Introduction: Metastatic spread to the upper gastrointestinal tract is rare. Typically, the stomach is more often affected than the duodenum. The most common primary cancers found in the upper gastrointestinal tract include lung cancer, breast cancer, and melanoma. Metastasis to the ampulla of Vater (ampulla) is rare with only 33 cases reported. Affected patients commonly present with abdominal pain, jaundice, pruritus and upper GI bleeding. We present a case of acute blood loss anemia and melena from metastatic renal cell carcinoma to ampulla.
Case Description/Methods: A 77-year-old female with history of stage IV, clear-cell renal cell carcinoma (RCC) status post right nephrectomy and partial left nephrectomy three years prior, complicated by stable metastatic spread to the spine and lungs, actively on pembrolizumab, presented with a week of shortness of breath, fatigue, and dark stools. Her hemoglobin was 5.1mg/dl, down from a baseline of 11mg/dl. CT scan of the abdomen revealed stable metastatic disease.
Esophagogastroduodenoscopy was significant for hematin in the stomach and a large fungating mass with bleeding was found at the ampulla (Figure 1a). Biopsy results returned positive for renal cell carcinoma (Figure 1b and 1c)
Discussion: We present a case of acute anemia due to metastatic renal cell carcinoma that had spread to the ampulla, 4 years after initial nephrectomy. Of the 33 cases of metastatic spread to the ampulla reported in the literature, 39% were renal carcinoma, 30% melanoma, and 12% breast cancer. Bone, ovary, uterus, bladder, and larynx primary cancers have also been reported. The time interval between the diagnosis of RCC and ampullary metastasis can be as high as 10 years. In our case, the patient had active disease in lungs, and given all her comorbidities, resection of all lesions was not possible. As the treatment of cancer rapidly progresses with advances in genetically guided therapeutics as well as immunotherapy, patients presenting with what today is considered a rare complication as a site of metastatic disease will become more common and recognizing such rare complications can aid in a faster diagnosis and therapy.
