Introduction: Pancreas is an uncommon site of metastatic disease. Almost 63% of pancreatic metastasis arise from renal cell cancer. We report a case of metastatic renal cell cancer to pancreas, with contralateral adrenal metastasis 15 years after a radical nephrectomy.
Case Description/Methods: 61 years old man with past medical history of renal cell cancer, status post left radical nephrectomy fifteen years ago, presented with dull pain in right lower abdominal for one day. He denied any other abdominal symptoms or weight loss. He smokes up to half a pack of cigarettes daily. His examination was unremarkable but he was noted to have elevated lipase (213U/L) and a bilirubin of 1.1 mg%. On computer tomography abdomen he had bulky, enhancing, soft tissue mass (~6.7 cm), with dilated pancreatic duct of 1.5 cm with right adrenal mass (Figure 1). On EUS, the lesion appeared well circumscribed and previously known pancreatic duct dilation was seen. Fine needle biopsy of the mass, which showed numerous atypical cells with round irregular nuclei with prominent nucleoli with clear cytoplasm suggestive of clear cell renal cell carcinoma (Figure 2). On immune -histochemistry, the tumor was positive for CD10, renal cell carcinoma antigen and PAX 8( Figure 2)
Discussion: Metachronous renal cell cancer to pancreas fifteen years after radial nephrectomy is rare. Our patient had pancreatic metastasis with adrenal involvement and presented with vague abdominal symptoms. .He was noted to have elevated lipase and dilation of main pancreatic duct. Due to a remote history of nephrectomy and the presenting complaints, pancreatic primary was suspected. However, on endoscopic ultrasound the patient was noted to have a well circumscribed lesion in the head of pancreas with dilated pancreatic duct(Figure 1). Regular borders and absence of pancreatic duct dilation suggested metastatic disease. Our patient had well circumscribed lesion but with a dilated duct.
Most pancreatic metastasis are reported to occur within ten years after treatment of the primary disease but our patient had metastasis fifteen years later without any loco-regional recurrence. Endoscopic ultrasound is extremely important and allows to evaluate the extent of the disease, involvement of portal vein/ superior mesenteric artery, presence of enlarged lymph nodes, which are a must for evaluating the surgical candidature besides providing tissue diagnosis which helped us establish the diagnosis of metastasis.
