Bogut, Ante

Dragišić, Vedran

Karin, Maja

Klupke Sarić, Inge

Kordić, Marko

Mišković, Josip

Šutalo, Nikica

English

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 97 Psychiatria Danubina, 2021; Vol. 33, Suppl. 10, pp S97-98 Medicina Academica Mostariensia, 2021; Vol. 9, No. 1, pp 97-98 Case report nska naklada - Zagreb, Croatia DUODENAL METASTASIS OF CLEAR CELL RENAL CARCINOMA PRESENTING WITH GASTROINTESTINAL BLEEDING 1, 1, 1, 1, 2,  Ante Bogut3 & Maja Karin3 1Department of Surgery, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina 2Department of Neurology, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina 3Department of Internal Medicine, University Clinical Hospital Mostar, Mostar, Bosnia and Herzegovina received: 18.3.2021; revised: 20.5.2021; accepted: 14.6.2021 *  *  *  *  *  INTRODUCTION Clear cell renal carcinoma accounts for approxi-mately 75% of all renal cancer diagnosis. It commonly metastasizes haematogenously to the lungs, liver and bones (Chevrier et al 2017). Gastrointestinal metastases of clear cell renal carcinoma are a rare presentation of the disease. Here we present an unusual case of duo-denal metastasis of clear cell renal carcinoma.  CASE REPORT A 60 year old male patient was admitted with anemia and gastrointestinal bleeding presenting with melena and vomiting. His medical history included radical nephrectomy of the right kidney 10 years prior due to renal carcinoma with postoperative chemo-therapy. Abdominal and pelvic CT scan done 6 years after the operation showed no recurrence of the disease and no abdominal or pelvic metastasis.  Endoscopy showed a large submucose mass of the duodenal bulb, almost entirely obliterating the duodenal lumen, with a bleeding ulcer of the mucosa. MSCT scan of the abdomen revealed a partially necrotic tumor, situated in the submucosa of the duodenal bulb and the descending part of the duodenum. The tumor measured 5x4 cm in the transversal plane and expanded into the retroperitoneal space where it compressed the inferior vena cava. The MSCT scan also showed a distended stomach and no evident liver metastasis.  During surgery a tumor of the duodenal submucasa with infiltration of the retroperitoneal space and inferior vena cava was confirmed. The tumor was deemed in-operable but maximal reduction of the tumor was carr-ied out. A duodenotomy and tumor reduction was pre-formed after which a gastro-jejunal and jeujuno-jejunal anastmosis was created. The immediate postoperative recovery was uneventful. After recovery the patient was referred to an oncologist. The patient died 6 months after the surgery due to a pulmonary embolism.   DISCUSSION  Gastrointestinal metastases of clear cell renal carci-noma are exceedingly rare. A handful of cases have been published. A single centre review published in 2021 sho-wed that 1.6% of patients with metastatic clear cell carci-noma had gastrointestinal metastases (Maelle et al. 2021). Of all the metastases of clear cell renal carcinoma to the gastrointestinal tract duodenal metastasis are the rarest and rearly reported in literature (Short et al 1993).    Figure 1. Sample slices of a CT image with arrows indicating tumor mass , , lo, , Inge Klup , Ante Bogut & Maja Karin: DUODENAL METASTASIS  OF CLEAR CELL RENAL CARCINOMA PRESENTING WITH GASTROINTESTINAL BLEEDING Medicina Academica Mostariensia, 2021; Vol. 9, No. 1, pp 97-98   98 In the cases reported in literature one of the common presenting symptoms is jaundice due to the obstruction of the major duodenal papilla. The patient presented in this case report did not have papillary involvement, but due to the size of the tumor symptoms manifested with a bleeding ulceration of the duodenal mucosa, melena and vomiting. It is worth noting that renal cell carcinoma is characterized by late recurrence and late gastrointestinal metastases have been described (Saito et al. 2018). Lite-rature findings suggest an individual approach to soli-tary gastrointestinal metastasis management. Endoscopic haemostasis is usually difficult to perform and endo-vascular embolization of tumor supplying artery should be considered in patient with poor general condition (Farrokh et al. 2019.). Surgical management depends on the general condition of the patient. As shown in the case reported here radical excision of metastasis is often impossible but findings suggest any type of metasta-sectomy increases the survival of the patient (Omrani-pour et al. 2017). The cause of death of the patient presented in this paper is pulmonary embolism due to tumor infiltration of inferior vena cava.   CONCLUSION The case presented here and earlier cases publish suggest that there is no upper time limit for occurrence of distant metastasis of clear cell renal carcinoma after surgery Gastrointestinal metastases after surgery for clear cell renal carcinoma should be considered as the pos-sible cause of gastrointestinal bleeding in all patients with history of renal cell carcinoma.   Acknowledgements: None. Conflict of interest: None to declare. Contribution of individual authors: All authors reviewed and discussed the manuscript draft and contributed to the final manuscript and all authors give final approval of the version to be submitted.  References 1. Chevrier S, Levine JH, Zanotelli VRT, et al.: An Immune Atlas of Clear Cell Renal Cell Carcinoma. Cell 2017; 169:736-749.e18. doi:10.1016/j.cell.2017.04.016 2. Farrokh D, Rad MP, Mortazavi R, Akhavan R, Abbasi B: Local recurrence of renal cell carcinoma presented with massive gastrointestinal bleeding: management with renal artery embolization. CVIR Endovasc. 2019; 2:10. Publi-shed 2019 Mar 15. doi:10.1186/s42155-019-0054-4 3. Maelle R, Jean-Philippe R, Jochen W, et al.: Gastrointes-tinal Metastases From Primary Renal Cell Cancer: A Single Center Review. Front Oncol 2021; 11:644301. Published 2021 Mar 23. doi:10.3389/fonc.2021.644301  4. Omranipour R, Mahmoud Zadeh H, Ensani F, Yadegari S, Miri SR: Duodenal Metastases From Renal Cell Carci-noma Presented With Melena: Review and Case Report. Iran J Pathol 2017; 12:272-276 5. Saito M, Senjo H, Kanaya M, et al.: Late duodenal meta-stasis from renal cell carcinoma with newly developed malignant lymphoma: A case report. Mol Clin Oncol 2018; 8:549-552. doi:10.3892/mco.2018.1563 6. Short TP, Thomas E, Joshi PN, Martin A, Mullins R: Occult gastrointestinal bleeding in renal cell carcinoma: value of endoscopic evaluation. Am J Gastroenterol 1993; 88:300-2. PMID:8424439  Correspondence:  Department of Surgery, University Clinical Hospital Mostar Bijeli brijeg b.b, 88 000 Mostar, Bosnia and Herzegovina E-mail: markokordic007@gmail.com 

DUODENAL METASTASIS OF CLEAR CELL RENAL CARCINOMA PRESENTING WITH GASTROINTESTINAL BLEEDING

DUODENAL METASTASIS OF CLEAR CELL RENAL CARCINOMA PRESENTING WITH GASTROINTESTINAL BLEEDING

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