David Leung, MD, MS1, Behnam Moein Jahromi, MD2, Matthew Skinner, MD1, Quan M. Nhu, MD, PhD3 1Scripps Green - Scripps Clinic, San Diego, CA; 2Scripps Green - Scripps Clinic, La Jolla, CA; 3Scripps Clinic, La Jolla, CA
Introduction: Renal cell carcinoma (RCC) is the most common renal tumor and accounts for 3% of all cancer deaths worldwide. Even after resection of a primary tumor, a significant percentage develop recurrence. RCC’s clinical course is unpredictable and cases of late metastasis (≥10 years) are not uncommon. We present a rare case of female who was diagnosed with RCC late metastasis of the duodenum.
Case Description/Methods: A 55 year old female with a history of clear cell RCC status-post left nephrectomy (10-years prior) presented with epigastric pain and melena. EGD revealed firm submucosal mass-like lesions in the gastric fundus and an actively bleeding exophytic mass in the proximal duodenum. Hemostasis was achieved with endoscopic clip, argon plasma coagulation and hemostatic powder spray. CT imaging revealed right renal and pancreatic masses with gastric wall impingement and invasion of the descending duodenum. Duodenal and kidney biopsies confirmed metastatic clear cell RCC. Patient required close monitoring post-EGD with additional PRBC transfusions but did not need further endoscopic nor angiographic hemostatic interventions. Multidisciplinary discussions converged to radiation and systemic therapy (Pembrolizumab and Axitinib).
Discussion: Most recurrence of RCC after radical nephrectomies occur within the first 5 years. However, the clinical course is notoriously unpredictable and recurrence can have a sinister latency. The clear cell variant is especially infamous for late metastasis. Metastasis of the luminal tract is exceptionally rare and the duodenum is the least frequently affected site. Endoscopic biopsy provides histologic diagnosis of metastasis and is crucial to distinguish from primary GI malignancies. Submucosal lesions may need aggressive biopsy techniques or surgical biopsy to obtain sufficient tissue for diagnosis. Biopsies of submucosal or luminal lesions entail a high likelihood of further hemorrhage due to the highly vascular nature of the disease. As such, control of GI bleeds on presentation or post-biopsy is a concern. Hemostasis of bleeding luminal metastasis is difficult to manage endoscopically and there is limited data on endoscopic therapy. A multidisciplinary approach is key to manage persistent bleeding. This case highlights the importance of investigating cases of GI symptoms along with a history of RCC and nephrectomy, no matter the time since the original diagnosis. It is also important to recognize the high risk for bleeding and that endoscopic management is difficult.
Figure: Figure 1: (A) EGD retro-flexed view in stomach showing a gastric sub-mucosal mass; (B) View of the largest gastric sub-mucosal mass; (C) Duodenal mass seen just beyond the duodenal sweep; (D) Actively bleeding duodenal mass.
Disclosures: David Leung indicated no relevant financial relationships. Behnam Moein Jahromi indicated no relevant financial relationships. Matthew Skinner indicated no relevant financial relationships. Quan Nhu indicated no relevant financial relationships.
David Leung, MD, MS1, Behnam Moein Jahromi, MD2, Matthew Skinner, MD1, Quan M. Nhu, MD, PhD3. P3062 - Acute Duodenal Bleeding Secondary to Metastatic Renal Cell Carcinoma, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.
.jpg)