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Late pancreatic metastases from renal cell carcinoma
240
Letters to the editors
Late pancreatic metastases from renal cell carcinoma To the Editors: We read with interest the brief clinical report by Dousset et al. (SURGERY1995;117:591-4). Renal cell carcinoma (RCC) is well known for its rather unusual biologic behavior. Long dormancy is one of its notable features. Late recurrence has been arbitrarily defined as that occurring 10 years or more after nephrectomy, which is not the case with the patient of Dousset et al. Eleven percent of patients surviving more than 10 years after nephrectomy for RCC have late recurrence. 1 Most frequent sites are the lungs, lymph nodes, bones, and liver. However, metastatic RCC also occurs in a great variety of rare sites up to 31 years after nephrectomy.2 The pancreas is such a rare site. Three percent of patients treated for RCC may have pancreatic metastases during their life.3 Gastrointestinal bleeding from the papilla is one of the main complaints of these patients with weight loss and diarrhea. 4 The pancreatic metastases usually appear on ultrasonogram as single or multiple hypoechoic masses. They are hypervascular in computed tomography (CT) scanning after intravenous injection. Cytologic examination by means of percutaneous fine-needle aspiration may contribute to correct diagnosis, but the specimens are usually very hemorrhagic. One of the clues to diagnosis may be to review previous clinical history and pathologic material in patients who previously had a nonpancreatic malignancy and later a pancreatic tumor developed. Dousset et al. stated that differentiation from a primary pancreatic tumor is important because of a satisfactory life expectancy after surgical excision. Our recent experience with a patient with multiple late pancreatic metastases from a RCC strongly supports this recommendation. A 54-year-old female patient underwent a right-sided nephrectomy for RCC in 1979. In September 1992 ultrasonogram revealed four hypoechoic masses in the pancreas (three in the tail and one in the head). A C T scan With intravenous bolus injection confirmed the four lesions and revealed they
Surgery February 1996
were hypervascular. Fine-needle aspiration of one of the lesions was performed, but specimens were too hemorrhagic with insufficient cells for a definite cytologic diagnosis. Extensive metastatic work-up including bone scan and chest and brain CT scans disclosed no evidence of extrapancreatic disease. The patient underwent a splenopancreatectomy and enucleation of the lesion of the head of the pancreas. O n pathologic examination the four lesions proved to be pancreatic metastasis of a RCC. The postoperative course was uneventful, and the patient was discharged h o m e at day 10. Twenty-one months later she had an isolated forearm mass that was resected and proved to be an intramuscular RCC metastasis. The patient was alive 33 months after pancreas operation without evidence of recurrent disease. O u r clinical case and the one from Dousset et al. emphasize the n e e d for long-term follow-up of patients from whom a primary RCC has been removed. In this situation endoscopic ultrasonography may hold an important place for early diagnosis.
Michel Rivoire, MD E. J. Voiglio, MD Department of Surgery Lyon CancerInstitute 28 Rue Lagnnec 69373 Lyon Cedex 08, France References 1. McNichols DW, Segura JW, De Weerd JH. Renal cell carcinoma in long term survival and late recurrence.J Urol 1981;126:17-23. 2. Kradjian RM, BenningtonJL. Renal cell carcinoma recurrent 31 years after nephrectomy. Arch Surg 1965;90:192-5. 3. Klugo RC, Detmers M, Stiles RE, Talley RW, CernyJC. Aggressive venus conservative management of stage 1Vrenal cell carcinoma. J Urol 1977;118:244-6. 4. Strijk SP. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointest Radiol 1989;14:1236.
11/59/69918
Letters to the editors
Late pancreatic metastases from renal cell carcinoma To the Editors: We read with interest the brief clinical report by Dousset et al. (SURGERY1995;117:591-4). Renal cell carcinoma (RCC) is well known for its rather unusual biologic behavior. Long dormancy is one of its notable features. Late recurrence has been arbitrarily defined as that occurring 10 years or more after nephrectomy, which is not the case with the patient of Dousset et al. Eleven percent of patients surviving more than 10 years after nephrectomy for RCC have late recurrence. 1 Most frequent sites are the lungs, lymph nodes, bones, and liver. However, metastatic RCC also occurs in a great variety of rare sites up to 31 years after nephrectomy.2 The pancreas is such a rare site. Three percent of patients treated for RCC may have pancreatic metastases during their life.3 Gastrointestinal bleeding from the papilla is one of the main complaints of these patients with weight loss and diarrhea. 4 The pancreatic metastases usually appear on ultrasonogram as single or multiple hypoechoic masses. They are hypervascular in computed tomography (CT) scanning after intravenous injection. Cytologic examination by means of percutaneous fine-needle aspiration may contribute to correct diagnosis, but the specimens are usually very hemorrhagic. One of the clues to diagnosis may be to review previous clinical history and pathologic material in patients who previously had a nonpancreatic malignancy and later a pancreatic tumor developed. Dousset et al. stated that differentiation from a primary pancreatic tumor is important because of a satisfactory life expectancy after surgical excision. Our recent experience with a patient with multiple late pancreatic metastases from a RCC strongly supports this recommendation. A 54-year-old female patient underwent a right-sided nephrectomy for RCC in 1979. In September 1992 ultrasonogram revealed four hypoechoic masses in the pancreas (three in the tail and one in the head). A C T scan With intravenous bolus injection confirmed the four lesions and revealed they
Surgery February 1996
were hypervascular. Fine-needle aspiration of one of the lesions was performed, but specimens were too hemorrhagic with insufficient cells for a definite cytologic diagnosis. Extensive metastatic work-up including bone scan and chest and brain CT scans disclosed no evidence of extrapancreatic disease. The patient underwent a splenopancreatectomy and enucleation of the lesion of the head of the pancreas. O n pathologic examination the four lesions proved to be pancreatic metastasis of a RCC. The postoperative course was uneventful, and the patient was discharged h o m e at day 10. Twenty-one months later she had an isolated forearm mass that was resected and proved to be an intramuscular RCC metastasis. The patient was alive 33 months after pancreas operation without evidence of recurrent disease. O u r clinical case and the one from Dousset et al. emphasize the n e e d for long-term follow-up of patients from whom a primary RCC has been removed. In this situation endoscopic ultrasonography may hold an important place for early diagnosis.
Michel Rivoire, MD E. J. Voiglio, MD Department of Surgery Lyon CancerInstitute 28 Rue Lagnnec 69373 Lyon Cedex 08, France References 1. McNichols DW, Segura JW, De Weerd JH. Renal cell carcinoma in long term survival and late recurrence.J Urol 1981;126:17-23. 2. Kradjian RM, BenningtonJL. Renal cell carcinoma recurrent 31 years after nephrectomy. Arch Surg 1965;90:192-5. 3. Klugo RC, Detmers M, Stiles RE, Talley RW, CernyJC. Aggressive venus conservative management of stage 1Vrenal cell carcinoma. J Urol 1977;118:244-6. 4. Strijk SP. Pancreatic metastases of renal cell carcinoma: report of two cases. Gastrointest Radiol 1989;14:1236.
11/59/69918