BACKGROUND: Pancreatic metastases from previously treated renal cell carcinoma are uncommon. Surgical resection of pancreatic metastasis remains the only worthwhile modality of treatment. CASE PRESENTATION: A case where pancreatic metastasis from previously resected right sided renal cell carcinoma was resected with a subtotal left pancreatectomy is described. An unusual feature was the presence of a large splenic vein tumor thrombus extending into the portal vein with associated portal hypertension. The patient underwent an uneventful portal vein resection with primary anastomosis. CONCLUSION: This is possibly the first documented case of portal vein renal tumor thrombosis in a case of isolated pancreatic metastasis from previously operated renal cell carcinoma in published world surgical literature

Büchler, Markus W

Büchler, Peter

Esposito, Irene

Friess, Helmut

Loos, Martin

Shrikhande, Shailesh V

English

PubMed

Abstract Background Pancreatic metastases from previously treated renal cell carcinoma are uncommon. Surgical resection of pancreatic metastasis remains the only worthwhile modality of treatment. Case presentation A case where pancreatic metastasis from previously resected right sided renal cell carcinoma was resected with a subtotal left pancreatectomy is described. An unusual feature was the presence of a large splenic vein tumor thrombus extending into the portal vein with associated portal hypertension. The patient underwent an uneventful portal vein resection with primary anastomosis. Conclusion This is possibly the first documented case of portal vein renal tumor thrombosis in a case of isolated pancreatic metastasis from previously operated renal cell carcinoma in published world surgical literature.</p

Loos Martin

Esposito Irene

Büchler Peter

Shrikhande Shailesh V

Büchler Markus W

Friess Helmut

Directory of Open Access Journals

World Journal of Surgical Oncology

Splenic and portal vein thrombosis in pancreatic metastasis from Renal cell carcinoma

Shailesh V Shrikhande

Peter Büchler

Irene Esposito

Martin Loos

Markus W Büchler

Helmut Friess

Springer - Publisher Connector

BioMed Central
World Journal of Surgical Oncology
ssOpen AcceCase report
Splenic and portal vein thrombosis in pancreatic metastasis from 
Renal cell carcinoma
Shailesh V Shrikhande1, Peter Büchler1, Irene Esposito2, Martin Loos1, 
Markus W Büchler1 and Helmut Friess*1
Address: 1Department of General Surgery, University of Heidelberg, Heidelberg, Germany and 2Department of Pathology, University of 
Heidelberg, Heidelberg, Germany
Email: Shailesh V Shrikhande - shailesh_shrikhande@med.uni-heidelberg.de; Peter Büchler - peter_buechler@med.uni-heidelberg.de; 
Irene Esposito - irene_esposito@med.uni-heidelberg.de; Martin Loos - martin_loos@med.uni-heidelberg.de; 
Markus W Büchler - markus_buechler@med.uni-heidelberg.de; Helmut Friess* - helmut_friess@med.uni-heidelberg.de
* Corresponding author    
Abstract
Background: Pancreatic metastases from previously treated renal cell carcinoma are uncommon.
Surgical resection of pancreatic metastasis remains the only worthwhile modality of treatment.
Case presentation: A case where pancreatic metastasis from previously resected right sided
renal cell carcinoma was resected with a subtotal left pancreatectomy is described. An unusual
feature was the presence of a large splenic vein tumor thrombus extending into the portal vein with
associated portal hypertension. The patient underwent an uneventful portal vein resection with
primary anastomosis.
Conclusion: This is possibly the first documented case of portal vein renal tumor thrombosis in
a case of isolated pancreatic metastasis from previously operated renal cell carcinoma in published
world surgical literature.
Background
Pancreatic metastases from previously treated renal cell
carcinoma are known but uncommon. Surgical resection
of pancreatic metastasis remains the only worthwhile
modality of treatment. We describe our experience where
a pancreatic metastasis from previously resected right
sided renal cell carcinoma was resected with a subtotal left
pancreatectomy with portal vein resection and primary
anastomosis for a renal tumor thrombus in the splenic
and portal vein.
Case presentation
A 62 year old patient was treated for right sided renal cell
carcinoma by a radical nephrectomy in March 2004. In
February 2005, he complained of abdominal pain and
weight loss and on radiologic evaluation by a computed
tomography (CT) scan, was diagnosed to have a pancre-
atic mass with evidence of portal hypertension and a por-
tal vein thrombosis (Figure 1). In view of the solitary
lesion with a differential diagnosis of primary pancreatic
pathology or metastasis from renal cell carcinoma, the
patient was subjected to an exploratory laparotomy in
March 2005. Exploratory findings were those of a large
pancreatic body and tail mass associated with signs of por-
tal hypertension. After a careful assessment of resectability
that included mobilization of the pancreatic neck from
the superior mesenteric vein, a decision to perform a left
sided pancreatectomy with splenectomy was taken. Divi-
Published: 17 May 2006
World Journal of Surgical Oncology 2006, 4:25 doi:10.1186/1477-7819-4-25
Received: 31 October 2005
Accepted: 17 May 2006
This article is available from: http://www.wjso.com/content/4/1/25
© 2006 Shrikhande et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
World Journal of Surgical Oncology 2006, 4:25 http://www.wjso.com/content/4/1/25sion of the pancreatic neck by a vascular stapler confirmed
our preoperative radiological findings. There was a large
tumor thrombus in the splenic vein and it was extending
via its confluence with the superior mesenteric vein into
the portal vein occupying approximately 80% of its entire
lumen. In view of these findings, a portal vein segment
resection of 2.5 cm with primary anastomosis was added
to the stapled left pancreatectomy and splenectomy. The
patient had a smooth postoperative recovery and was dis-
charged from the hospital on the 9th postoperative day.
Final histopathology confirmed a metastatic renal cell car-
cinoma to the pancreas with tumor thrombus in the por-
tal vein (Figure 2). Furthermore, the thrombus was
adherent to the wall of the vein (Figure 2, inset). The
patient refused any form of adjuvant treatment and died 5
months later with systemic metastases.
Discussion
Our case raised three questions. First, is a radial resection
justified in view of a locally advanced (metastatic) pathol-
ogy? Second, is a major pancreatic resection safe enough
in these patients and last but not the least, the rarity of our
intraoperative findings that prompted us to write this
report.
Despite the unsatisfactory survival in our case, isolated
pancreatic metastasis from renal call carcinoma are best
treated by surgical resection. While the 5 – year survival
for metastatic renal cell carcinoma is poor and hovers
around 9% [1], aggressive resection of pancreatic metasta-
sis from renal and various other tumors has shown a bet-
ter survival [2-5]. Moussa et al., reported a mean survival
of 61 months after resection for metastasis to the pancreas
from renal cell carcinoma [3]. This could also be partly
explained by the fact that an R0 resection of renal cell car-
cinoma metastasis to the pancreas is more likely than an
R0 resection in primary pancreatic neoplasms and the
resectability rate is around 80% [6]. Furthermore, if the
disease free interval between the primary surgery and the
resection of pancreatic metastasis is long, a better out-
come can often be expected. In our specific case, this inter-
val was only 11 months.
Pancreatectomy with portal vein resection is well
described. A number of large studies have evaluated the
safety of pancreatectomy with resection of tumor infil-
trated retropancreatic vessels [7,8]. The conclusions from
these studies were that segmental venous resection can be
performed safely and that localized invasion of the vessel
wall is not associated with a poor prognosis. Furthermore,
since the results of alternative oncologic modalities con-
tinue to remain worse, it appears that aggressive pancre-
atic resection remains the best treatment option.
Portal hypertension in primary renal cell carcinoma is
extremely rare and a medline search of recent literature
revealed a solitary report of a hypernephroma infiltrating
the pancreas, causing splenic vein thrombosis with result-
ant gastric varices as a manifestation of portal hyperten-
sion [9]. However, a medline search performed with the
key words "renal cell carcinoma, pancreatic metastasis, portal
vein thrombosis" did not reveal a single documented case of
splenic and portal vein thrombosis in pancreatic metasta-
sis from a previously treated renal cell carcinoma.
A renal cell carcinoma thrombus projects into the lumen of the portal vein a d is partially attached to the veno s wall (ins t)Figure 2
A renal cell carcinoma thrombus projects into the lumen of 
the portal vein and is partially attached to the venous wall 
(inset). (H & E staining. Original figure magnification: 50 ×; 
inset magnification 100 ×.)
CT scan showing a pancreatic body mass and tail mass (white arrows) with portal vein thrombus (black arrows)Figure 1
CT scan showing a pancreatic body mass and tail mass (white 
arrows) with portal vein thrombus (black arrows).Page 2 of 3
(page number not for citation purposes)
World Journal of Surgical Oncology 2006, 4:25 http://www.wjso.com/content/4/1/25Publish with BioMed Central   and  every 
scientist can read your work free of charge
"BioMed Central will be the most significant development for 
disseminating the results of biomedical research in our lifetime."
Sir Paul Nurse, Cancer Research UK
Your research papers will be:
available free of charge to the entire biomedical community
peer reviewed and published immediately upon acceptance
cited in PubMed and archived on PubMed Central 
yours — you keep the copyright
Submit your manuscript here:
http://www.biomedcentral.com/info/publishing_adv.asp
BioMedcentral
Summary
While our group has recently published a single center
experience with metastases to the pancreas from renal
tumors [10], this rare clinical situation is a new recent
addition and adds to the pool of existing information
regarding metastatic lesions of renal cell carcinoma to the
pancreas. Thus our case, probably for the first time in pub-
lished literature, documents the presence of splenic and
portal vein tumor thrombus in a case of pancreatic metas-
tasis from renal cell carcinoma. Radical surgery remains
the treatment mainstay and portal vein resection, espe-
cially in high volume centers, does not influence the peri-
operative outcome in such locally advanced surgical
scenarios. While our series has documented a degree of
survival benefit for metastases to the pancreas from renal
cell carcinomas [10], the long-term outcome of such radi-
cal procedures needs a larger collective experience to reach
a meaningful conclusion.
References
1. Maldazys JD, deKernion JB: Prognostic factors in metastatic
renal carcinoma.  J Urol 1986, 136:376-379.
2. Bassi C, Butturini G, Falconi M, Sargenti M, Mantovani W, Pederzoli
P: High recurrence rate after atypical resection for pancre-
atic metastases from renal cell carcinoma.  Br J Surg 2003,
90:555-559.
3. Moussa A, Mitry E, Hammel P, Sauvanet A, Nassif T, Palazzo L, Malka
D, Delchier JC, Buffet C, Chaussade S, Aparicio T, Lasser P, Rougier
P, Lesur G: Pancreatic metastases: a multicentric study of 22
patients.  Gastroenterol Clin Biol 2004, 28:872-876.
4. De Fazio S, Destito C, Ricciardi V, Marin AW: Pancreatic metas-
tasis of renal cell carcinoma: a case report and review of the
literature.  G Chir 2004, 25:351-355.
5. Hiotis SP, Klimstra DS, Conlon KC, Brennan MF: Results after pan-
creatic resection for metastatic lesions.  Ann Surg Oncol 2002,
9:675-679.
6. Faure JP, Tuech JJ, Richer JP, Pessaux P, Arnaud JP, Carretier M: Pan-
creatic metastasis of renal cell carcinoma: presentation,
treatment and survival.  J Urol 2001, 165:20-22.
7. Baulieux J, Adham M, Oussoultzoglou E, De la Roche E, Berthoux N,
Bourdeix O, Ducerf C: Is pancreatectomy with resection of the
retro-pancreatic vessels for cancer justified?  Chirurgie 1998,
123:438-444.
8. Keck H, Knoop M, Langrehr JM, Henneken V, Neuhaus P: Extended
partial Kausch – Whipple duodenopancreatectomy by resec-
tion of tumor infiltrated vascular segments.  Zentralbl Chir
1995, 120:809-814.
9. Joya Seijo MD, del Valle Loarte P, Marco Martinez J, Herrera Merino
N, Agud Aparicio JL: Sinistral portal hypertension with bleeding
gastric varices as initial manifestation of renal cell carci-
noma.  An Med Interna 2004, 21:283-284.
10. Wente MN, Kleeff J, Esposito I, Hartel M, Muller MW, Frohlich BE,
Buchler MW, Friess H: Renal Cancer Cell Metastasis Into the
Pancreas: A Single-Center Experience and Overview of the
Literature.  Pancreas 2005, 30:218-222.Page 3 of 3
(page number not for citation purposes)


Agud Aparicio JL: Sinistral portal hypertension with bleeding gastric varices as initial manifestation of renal cell carcinoma. An Med Interna

AW: Pancreatic metastasis of renal cell carcinoma: a case report and review of the literature.

Carretier M: Pancreatic metastasis of renal cell carcinoma: presentation, treatment and survival.

deKernion JB: Prognostic factors in metastatic renal carcinoma.

Ducerf C: Is pancreatectomy with resection of the retro-pancreatic vessels for cancer justified? Chirurgie

Extended partial Kausch – Whipple duodenopancreatectomy by resection of tumor infiltrated vascular segments. Zentralbl Chir

High recurrence rate after atypical resection for pancreatic metastases from renal cell carcinoma.

Lesur G: Pancreatic metastases: a multicentric study of 22 patients. Gastroenterol Clin Biol

MF: Results after pancreatic resection for metastatic lesions. Ann Surg Oncol

Renal Cancer Cell Metastasis Into the Pancreas: A Single-Center Experience and Overview of the Literature. Pancreas

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1482706

Splenic and portal vein thrombosis in pancreatic metastasis from Renal cell carcinoma

Abstract

Similar works

Full text

Available Versions

Directory of Open Access Journals

Springer - Publisher Connector