease post-nephrectomy. This study aimed to identify risk factors associated with liver and pancreatic metastases in patients who have previously undergone curative nephrectomy for RCC.

METHODS

This retrospective cohort study with a nested case-control design included adults who underwent nephrectomy for non-metastatic RCC (non-mRCC) between 2009 and 2021. Patients who developed liver or pancreatic metastases, confirmed by secondary surgery, formed the case group. A randomly selected control group of non-mRCC patients were included to assess risk factors. Clinical, radiological, and pathological data were analyzed.

RESULTS

Among 967 nephrectomy patients, 754 (78%) had RCC, and 6% developed liver or pancreatic metastases. Advanced tumor stage (T3) was a significant predictor of RCC metastasis in these patients. Patients with a prolonged disease-free interval demonstrated better surgical eligibility and survival outcomes. Median time from nephrectomy to metastasis was 57 months in surgical cases compared to 22 months in non-surgical cases. Notably, 92% of patients eligible for metastasis surgery had clear cell RCC (ccRCC). Surgical resection was associated with improved survival, with 1-, 3-, and 5-year survival rates of 92%, 83%, and 75%, respectively, compared to 77%, 65%, and 56% for non-surgical patients.

CONCLUSIONS

Advanced tumor stage and local invasiveness were key predictors of liver and pancreatic metastases in RCC. Prolonged time to metastasis improved surgical eligibility and survival. The majority of patients eligible for metastasis surgery had ccRCC. Further studies are needed to evaluate whether early, individualized follow-up for high-risk RCC subtypes improved surgical eligibility for liver and pancreatic metastasis.

Pancreatic Serous Neoplasm and Metastatic Clear Cell Renal Cell Carcinoma: Diagnostic Pitfalls Resolvable by a Panel of Immunohistochemical Stains to Include PAX8 and CK7 But Not CAIX

Pancreatic serous neoplasms can morphologically resemble metastatic clear cell renal cell carcinoma (ccRCC) and may present a diagnostic dilemma, particularly if the solid variant is in small biopsy specimens and/or in patients with von Hippel Lindau (VHL) syndrome. We investigate the utility of immunohistochemical staining in this differential diagnosis by performing head-to-head comparisons of commonly used immunohistochemical markers for these 2 tumor types. We examined 16 pancreatic serous neoplasms and 24 ccRCCs (12 metastatic to pancreas and 12 primaries in patients with VHL). All pancreatic serous neoplasms stained positive for CK7, and most were positive for CAIX (15/16) and GLUT1 (15/16), variable for alpha-inhibin and vimentin (each 8/16 weak/focal; and 7/16 and 8/16, respectively, positive), and weak/focal for synaptophysin (14/16). All pancreatic serous neoplasms were negative for PAX8 and Periodic acid-Schiff without diastase. In contrast, ccRCC, both metastatic and in VHL patients, were mostly positive for PAX8 (18/24; 6/24 were weak/focal), negative for CK7 (15/24; 8/24 were weak/focal, one case diffuse positive), and negative for alpha-inhibin (100%) and synaptophysin (22/24). Like pancreatic serous neoplasms, all ccRCC showed weak/focal or positive staining for GLUT1, CAIX, and vimentin, and were negative for PAS-D. In conclusion, CK7 and PAX8 are the most useful stains in distinguishing between pancreatic serous neoplasm and ccRCC; however, weak/focal CK7 or PAX8 staining can be seen in a minority of ccRCC, thereby presenting a diagnostic pitfall. Alpha-inhibin was at least weak/focal in most pancreatic serous neoplasms and negative in all ccRCC and may be useful as an adjunct stain in difficult cases.

Differentiation between renal cell carcinoma metastases to the pancreas and pancreatic neuroendocrine tumors in patients with renal cell carcinoma on CT or MRI

PURPOSE

To determine whether renal cell carcinoma metastases (RCC-Mets) to the pancreas can be differentiated from pancreatic neuroendocrine tumors (PNETs) in patients with RCC on CT or MRI at presentation.

METHODS

This retrospective study included patients with biopsy-proven RCC-Mets (n = 102) or PNETs (n = 32) at diagnosis or after nephrectomy for RCC. Inter-observer agreement (Cohen kappa) was assessed in 95 patients with independent reads by two radiologists, with discrepancies resolved by consensus for final analysis. The remaining 39 cases underwent consensus reads by two different radiologists for final analysis. The CT/MRI images were reviewed for number, size, regional distribution, parenchymal location (exophytic or intrapancreatic), contrast-enhancement, and enhancement pattern of pancreatic lesions in the available phases. Statistical tests were conducted using two sample t-tests and Pearson's chi-squared test for numeric and categorical variables respectively.

RESULTS

The study group comprised of 134 patients (90 males) with 265 lesions (229 RCC-Mets and 36 PNETs). Patients with PNETs were significantly younger (62 ± 12 years vs. 67 ± 9 years, p = 0.013). Inter-observer agreement for CT/MRI features was excellent across multiple imaging variables (k = 0.86-1.00). Most PNETs were single lesions (88 vs. 63%, p = 0.008), smaller in size (14 mm vs. 23 mm, p = 0.042), more common in the body and tail (81 vs. 57%, p = 0.01), showed homogeneous contrast enhancement (64-79% vs. 39-49%, p < 0.01-0.03), less T1-hypointense (80 vs. 99%, p = 0.002) and more DWI hyperintense (71 vs. 58%, p < 0.001) compared to RCC-Mets.

CONCLUSION

PNETs are typically single, occur in distal pancreas, and enhance homogeneously compared to RCC-Mets which are often multiple, occur in the proximal pancreas, and enhance heterogeneously.

Pancreatic Metastases of Esophageal Squamous Cell Carcinoma: A Case Report and Review of the Literature

Esophageal carcinoma is an aggressive cancer with a poor therapeutic response and a significant risk of recurrence after radical resection. It usually metastasizes to the lung, bones, or liver. Unusual spread can be found in other organs, but only nine cases of pancreatic metastases have been reported in the Medline database. In the present paper, a literature review of nine cases with esophageal squamous cell carcinoma and pancreatic metastasis was carried out. In addition to these cases, we present our case, the tenth case in the literature. It involved a patient who underwent surgery for esophageal squamous cell carcinoma and developed metachronous pancreatic metastasis 67 months after esophagectomy. Histopathological examination confirmed a squamous cell carcinoma metastasis. Conclusions: Pancreatic metastasis of esophageal squamous cell carcinoma is extremely rare. Pancreatic metastasis may develop several years after the treatment of the primary lesion. The diagnosis of metastasis is difficult, requiring histopathological and immunohistochemical examination.

Metastatic Neuroendocrine Neoplasms to the Pancreas: Two Unusual Cases and a Review of the Literature

Neuroendocrine tumor metastases to the pancreas are rare, and they share substantial overlap with the significantly more common primary pancreatic neuroendocrine neoplasms, representing a potential diagnostic pitfall. Elucidating whether a neuroendocrine tumor within the pancreas is a primary neoplasm versus a metastasis has significant prognostic and treatment implications. Correlation with clinical history and imaging as well as incorporating an appropriate immunohistochemical panel are essential to establish the correct diagnosis. Herein, we present 2 rare neuroendocrine tumors that metastasized to the pancreas: a medullary thyroid carcinoma and an atypical carcinoid tumor of lung origin. We also provide a brief review of the literature.

Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID)

BACKGROUND AND OBJECTIVES

Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with a repeated pancreatic resection, and to analyse the results of both overall and disease-free survival.

METHODS

Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected.

RESULTS

The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2-56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively (p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895).

CONCLUSION

Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection.

Metastasis of Renal Cell Carcinoma to Pancreatic Bile Duct

Secondary pancreatic neoplasms account for less than 5% of all pancreatic malignancies, with renal cell carcinoma (RCC) being one of the most common primary tumors. Here, we present the case of a patient with obstructive jaundice secondary to an isolated metastatic RCC, to the intrapancreatic portion of the common bile duct, ampulla of Vater, and pancreatic parenchyma. Patient had a history of a left radical nephrectomy due to a primary RCC 10 years prior to presentation, and eventually underwent a pylorus-sparing pancreaticoduodenectomy (PD) with minor morbidity. While metastases of RCC to the pancreatic body and tail have been reported, isolated metastasis to the pancreatic bile duct comprises an even rarer subgroup.

Rare Solid Pancreatic Lesions on Cross-Sectional Imaging

Several solid lesions can be found within the pancreas mainly arising from the exocrine and endocrine pancreatic tissue. Among all pancreatic malignancies, the most common subtype is pancreatic ductal adenocarcinoma (PDAC), to a point that pancreatic cancer and PDAC are used interchangeably. But, in addition to PDAC, and to the other most common and well-known solid lesions, either related to benign conditions, such as pancreatitis, or not so benign, such as pancreatic neuroendocrine neoplasms (pNENs), there are solid pancreatic lesions considered rare due to their low incidence. These lesions may originate from a cell line with a differentiation other than exocrine/endocrine, such as from the nerve sheath as for pancreatic schwannoma or from mesenchymal cells as for solitary fibrous tumour. These rare solid pancreatic lesions may show a behaviour that ranges in a benign to highly aggressive malignant spectrum. This review includes cases of an intrapancreatic accessory spleen, pancreatic tuberculosis, solid serous cystadenoma, solid pseudopapillary tumour, pancreatic schwannoma, purely intraductal neuroendocrine tumour, pancreatic fibrous solitary tumour, acinar cell carcinoma, undifferentiated carcinoma with osteoclastic-like giant cells, adenosquamous carcinoma, colloid carcinoma of the pancreas, primary leiomyosarcoma of the pancreas, primary and secondary pancreatic lymphoma and metastases within the pancreas. Therefore, it is important to determine the correct diagnosis to ensure optimal patient management. Because of their rarity, their existence is less well known and, when depicted, in most cases incidentally, the correct diagnosis remains challenging. However, there are some typical imaging features present on cross-sectional imaging modalities that, taken into account with the clinical and biological context, contribute substantially to achieve the correct diagnosis.

Metastatic Renal Cell Carcinoma to Pancreas: Case Series and Review of the Literature

Metastasis to the pancreas represents a small proportion of all pancreatic malignancies. Among primary tumors that metastasize to the pancreas, renal cell carcinoma (RCC) is one of the most common causes of metastatic pancreatic lesions. We herein report a case series of three patients with pancreatic metastasis from RCC. The first is a 54-year-old male with a history of left nephrectomy for RCC, in whom an isthmic pancreatic mass suggestive of a neuroendocrine lesion was found during oncological follow-up. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) identified pancreatic metastasis of RCC and the patient was referred for surgery. The second case is a 61-year-old male, hypertensive, diabetic, with left nephrectomy for RCC six years previously, who complained of weight loss and was found with a hyperenhancing mass in the head of the pancreas and a lesion with a similar pattern in the gallbladder. EUS-FNB from the pancreas proved to be a metastatic pancreatic lesion. Cholecystectomy and treatment with tyrosine kinase inhibitors were recommended. The third case is a 68-year-old dialysis patient referred for evaluation of a pancreatic mass, also confirmed by EUS-FNB, who was started on sunitinib treatment. We report a literature summary on epidemiology and clinical features, diagnosis and differential diagnosis and treatment and outcomes in pancreatic metastasis of RCC.

Metastatic Renal Cell Carcinoma to Pancreas: Case Series and Review of the Literature

Metastasis to the pancreas represents a small proportion of all pancreatic malignancies. Among primary tumors that metastasize to the pancreas, renal cell carcinoma (RCC) is one of the most common causes of metastatic pancreatic lesions. We herein report a case series of three patients with pancreatic metastasis from RCC. The first is a 54-year-old male with a history of left nephrectomy for RCC, in whom an isthmic pancreatic mass suggestive of a neuroendocrine lesion was found during oncological follow-up. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) identified pancreatic metastasis of RCC and the patient was referred for surgery. The second case is a 61-year-old male, hypertensive, diabetic, with left nephrectomy for RCC six years previously, who complained of weight loss and was found with a hyperenhancing mass in the head of the pancreas and a lesion with a similar pattern in the gallbladder. EUS-FNB from the pancreas proved to be a metastatic pancreatic lesion. Cholecystectomy and treatment with tyrosine kinase inhibitors were recommended. The third case is a 68-year-old dialysis patient referred for evaluation of a pancreatic mass, also confirmed by EUS-FNB, who was started on sunitinib treatment. We report a literature summary on epidemiology and clinical features, diagnosis and differential diagnosis and treatment and outcomes in pancreatic metastasis of RCC.

A Rare Case of Single Gallbladder and Multiple Pancreatic Metastases of Renal Cell Carcinoma

Renal cell carcinoma (RCC) is the most common tumor to metastasize to uncommon sites. Synchronous metastases in the gall bladder and pancreas are rare entities. In this report, we present the case of a 43-year-old male with a complaint of hematuria presenting with a left renal mass. Contrast-enhanced CT revealed an arterially enhancing mass in the left kidney, a synchronous tiny polyp in the gall bladder, and multiple focal lesions in the pancreas. The patient underwent surgery and the tumor was histopathologically labeled as a clear cell RCC with metastases to the pancreas and gall bladder. Post-surgery, the patient has been followed up.

Literature review of imaging, pathological diagnosis, and outcomes of metachronous lung and pancreatic metastasis of cecal cancer

Background

Pancreatic metastasis from colorectal cancer is extremely rare. Here, we report a case of colorectal cancer with lung and pancreatic metastasis and analyze the histopathology, immunohistochemistry, and next-generation sequencing (NGS) to generate a differential diagnosis and treatment of metastatic colon cancer.

Case presentation

AC1

A 78-year-old man was admitted because of a recently elevated carcinoembryonic antigen. This patient had undergone laparoscopic right hemicolectomy for cecal cancer IIA (T3N0M0) 5 years before admission, and thoracoscopic left upper lung wedge resection for primary colon cancer lung metastasis 2 years before admission. At that time, the patient was thought to have pancreatic metastasis from colon cancer. He underwent laparoscopic distal pancreatectomy (combined with splenectomy). Postoperative pathology revealed colon cancer metastasis. We performed NGS on tumor samples at three loci and found colon cancer's most common oncogenic driver genes (KRAS, APC, and TP53). One month after surgery, the patient was given capecitabine for six cycles of chemotherapy. At present, no high adverse reactions have been reported.

Discussion

For patients with pancreatic space-occupying, such as a previous history of colorectal cancer, and recent carcinoembryonic antigen elevation, we should highly suspect pancreatic metastatic colorectal cancer. NGS is an essential auxiliary for identifying metastatic tumors. Surgery combined with postoperative chemotherapy is an effective treatment.

Misdiagnosis of pancreatic metastasis from renal cell carcinoma: A case report

BACKGROUND

Pancreatic metastases account for only a small proportion of all pancreatic malignancies. Isolated pancreatic metastasis from renal cell cancer (isPM-RCC) is extremely rare and may be difficult to differentiate from more common primary neoplasms. A history of nephrectomy is crucial for the diagnosis.

CASE SUMMARY

We report the case of a 64-year-old Asian man who was diagnosed with a mass in the pancreatic head using computed tomography. He had no related symptoms, and his medical history was unremarkable, except for unilateral nephrectomy performed to remove a “benign” tumor 19 years ago. All preoperative imaging findings suggested a diagnosis of pancreatic neuroendocrine tumor. However, ultrasound-guided biopsy revealed features of clear cell renal cell carcinoma (ccRCC). Re-examination of the specimen resected 19 years ago confirmed that he had a ccRCC. The pancreatic mass was resected and pathological examination confirmed isPM-RCC.

CONCLUSION

Misdiagnosis of isPM-RCC is common because of its rarity and the long interval from resection of the primary tumor and manifestation of the metastasis. The history of the previous surgery may be the only clue.

MiR-4461 Inhibits Tumorigenesis of Renal Cell Carcinoma by Targeting PPP1R3C

Background: Renal cell carcinoma (RCC) is one of the most common and malignant tumors in the urinary system. The aim of this research was to investigate the mechanism and clinical significance of miR-4461 in the RCC progression. Materials and Methods: Twenty-eight (28) paired RCC tissue samples and adjacent nontumor tissue samples, as well as RCC cell lines were used to measure the expression of miR-4461 and protein phosphatase 1 regulatory subunit 3C (PPP1R3C) transcript by real-time quantitative PCR. The target relationship between miR-4461 and PPP1R3C was predicted by TargetScan and further verified by dual-luciferase reporter gene assay and RNA pull-down assay. Cell Counting Kit-8 (CCK-8) assay and BrdU ELISA assay were performed to measure RCC cell viability and proliferation. In addition, caspase-3 activity assay and cell adhesion assay were implemented to measure RCC cell apoptosis and adhesion. Results: MiR-4461 was lowly expressed both in RCC tissues and cells, while upregulated PPP1R3C was tested in RCC tissues and cells. In addition, miR-4461 was validated to directly target PPP1R3C, thereby negatively regulating PPP1R3C. Particularly, miR-4461 exerted a clear inhibitory effect on the malignant phenotypes of RCC cells by binding and inhibiting PPP1R3C. Conclusion: MiR-4461, which served as a tumor suppressor, inhibited RCC progression by targeting and downregulating PPP1R3C.

An exceptionally rare case of metastatic high-grade urothelial carcinoma of the renal pelvis to the pancreas diagnosed on endoscopic ultrasound-guided fine-needle aspiration: A diagnostic challenge

Metastases to the pancreas are rare and can be confused with the primary adenocarcinoma of the pancreas. Metastasis of renal pelvis urothelial carcinomas to the pancreas are extremely rare. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy is a very safe and effective diagnostic method. In this study, we present a 65-year-old male patient with a solitary mass in the pancreas. A moderate cellular tumoral lesion was observed in the aspiration cytology performed from the 55-millimeter solid mass invading the head of the pancreas via EUS-FNA. Tumor cells consisted of cells with irregular borders, different shapes and sizes, hyperchromatic, narrow cytoplasm with dark nuclei, and cells with anisonucleosis in focal areas. Cellblock obtained from aspirated was found diffusely positive with high molecular weight cytokeratin, Thrombomodulin, p63, GATA-3, and CK7, and negative with CK20, PAX8, and PSA. Having a primary malignancy in the medical history of the patients is very important in the differential diagnosis of primary and secondary pancreatic cancers. The potential for metastasectomy in pancreatic metastases can be applied in cases with isolated metastatic disease. Primary tumor histopathology may have an impact on the long-term survival of the case. This study aimed to describe the cytomorphological features of solid and solitary pancreatic malignancies and to evaluate the role of immunohistochemistry performed from aspirate cell block in detecting the primary tumor origin.

Pancreatic metastases from renal cell carcinoma. Postoperative outcome after surgical treatment in a Spanish multicenter study (PANMEKID)

BACKGROUND

Renal Cell Carcinoma (RCC) occasionally spreads to the pancreas. The purpose of our study is to evaluate the short and long-term results of a multicenter series in order to determine the effect of surgical treatment on the prognosis of these patients.

METHODS

Multicenter retrospective study of patients undergoing surgery for RCC pancreatic metastases, from January 2010 to May 2020. Variables related to the primary tumor, demographics, clinical characteristics of metastasis, location in the pancreas, type of pancreatic resection performed and data on short and long-term evolution after pancreatic resection were collected.

RESULTS

The study included 116 patients. The mean time between nephrectomy and pancreatic metastases' resection was 87.35 months (ICR: 1.51-332.55). Distal pancreatectomy was the most performed technique employed (50 %). Postoperative morbidity was observed in 60.9 % of cases (Clavien-Dindo greater than IIIa in 14 %). The median follow-up time was 43 months (13-78). Overall survival (OS) rates at 1, 3, and 5 years were 96 %, 88 %, and 83 %, respectively. The disease-free survival (DFS) rate at 1, 3, and 5 years was 73 %, 49 %, and 35 %, respectively. Significant prognostic factors of relapse were a disease free interval of less than 10 years (2.05 [1.13-3.72], p 0.02) and a history of previous extrapancreatic metastasis (2.44 [1.22-4.86], p 0.01).

CONCLUSIONS

Pancreatic resection if metastatic RCC is found in the pancreas is warranted to achieve higher overall survival and disease-free survival, even if extrapancreatic metastases were previously removed. The existence of intrapancreatic multifocal compromise does not always warrant the performance of a total pancreatectomy in order to improve survival.

Quaking I-5 protein inhibits invasion and migration of kidney renal clear cell carcinoma via inhibiting epithelial-mesenchymal transition suppression through the regulation of microRNA 200c

Background

It has been demonstrated that quaking I-5 protein (QKI-5) plays crucial roles in the metastasis of various kinds of cancers. However, the function and mechanism of QKI-5 in kidney renal clear cell carcinoma (KIRC) metastasis remains unclear. Therefore, this study aimed to explore the mechanism of QKI-5 in the metastasis of KIRC.

Methods

The expression of QKI-5 was detected using real-time quantitative reverse transcription polymerase chain reaction (qRT-PCR) and western blot in KIRC tissues and different cell lines. Immunohistochemical staining was used to detect the quantity of QKI-5 in primary and metastases of KIRC. Cell migration and invasion were measured using wound healing and transwell assays respectively. The quantity of epithelial mesenchymal transition marker proteins was detected using western blot and immunofluorescence staining. The interaction of QKI-5 via microRNA 200c (miR-200c) was confirmed using dual luciferase reporter assay.

Results

Although QKI-5 was significantly more likely to be downregulated in KIRC tissues than that in normal Kidney tissues, it was dramatically elevated in metastatic KIRC tumors. Upregulation of QKI-5 promoted cell migration and invasion and elevated the expression of epithelial-mesenchymal transition (EMT) marker proteins, including vimentin, snail and slug, while it was downregulated for E-cadherin. Furthermore, a dual luciferase reporter assay demonstrated that QKI-5 was a direct target of miR-200c, and that miR-200c could reverse the effect of QKI-5 on cell migration, invasion, and expression of EMT marker proteins.

Conclusions

Our results revealed that downregulation of QKI-5 by miR-200c attenuated KIRC migration and invasion via the EMT process, indicating that QKI-5 may be a potential therapeutic target and a key indicator of KIRC progression.

A Novel ZNF304/miR-183-5p/FOXO4 Pathway Regulates Cell Proliferation in Clear Cell Renal Carcinoma

Zinc-finger protein 304 (ZNF304) plays a critical role in silencing genes through transcription, regulating cell survival, proliferation, apoptosis, and differentiation during development. However, the roles of transcription factor ZNF304 and its clinical significance in clear cell renal carcinoma (ccRCC) remain unclear. In this study, we found that the expression of ZNF304 was downregulated in ccRCC tissues. Lower levels of ZNF304 were correlated with poor survival. Downregulation of ZNF304 promoted ccRCC cell growth in vitro, whereas overexpression of ZNF304 inhibited growth. Our results indicated that miR-183-5p/FOXO4 mediated ZNF304 regulation of cell growth. Interestingly, we revealed that ZNF304 promoted FOXO4 expression in ccRCC cells. Mechanistically, ZNF304 binds to miR-183 promoter and inhibits miR-183-5p transcription. Furthermore, the expression of miR-183-5p wes increased in ccRCC tissues, and the upregulation of miR-183-5p was related to the poor prognosis of ccRCC patients. miR-183-5p upregulation repressed the expression of FOXO4 and promoted ccRCC progression. These results demonstrated that ZNF304/miR-183-5p/FOXO4 axis played essential role in promoting ccRCC progression, which suggests that disruption of this axis may be a potential therapeutic target in ccRCC.

Differentiation between pancreatic metastases from renal cell carcinoma and pancreatic neuroendocrine neoplasm using endoscopic ultrasound

OBJECTIVES

Pancreatic metastases from renal cell carcinoma (PRCC) often appear many years after treatment of the primary tumor, and differentiation from pancreatic neuroendocrine neoplasm (PanNEN) can be challenging due to their hypervascularity. Here, we investigated the utility of endoscopic ultrasound (EUS) for differentiation of these conditions.

METHODS

A retrospective analysis was performed in 17 and 79 consecutive patients with pathologically proven PRCC and non-functional PanNEN who were examined by EUS. In cases examined by EUS elastography or contrast-enhanced harmonic EUS (CH-EUS), the lesions were classified as stiff or soft, or into three vascular patterns as hypoechoic, isoechoic, and hyperechoic. CH-EUS images at 20 s, 40 s, 60 s, 3 min and 5 min were used for evaluation. EUS images were independently reviewed by two readers who were blinded to all clinical information.

RESULTS

The patients with PRCC were significantly older than those with PanNEN (median, 71 (range, 45-81) vs. 58 (22-76), P = 0.001) and more often had multiple tumors (6/17 (35%) vs. 7/79 (9%), P = 0.010). In EUS findings, PRCC lesions significantly more frequently had a marginal hypoechoic zone (MHZ) (11/17 (65%) vs. 27/79 (34%), P = 0.028), being classified as soft (12/13 (92%) vs. 26/58 (45%), P = 0.002), and showed sustained hyperechoic vascular patterns at 5 min (7/8 (88%) vs. 4/59 (7%), P < 0.001) compared to PanNEN lesions.

CONCLUSIONS

The presence of a MHZ, a soft lesion, and a sustained hyperechoic vascular pattern in EUS may be useful for differentiating PRCC from PanNEN.

Late Onset of Pancreatic Metastases from Renal Cell Carcinoma. A Case Report

Metastasis of renal cell carcinoma (RCC) to the pancreas is a rare entity accounting only 0.25-3% of all pancreatic tumors. We present a rare case of isolated three focal pancreatic metastases from RCC, occurring 15 years after the left nephrectomy. The majority of the pancreatic metastases are asymptomatic, as it was in case of our patient excluding the weight loss for the last three months. We demonstrate the importance of the medical history, radiological examinations, histological and immunohistochemical analysis in making a definitive diagnosis.

Catastrophic Aortoenteric Fistula Due to an Eroding Bare Metal Duodenal Stent

Deployment of bare metal duodenal stents for individuals with gastric outlet obstructions (GOOs) is a well-characterized measure to improve the quality of life. However, these interventions are palliative in nature and are associated with known complications. We present an unfortunate case of a previously not well described, albeit not surprising, a complication of stent placement. The individual underwent duodenal stent placement due to obstructive metastatic disease and subsequently presented for gastrointestinal (GI) bleed. It was determined that an aortoduodenal fistula acutely developed and, despite heroic efforts, the patient ultimately expired.

Pancreatic metastasis from renal cell carcinoma presenting as gastrointestinal hemorrhage: a case report

In some patients with metastatic renal cell carcinoma to the pancreas, gastrointestinal hemorrhages occur, but because of the rarity of this condition, treatment strategies have not been established. A 71-year-old man who had undergone a nephrectomy for renal cell carcinoma (RCC) went to a hospital in a state of shock. Computed tomography revealed a hypervascularized tumor in the head of the pancreas, suggesting metastatic RCC. Upper endoscopy revealed bleeding in the duodenum due to tumor invasion. An emergency angiogram showed that the tumor received its blood supply mainly from the gastroduodenal artery. Transarterial embolization (TAE) of the gastroduodenal artery was performed and bleeding was controlled. Two months after TAE, elective pancreaticoduodenectomy was performed. The patient currently continues to undergo outpatient follow-up 2 years later without recurrence. TAE was very effective in controlling the acute phase of severe gastrointestinal hemorrhage from pancreatic metastasis of RCC.

Neutrophil-lymphocyte ratio as a prognostic factor for minute clear cell renal cell carcinoma diagnosed using multi-slice spiral CT

Minute clear cell renal cell carcinoma (MccRCC) has a diameter of <1.5 cm and can be diagnosed using multi-slice spiral CT (MSCT). Recently, the role of the neutrophil-lymphocyte ratio (NLR) in the development of MccRCC has attracted attention. This study aimed to further explore the relationship between the NLR and MccRCC.This was a prospective study of 100 patients who were diagnosed with MccRCC using MSCT at Urumqi Friendship Hospital, China. The study investigated a series of pretreatment factors, including NLR and patients' general clinical data. Statistical methods employed included Pearson's chi-square test, Spearman-rho correlation test, Cox regression analysis, and receiver operator characteristic curve analysis.Based on Pearson's χ2, Spearman-rho test, and univariate/multivariate Cox regression analysis, the overall survival of patients with MccRCC was shown to be significantly related to NLR (P < .001). NLR (hazard ratio = 50.676, 95%CI, 17.543-146.390, P < .001) is a significant independent risk-factor for MccRCC. A receiver operator characteristic curve was plotted to examine specificity and sensitivity between NLR and MccRCC (area under curve = 0.958, P < .001).The level of the NLR plays a crucial role in the survival of patients with MccRCC, as diagnosed with MSCT. The higher the NLR, the worse the prognosis for patients with MccRCC.

Metastatic renal cell carcinoma to pancreas and gastrointestinal tract: a clinicopathological study of 3 cases and review of literature

BACKGROUND

Renal Cell Carcinoma (RCC) metastasizes in approximately 20-30% cases. The most common sites for metastases are the lungs, bones, liver, and brain. Metastases of RCC in the gastrointestinal tract (GIT) are very rare. Metastatic RCC has a poor prognosis. We herein present a case series of three patients with metastatic disease in the colon, duodenum, and pancreas following complete resection of RCC.

METHODS

Hematoxylin and Eosin and immunohistochemical slides of 3 cases of RCC metastatic to GIT were reviewed. These cases were diagnosed between 2002 and 2019 at French Medical Institute for Mothers and Children (FMIC), Kabul, Afghanistan, and Aga Khan University Hospital (AKUH), Karachi, Pakistan. We also present a detailed review of published literature.

RESULTS

We reviewed cases of three patients, two females and one male, with a mean age of 57.3 years (range 40-67 years) who underwent nephrectomy for RCC. They developed metastases in the colon, pancreas, and duodenum, respectively 12-168 months (median time 156 months) following primary tumor resection. The patient with metastatic RCC in colon presented with abdominal pain and constipation. An ulcerated mass was found on colonoscopy 30 cm from the anal verge. Diagnosis of RCC with rhabdoid features was confirmed in both primary and metastatic tumors. The second patient developed a metastatic nodule in the head of pancreatic while the third patient developed metastatic nodules in the duodenum and pancreas which were detected by Computed Tomography (CT) scanning. Histopathological examination confirmed the presence of clear cell RCC in the metastatic nodules in both cases.

CONCLUSION

Metastatic RCC should be considered in the differential diagnosis of mass in the gastrointestinal (including pancreaticobiliary) tract especially in presence of a past history of RCC. These patients should be screened thoroughly by physical examination and appropriate imaging studies.

Inhibition of KIF20A by transcription factor IRF6 affects the progression of renal clear cell carcinoma

BACKGROUND

Renal clear cell carcinoma (ccRCC) is one of the most common malignant tumors, whose incidence is increasing year by year. IRF6 plays an important role in the occurrence of tumors, although there is yet no report on its expression in ccRCC.

METHODS

The expression of IRF6 and KIF20A in ccRCC was predicted by GEPIA and HAP databases. In addition, GEPIA database predicted the relationship between IRF6 and KIF20A expressions and the pathological staging, overall survival, and disease-free survival of ccRCC. The possible binding sites of IRF6 and KIF20A promoters were predicted by JASPAR database and verified by luciferase and ChIP assays. The specific effects of IRF6 on ccRCC cell proliferation, invasion and apoptosis were subsequently examined at both cellular level and animal level.

RESULTS

The database predicted down-regulated IRF6 expression in renal carcinoma tissues and its correlation with poor prognosis. IRF6 overexpression inhibited cRCC cell proliferation, invasion and migration. In addition, up-regulated KIF20A expression in renal carcinoma tissues and its association with prognosis were also predicted. Interference with KIF20A inhibited the proliferation, invasion, and migration of ccRCC cells. Finally, we confirmed that KIF20A is a functional target of IRF6 and can partially reverse the effects of IRF6 on the proliferation, invasion and migration of ccRCC cells.

CONCLUSION

Inhibition of KIF20A by transcription factor IRF6 affects cell proliferation, invasion and migration in renal clear cell carcinoma.

Pancreatic Metastasis of Renal Cell Carcinoma: A Surgical Indication for a Disseminated Disease

Pancreatic metastasis (PM) of renal cancer is a rare condition. It is characterized by a long period after initial nephrectomy and a favorable prognosis compared to other pancreatic malignancies. Its diagnosis may confuse clinicians if the medical history is not known. In the era of targeted therapies for metastatic renal carcinoma, surgery stands as the best treatment option for PM of renal cancer. We report the case of a woman who underwent successfully left splenopancreatectomy for corporeal PM of renal cancer treated seven years ago. This case underlines the necessity of long-term follow-up of patients treated for kidney cancer.

Metastatic renal cell carcinoma involving colon with unusual histologic features and diagnostic challenges: A case report

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Metastatic RCC in the colon, although very rare, should be kept in the differential diagnosis of patients with lower GI bleeding, particularly patients with a prior history of kidney mass or nephrectomy

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Most common type of primary or metastatic RCC is Clear-cell-type.

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We reported the first case of rhabdoid-RCC metastasizing to colon.

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In the absence of IHC-stains, rhabdoid-RCC may be misdiagnosed as soft-tissue-sarcoma or other poorly differentiated carcinomas.

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Our case exclusively occurred in a woman while colonic metastasis of RCC commonly occurring in males.

Introduction and importance

Renal cell carcinoma (RCC) accounts for 3% of all malignancies in adults, on its own being the 3rd most common urologic malignancy. Commonly RCC metastasizes to lung, bone, liver, brain but rarely to colorectum. Here we present the metastasis of RCC to colon with unusual histologic features.

Case presentation

A 40-year-old woman presented with abdominal pain and constipation. Colonoscopy showed an ulcerative mass 30 cm from anal verge. Subsequently, she underwent abdominoperineal resection of the involved portion of colon and the biopsy was sent to us for histopathological analysis. Grossly, it was a large fungating mass. Microscopic examination revealed a malignant neoplasm with polygonal cells, abundant eosinophilic cytoplasm, eccentric nuclei and prominent nucleoli. Immunohistochemistry confirmed the diagnosis of RCC.

Clinical discussion

Colon rarely infiltrated by metastasis from RCC and so far, around 25 of such cases have been reported in the literature. Most common metastatic type of RCC to gastrointestinal tract is clear cell type. In our patient, the type of the metastatic RCC to colon was RCC with rhabdoid features. RCC with rhabdoid features is rare (3–5% of all RCC), but it is highly aggressive with higher chance of metastasis, extra renal invasion and poorer prognosis.

Conclusion

RCC should be considered as one of the differential diagnosis of colorectal cancers. Appropriate immunohistochemical workup would then reveal the correct diagnosis.

A Novel mRNA-miRNA Regulatory Sub-Network Associated With Prognosis of Metastatic Clear Cell Renal Cell Carcinoma

Background

Clear cell renal cell carcinoma (ccRCC) is a urinary disease with high incidence. The high incidence of metastasis is the leading cause of death in patients with ccRCC. This study was aimed to identify the gene signatures during the metastasis of ccRCC.

Methods

Two datasets, including one gene expression profile dataset and one microRNA (miRNA) expression profile dataset, were downloaded from Gene Expression Omnibus (GEO) database. The integrated bioinformatics analysis was performed using the (limma) R package, miRWalk, DAVID, STRING, Kaplan-Meier plotter databases. Quantitative real-time polymerase chain reaction (qPCR) was conducted to validate the expression of differentially expressed genes (DEGs) and DE-miRNAs.

Results

In total, 84 DEGs (68 up-regulated and 16 down-regulated) and 41 DE-miRNAs (24 up-regulated and 17 down-regulated) were screened from GSE22541 and GSE37989 datasets, respectively. Furthermore, 11 hub genes and 3 key miRNAs were identified from the PPI network, including FBLN1, THBS2, SCGB1A1, NKX2-1, COL11A1, DCN, LUM, COL1A1, COL6A3, SFTPC, SFTPB, miR-328, miR-502, and miR-504. The qPCR data showed that most of the selected genes and miRNAs were consistent with that in our integrated analysis. A novel mRNA-miRNA network, SFTPB-miR-328-miR-502-miR-504-NKX2-1 was found in metastatic ccRCC after the combination of data from expression, survival analysis, and experiment validation.

Conclusion

In conclusion, key candidate genes and miRNAs were identified and a novel mRNA-miRNA network was constructed in ccRCC metastasis using integrated bioinformatics analysis and qPCR validation, which might be utilized as diagnostic biomarkers and molecular targets of metastatic ccRCC.

Prognostic and predictive factors to nivolumab in patients with metastatic renal cell carcinoma: a single center study

Renal cell carcinoma (RCC) scenario has radically changed with the advent of immunotherapy; in this setting, the identification of predictive and prognostic factors represents an urgent clinical need to evaluate which patients are the best candidate for an immunotherapy approach. The aim of our study was to analyze the association between nivolumab in pretreated patients with metastatic RCC and clinicopathological features, metastatic sites, and clinical outcomes. A total of 37 patients treated between January 2017 and April 2020 in our institution were retrospectively evaluated. All patients received nivolumab as second- or later-line of therapy after progression on previous tyrosine kinase inhibitors. The primary outcomes were overall survival (OS) from immunotherapy start and OS from first-line start. Univariate analysis was performed through the log-rank test and a Cox regression proportional hazards model was employed in multivariable analysis. Of the 12 variables analyzed, 4 were significantly associated with prognoses at multivariate analysis. Cox proportional hazard ratio models confirmed that International Metastatic Renal-Cell Carcinoma Database Consortium (IMDC) risk group, liver metastases at diagnosis, and central nervous system (CNS) metastases at diagnosis were associated with worse OS with an estimated hazard ratio of 4.76 [95% confidence interval (CI), 2.05-19.8] for liver metastases and 2.27 (95% CI, 1.13-28.9) for CNS metastases. Pancreatic metastases at diagnosis were correlated to a better prognosis with an estimated hazard ratio of 0.15 (95% CI, 0.02-0.38). IMDC risk group, liver metastases at diagnosis, and CNS metastases at diagnosis may identify a population of patients treated with immunotherapy in second- or later-line associated with worse prognosis.

Long intergenic non-coding RNA 1939 eliminates proliferation and migration of human renal cell carcinoma (RCC) cells by down-regulation of miR-154

Renal carcinoma (RCC) is widely accepted as a malignant tumour of urinary system. Long intergenic non-coding RNA 1939 (LINC01939) is a novel lncRNA which was found to be down-regulated in RCC. Thus, we set out to explore the effect and regulation mechanism of LINC01939 in RCC. LINC01939 and miR-154 in RCC tissues and cell lines were detected using qRT-PCR assay. To examine cellular viability of ACHN and CAKI-1 cells, cell counting kit-8 (CCK-8) assay was exploited here. Flow cytometric analysis was conducted to examine apoptosis. Cell mobility was valued through wound healing assays. Western blotting was applied for examination of proteins related to proliferation, apoptosis, migration and Wnt/β-catenin/Notch. LINC01939 was down-regulated in RCC tissues. LINC01939 overexpression impeded proliferation and migration, and induced apoptosis. Further study found that the overexpression of LINC01939 strongly suppressed miR-154 expression. Then, the inhibiting effect of overexpressed LINC01939 on proliferation and mobility and the promoting role of LINC01939 in apoptosis were abolished by the combination of miR-154 mimic. Finally, we found that overexpressed LINC01939 inactivated Wnt/β-catenin and Notch through suppressing miR-154. Up-regulation of LINC01939 inhibited proliferation and migration of RCC cells by down-regulating miR-154.

Solid Tumor Metastases to the Pancreas Diagnosed Using Fine-Needle Aspiration

OBJECTIVES

Solid tumor metastases to the pancreas are rare, and only limited literature on the topic is available. In this retrospective study, we reviewed 107 cases of solid tumor metastases to the pancreas diagnosed by fine-needle aspiration (FNA) from 2005 to 2019.

METHODS

Information including the patients' clinical histories, radiologic and pathologic findings, treatments, and follow-up were collected.

RESULTS

The mean age of the patients was 62.4 years. The mean tumor size was 2.64 cm with even distribution throughout the pancreas (head, neck and body, and tail). The most common primary site was the kidney, followed by the lung, skin, and breast and the gynecologic, gastrointestinal, and genitourinary tracts. The most common tumor type was carcinoma, followed by melanoma and sarcoma. In comparison to patients with nonkidney primary cancers, those with primary renal cell carcinoma had a longer median interval between primary diagnosis and metastasis (8.5 vs 4.0 years; P < .01), less often had metastasis outside the pancreas (38% vs 74%; P < .01), and had a significantly longer 5-year survival rate (65.7% vs 24.8%; P < .01).

CONCLUSIONS

FNA plays a crucial role in diagnosing metastases to the pancreas. Metastases originating from kidney and nonkidney primary tumors have distinct clinicopathologic features and prognoses.

Diagnosis and Treatment of Metastatic Disease to the Pancreas

Introduction: Metastatic disease to the pancreas is a rare entity from all malignant pancreatic masses. Its diagnosis is very challenging, but with the introduction of endoscopic ultrasound (EUS)-fine needle aspiration (FNA), now there is a feasible way to make an accurate histopathological and definitive diagnosis. Materials and Methods: This is a retrospective review of 11 patients with metastasis to the pancreas diagnosed with EUS-FNA in a tertiary referral center over a period of 3 years. We describe our institutional experience in diagnosing metastatic disease to the pancreas through EUS-FNA. Results: Between January 2015 and June 2018, 115 patients were diagnosed with pancreatic malignancy by EUS-FNA and only 11 (10%) with metastatic disease to the pancreas. Most common primary malignancy was renal cell carcinoma, followed by colon carcinoma, squamous/small cell carcinoma of the lung, and urothelial carcinoma. Five of 11 patients presented as a solitary pancreatic mass on initial imaging without any evidence of primary or metastatic disease elsewhere. Conclusions: In our experience, metastatic disease to the pancreas can represent up to 10% of solid pancreatic masses, which is lower compared to the reported incidence in previous literature. Our findings reveal that early identification and diagnosis help patient management and limit surgical morbidity and mortality.

Pancreas Solid Tumors

Solid tumors of the pancreas encompass a variety of diagnoses with treatments ranging from observation to major abdominal surgery. Pancreatic ductal adenocarcinoma remains one of the most common and most lethal of these differential of diagnoses and requires a multimodality approach through a multidisciplinary team of specialists. This article reviews the classification, clinical presentation, and workup in differentiating solid tumors of the pancreas and serves as an additional tool for general surgeons faced with such a clinical finding, from a surgical oncology perspective.

Pancreatic tropism of metastatic renal cell carcinoma

Renal cell carcinoma (RCC) is characterized by a particularly broad metastatic swath, and, enigmatically, when the pancreas is a destination, the disease is associated with improved survival. Intrigued by this observation, we sought to characterize the clinical behavior, therapeutic implications, and underlying biology. While pancreatic metastases (PM) are infrequent, we identified 31 patients across 2 institutional cohorts and show that improved survival is independent of established prognostic variables, that these tumors are exquisitely sensitive to antiangiogenic agents and resistant to immune checkpoint inhibitors (ICIs), and that they are characterized by a distinctive biology. Primary tumors of patients with PM exhibited frequent PBRM1 mutations, 3p loss, and 5q amplification, along with a lower frequency of aggressive features such as BAP1 mutations and loss of 9p, 14q, and 4q. Gene expression analyses revealed constrained evolution with remarkable uniformity, reduced effector T cell gene signatures, and increased angiogenesis. Similar findings were observed histopathologically. Thus, RCC metastatic to the pancreas is characterized by indolent biology, heightened angiogenesis, and an uninflamed stroma, likely underlying its good prognosis, sensitivity to antiangiogenic therapies, and refractoriness to ICI. These data suggest that metastatic organotropism may be an indicator of a particular biology with prognostic and treatment implications for patients.

Solitary Colorectal Cancer Metastasis to the Pancreas

Introduction

Secondary pancreatic metastasis from other solid organ malignancy is rare and accounts for less than 2% of all pancreatic tumors. The aim of this study is to highlight that colorectal metastatic disease in the pancreas could be in selected cases an indication for surgery rather than for palliative chemotherapy.

Case Presentation

We present a case of a 62-year-old Caucasian female with a history of rectal adenocarcinoma. Four years ago, the patient underwent low anterior resection of the rectosigmoid, post neoadjuvant chemoradiotherapy, with adjuvant chemotherapy. During her follow-up, imaging examinations revealed a lesion in the pancreatic neck with features indicating primary pancreatic cancer. Near-total distal pancreatectomy with en bloc splenectomy was performed. Histopathology revealed metastatic disease compatible with colorectal adenocarcinoma as the primary cancer. Second-line chemotherapy was decided from the institutional tumor board. The patient remains disease free one year later.

Conclusion

Pancreatic lesions in patients with a history of extrapancreatic malignancy should raise suspicions of metastatic disease. Surgical intervention is a legitimate treatment option for these pancreatic lesions, since they represent solitary disease deposits and of course in the context of multidisciplinary meeting decisions, and after proper and extensive staging investigations.

Evaluation of metastases to the pancreas with fine needle aspiration: A case series from a single centre with review of the literature

OBJECTIVE

Fine needle aspiration (FNA) is a minimally invasive albeit highly effective modality used to detect solid and cystic pancreatic lesions. This manuscript aims to present our experience in diagnosing metastases to the pancreas and highlight the importance of immunocytochemistry in the diagnostic process. It also aims to provide a brief review of the literature on this topic.

METHODS

We retrospectively searched our archives for cases of metastatic deposits to the pancreas diagnosed with FNA over a 5-year period. We also reviewed the literature for such cases.

RESULTS

We describe seven cases from our archives that metastasised to the pancreas. Three of them (43%) represented metastatic renal cell carcinoma while the rest four comprised deposits from a lung adenocarcinoma, a colon adenocarcinoma, an adrenal leiomyosarcoma, and a small cell carcinoma of the urinary bladder, respectively. History of primary malignancy was available for all seven patients. All diagnoses were confirmed with the use of immunostains. In our literature review, similar to our case series, renal cell carcinoma was the most common metastasis to the pancreas managed with FNA (around one out of three patients; 35%). Of interest, our endoscopic ultrasound-FNA case of pancreatic metastasis from urinary bladder small cell carcinoma is the first reported.

CONCLUSIONS

As metastases to the pancreas are commonly accompanied by diverse prognostic signatures and management strategies compared to primary pancreatic malignancies, their accurate identification is imperative. Pancreatic FNA is a diagnostic modality that can confirm or exclude metastasis to the organ, especially when immunocytochemistry is applied.

Improving IMDC Prognostic Prediction Through Evaluation of Initial Site of Metastasis in Patients With Metastatic Renal Cell Carcinoma

BACKGROUND

Several models are adopted in clinical practice to estimate prognosis of patients with metastatic renal cell carcinoma (mRCC); however, none of these models have evaluated patients treated by immune-checkpoint inhibitors. The aim of this study was to investigate if the site of initial metastasis could be a parameter able to stratified prognosis among patients with mRCC among different risk groups defined by the International Metastatic Renal Cell Database Consortium (IMDC) model. The site of initial metastasis was defined as the primary tissue or organ in which metastasis was diagnosed in the course of the medical history of the disease.

PATIENTS AND METHODS

A total of 134 patients treated between January 2010 and December 2018 in our institution were retrospectively evaluated. The primary outcome was overall survival (OS) defined as the time from initiation of first-line therapy to death from any cause. Of note, 26 (19.4%) patients received immune-checkpoint inhibitors. Univariable analysis was performed through the log-rank test to estimate the effect of number of metastatic sites and site of initial metastasis on OS. Subsequently, a Cox regression proportional hazards model was employed in multivariable analysis.

RESULTS

Of the 12 variables analyzed, 4 were statistically associated to worse OS in univariable analysis (number of metastases and liver, bone, or central nervous system metastases). Multivariate analysis confirmed that bone (hazard ratio [HR], 1.92; 95% confidence interval [CI], 1.17-3.13), liver (HR, 2.65; 95% CI, 1.59-4.42), and central nervous system (HR, 3.3; 95% CI, 1.62-6.74) initial metastases were independent parameters related to worse OS. The presence of 1 or more of the selected sites recognized specific populations of patients associated to worse prognosis in both good (P = .003) and intermediate (P = .047) risk groups.

CONCLUSION

The site of initial metastasis defines specific populations of patients associated with worse prognosis in the good and intermediate IMDC groups.

Intrapancreatic accessory spleen mimicking malignant tumor: three case reports

Intrapancreatic hypervascular lesions may represent metastases, neuroendocrine tumors, or intrapancreatic accessory spleens. The benign intrapancreatic accessory spleen can be difficult to separate from a malignant neuroendocrine tumor or metastasis. We report three cases of pancreatic lesions that underwent pancreatic surgery due to suspicion of malignancy on imaging; all cases were histologically intrapancreatic accessory spleens. Our cases point to the importance of performing single-photon emission computed tomography with heat-damaged Tc-99m-pertechnetate labelled erythrocytes to identify splenic tissue, even though small lesions can show a false-negative result.

Renal cell carcinoma staging: pitfalls, challenges, and updates

Renal cell carcinoma (RCC) is unusual among cancers in that it often grows as a spherical, well-circumscribed mass. Increasing tumour size influences the pathological pT stage category within pT1 and pT2, with cutoffs of 40, 70 and 100 mm; however, with increasing size also comes a sharp increase in the likelihood of renal sinus or renal vein tributary invasion, such that clear cell RCC rarely reaches 70 mm without invading one of these. To clarify some previous challenges in assigning tumour stage, the American Joint Committee on Cancer 2016 tumor-node-metastasis classification has removed the requirements than vein invasion be recognised grossly and that vein walls contain muscle for the diagnosis of vein invasion. Renal pelvis invasion has also been added as an additional route to pT3a. Multinodularity or finger-like extensions from a renal mass should be viewed with great suspicion for the possibility of vein or renal sinus invasion, and, as tumour size increases to over 40-50 mm, thorough sampling of the renal sinus interface should always be undertaken. With increasing interest in adjuvant therapy in renal cancer, the pathologist's role in RCC staging will continue to be an important prognostic parameter and a tool for selection of patients for enrolment in clinical trials.

A Retrospective Analysis of Preoperative Evaluation and Surgical Resection for Metastatic Tumors of the Pancreas

Pancreatectomy might confer a survival benefit in patients with metastatic tumors of the pancreas (MTPs); however, the optimal treatment for MTP has not been established. We reviewed six patients with MTP undergoing pancreatectomy and discussed the clinical features, surgical treatment, and survival. The sites of primary cancer included renal cell carcinoma (RCC) (n = 5; 83.3%) and rectal cancer (n = 1; 16.7%). The median interval between the resection of the primary site and the development of MTP was 157 months (range, 16-180 months). Three (60.0%) of the five cases of MTP-originating RCC and a MTP-originating rectal cancer, biopsy was performed under endoscopic ultrasonography guidance and MTP was pathologically diagnosed. All patients with MTP originating from RCC have remained alive for 3, 13, 18, 18, and 113 months without recurrence after pancreatectomy. In contrast, the patient with MTP originating from rectal cancer developed multiple liver metastases at 7 months after pancreatectomy, and then underwent chemotherapy. A preoperative pathological diagnosis using biopsy under endoscopic ultrasonography guidance was indispensable for the treatment of MTP. Pancreatectomy for MTP conferred a survival benefit in patients with metastatic RCC, whereas a combination of pancreatectomy and chemotherapy might be necessary to improve the prognosis of patients with metastatic colorectal cancer.

Clear Cell Variant of Solid Pseudopapillary Neoplasm of the Pancreas: A Report of a Rare Variant and Review of the Literature

The clear cell variant of solid pseudopapillary neoplasm (ccSPN) of the pancreas was first described in 2006. In this article, we report a case of this rare variant and review the few published reports. Both the current and previous reports show that ccSPN has several morphologic differences from conventional SPN, including clear vacuoles, fewer pseudopapillary formations, more solid/diffuse architecture, less hemorrhage, and fewer cholesterol clefts. Some of these features peculiar to ccSPN, such as solid/diffuse architecture, have been proposed to suggest aggressive behavior, though reports of ccSPN are rare and often have limited clinical follow-up. ccSPN also appears to occur more frequently in males than conventional SPNs. These clinical and pathologic features lead to unique set of differential diagnostic considerations for ccSPN, including metastatic renal cell carcinoma, perivascular epithelial cell tumor, and clear cell variants of other carcinomas. These unique features, atypical differential, and uncertain prognostic ramifications all make ccSPN an important variant to be aware of and report.

CT diagnosis for metastasis of clear cell renal cell carcinoma to the pancreas: Three case reports

RATIONALE

Clear cell renal cell carcinoma (CCRCC) metastasis to pancreas is clinically rare. Misdiagnosis for these cases is frequently due to the low incidence, lack of specific clinical symptoms, and laboratory results.

PATIENT CONCERNS

Three female patients aged 47 years, 69 years, and 76 years, respectively, were admitted to hospital for routine examination after resection of clear cell carcinoma of kidney for 69 months, 57 months, and 123 months, respectively. All 3 cases had no specific clinical symptoms. Routine laboratory tests and common tumor markers including CEA, AFP, CA19-9, and CA125 showed no obvious abnormality.

DIAGNOSIS

All 3 cases were finally diagnosed with CCRCC metastasis to pancreas on the basis of CT and pathological findings. On unenhanced CT, foci of the pancreas showed single or multiple nodules or masses with mildly low or equal density and obscure boundary. On enhanced CT, the enhanced mode of foci was similar to CCRCC and showed "fast in fast out." The main body was confined in the pancreas. The peripheral structure was clear relatively. Obstruction of common bile duct, main pancreatic duct, and local infringement of foci cannot be seen. Additional metastases of right adrenal gland can be seen in one case.

INTERVENTIONS

All 3 cases underwent CT examination and surgical treatment, with complete removal of metastatic tumors.

OUTCOMES

All 3 cases underwent surgical treatment successfully, and recovered successfully after operation.

LESSONS

The manifestations of pancreatic metastases from CCRCC on CT show certain characteristics, which may be useful to assess the histological features of pancreatic metastases from CCRCC and facilitate the preoperative diagnosis.

Differentiation between pancreatic metastases from clear cell renal cell carcinoma and pancreatic neuroendocrine tumor using double-echo chemical shift imaging

PURPOSE

The purpose of the study was to retrospectively analyze whether double-echo gradient-echo (GRE) chemical shift imaging (CSI) can differentiate between pancreatic metastases from clear cell renal cell carcinoma (PM-ccRCC) and pancreatic neuroendocrine tumor (pNET).

METHODS

Institutional review board approval and informed consent were waived. CSI, T2WI, DWI, and DCE magnetic resonance imaging (MRI) were performed in patients with PM-ccRCC and pNET. Eleven patients with PM-ccRCC and 24 patients with pNET were enrolled into this retrospective study. The signal intensity was measured in the pancreatic tumor and spleen on in-phase and opposed-phase images. The signal intensity index (SII) and tumor-to-spleen ratio (TSR) in PM-ccRCC and pNET were calculated and compared. Receiver operating characteristic (ROC) analysis was performed to evaluate the diagnostic accuracy of SII and TSR in the differentiation between PM-ccRCC and pNET.

RESULTS

The SII between PM-ccRCC and pNET (20.3% ± 16.8% vs. - 3.2% ± 11.4%) was significantly different (P < 0.001), as was the TSR (- 19.2% ± 16.6% vs. 6.0% ± 13.8%) (P < 0.001). The area under the ROC curve was 0.917 for the SII and 0.902 for the TSR. Additionally, an SII threshold value of 8.1% permitted the differentiation of PM-ccRCC from pNET with a sensitivity of 90.9%, a specificity of 91.7%, a positive predictive value of 90.1%, a negative predictive value of 91.7%, and an accuracy of 91.4%. A TSR cut-off value of - 4.7% enabled the differentiation of the two groups with a sensitivity of 79.2%, a specificity of 90.9%, a positive predictive value of 90.9%, a negative predictive value of 79.2% and an accuracy of 82.9%.

CONCLUSION

Double-echo GRE chemical shift MR imaging can accurately differentiate between PM-ccRCC and pNET.

Pancreatic Cytology

The diagnostic approach to pancreaticobiliary disease requires a multidisciplinary team in which the cytopathologist plays a crucial role. Fine-needle aspiration, obtained by endoscopic ultrasound, is the diagnostic test of choice for pancreatic lesions. Preoperative clinical management depends on many factors, many of which rely on accurate cytologic assessment. Pancreaticobiliary cytology is wrought with diagnostic pitfalls. Clinical history, imaging studies, cytology samples, and ancillary tests, including immunohistochemistry, biochemical analysis, and genetic sequencing, are integral to forming a complete diagnosis and guiding optimal patient management. This article reviews clinical aspects and the diagnostic work-up of commonly encountered diagnostic entities within the field of pancreatic cytology.

Apiaceous Vegetables and Cruciferous Phytochemicals Reduced PhIP-DNA Adducts in Prostate but Not in Pancreas of Wistar Rats

We previously showed rats fed with apiaceous vegetables, but not with their putative chemopreventive phytochemicals, reduced colonic DNA adducts formed by 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP), a dietary procarcinogen. We report here the effects of feeding apiaceous and cruciferous vegetables versus their purified predominant phytochemicals, either alone or combined, on prostate and pancreatic PhIP-DNA adduct formation. In experiment I, male Wistar rats received three supplemented diets: CRU (cruciferous vegetables), API (apiaceous vegetables), and CRU+API (both types of vegetables). In experiment II, rats received three diets supplemented with phytochemicals matched to their levels in the vegetables from experiment I: P + I (phenethyl isothiocyanate and indole-3-carbinol), FC (furanocoumarins; 5-methoxypsoralen, 8-methoxypsoralen, and isopimpinellin), and COMBO (P + I and FC combined). After 6 days of feeding, PhIP was injected (10 mg/kg body weight) and animals were killed on day 7. PhIP-DNA adducts were analyzed by LC-MS/MS. In prostate, PhIP-DNA adducts were reduced by API (33%, P < .05), P + I (45%, P < .001), and COMBO (30%, P < .01). There were no effects observed in pancreas. Our results suggest that fresh vegetables and purified phytochemicals lower PhIP-DNA adducts and may influence cancer risk.

Nonepithelial Neoplasms of the Pancreas, Part 2: Malignant Tumors and Tumors of Uncertain Malignant Potential From the Radiologic Pathology Archives

Almost all neoplasms of the pancreas are derived from pancreatic epithelial components, including the most common pancreatic mass, primary pancreatic ductal adenocarcinoma (PDAC). Nonepithelial neoplasms comprise only 1%-2% of all pancreatic neoplasms. Although some may arise directly from intrapancreatic elements, many originate from mesenchymal, hematopoietic, or neural elements in the retroperitoneal peripancreatic space and grow into the pancreas. Once these tumors reach a certain size, it can be challenging to identify their origin. Because these manifest at imaging as intrapancreatic masses, awareness of the existence and characteristic features of these nonepithelial neoplasms is crucial for the practicing radiologist in differentiating these tumors from primary epithelial pancreatic tumors, an important distinction given the vastly different management and prognosis. In part 1 of this article, the authors reviewed benign nonepithelial neoplasms of the pancreas. This article focuses on malignant nonepithelial neoplasms and those of uncertain malignant potential that can be seen in the pancreas. The most common malignant or potentially malignant nonepithelial pancreatic tumors are of mesenchymal origin and include soft-tissue sarcomas, solitary fibrous tumor, and inflammatory myofibroblastic tumor. These tumors commonly manifest as large heterogeneous masses, often containing areas of necrosis and hemorrhage. The clinical features associated with these tumors and the imaging characteristics including enhancement patterns and the presence of fat or calcification help distinguish these tumors from PDAC. Hematopoietic tumors, including lymphoma and extramedullary plasmacytoma, can manifest as isolated pancreatic involvement or secondarily involve the pancreas as widespread disease. Hyperenhancing paragangliomas or hypervascular metastatic disease can mimic primary pancreatic neuroendocrine tumors or vascular anomalies.

Two unusual variants of pancreatic neuroendocrine tumor and their potential pitfalls on fine-needle aspiration cytology

Endoscopic ultrasound-guided fine-needle aspiration is increasingly utilized for the diagnosis of pancreatic lesions. Although operator dependent, the procedure has good overall performance characteristics and is minimally invasive; however, accuracy and sensitivity are reportedly lower for pancreatic neuroendocrine tumor (PanNET) compared with the more common pancreatic ductal adenocarcinoma (pACA). The underperformance is further exacerbated by the unusual cases of PanNET presenting with variant cytomorphology. We report two separate diagnostically challenging cases: a pigmented PanNET and a clear cell PanNET. We briefly review the literature and emphasize the importance of recognizing these uncommon variants when encountered in aspirate material. Diagn. Cytopathol. 2017;45:371-378. © 2016 Wiley Periodicals, Inc.