Surgical Treatment of Pancreatic Metastases

Georgios C Sotiropoulos1, Hauke Lang1, Chao Liu2, Eirini I Brokalaki1, Ernesto Molmenti1,
Christoph E Broelsch1
1Department of General Surgery and Transplantation, University Hospital Essen. Essen, Germany.
2Department of General Surgery, Medical College, Sun Yat-sen University. Guangzhou, China
ABSTRACT
Context The pancreas is an unusual site for
metastases of renal cell carcinoma origin,
sometimes occurring many years after
nephrectomy. We herein present two cases of
pancreatic metastases of renal cell carcinoma
which occurred 17 and 19 years after the
primary diagnosis.
Case report In the first case, metastases were
found in the head of the pancreas, upper right
arm and the right lobe of the thyroid gland. In
the second case, a tumor was found in the tail
of the pancreas and a remnant of the right
kidney. This was the third recurrence of the
original tumor after an initial left
nephrectomy and two subsequent partial right
nephrectomies in the past. Treatment in the
first case consisted of excision of the tumor in
the upper right arm, a Whipple operation, and
a thyroidectomy. In the second case, a distal
pancreatectomy and remnant right
nephrectomy were undertaken. Both patients
recovered from the operations without
complications and remain free of tumor in
follow-up periods of 54 and 8 months
respectively.
Conclusions Resection of renal cell
carcinoma metastases involving the pancreas
provides satisfactory long-term survival, and
should be undertaken whenever possible.
INTRODUCTION
Renal cell carcinoma (RCC) is a malignant
tumor of unique biological behavior,
presenting, in some cases, with very late
metastases. The pancreas is an unusual site
for such metastases. In such cases, the
differential diagnosis includes mainly primary
pancreatic tumors, and the diagnosis of
metastatic RCC is frequently made at the time
of microscopic examination.
In this study, we present two cases of late
pancreatic metastases of RCC which occurred
17 and 19 years after the diagnosis of the
primary tumor; they were successfully treated
surgically.
CASE REPORT
Case 1
A 70-year-old man presented in January 2000
with acute gastrointestinal bleeding. His past
medical history showed that he had
undergone a left nephrectomy in 1983 for
renal cell carcinoma (pT2 pN0 Mx, G2).
Endoscopy revealed a tumor in the head of
the pancreas extending into the duodenum.
Based on quick contrast mean absorption in
computed tomography-scan images (Figure 1)
and positivity for chromogranin A (676 µg/L;
reference range: 0-100 µg/L) in laboratory
testing, the tumor was suspected to be of
neuroendocrine origin. CEA, CA 19-9, CA

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15-3, 5-hydroxyindolessig acid and serotonin
were within normal laboratory range values.
Further physical examination showed a
movable 2x3x3 cm tumor in the soft tissues of
the upper right arm. Somatostatin receptor
scintigraphy showed a pathological uptake in
the head of the pancreas, upper right arm, and
right lobe of the thyroid gland (Figure 2).
Thyroid gland scintigraphy showed a cold
node in the base of the right lobe. Given the
localized nature of the
lesions, and the absence
of further suspicious
masses, it was decided to
proceed with surgical
resection.
Excision in toto of the
tumor in the upper right
arm revealed metastatic
renal cell carcinoma. A
Whipple operation with
resection and reconstruct-
ion of the portal vein was
performed two weeks
later (Figure 3), aimed at preventing further
upper gastrointestinal hemorrhage. The
postoperative course was uneventful.
Histological exam showed pancreatic
metastases of renal cell carcinoma, with
tumor-free resection margins. Six weeks later,
a total thyroidectomy was performed based on
the macroscopic intraoperative suspicion of
multifocal metastases in both lobes of the
thyroid glands. Histopathological evaluation
of the resected specimen demonstrated RCC
metastatic disease in the right thyroid lobe.
Immunohistochemistry was negative for
chromogranin A in all cases. Nevertheless,
chromogranin A levels returned to 152 µg/L
after the resections.
Fifty-four months after surgical treatment, the
patient is in excellent health with no evidence
of residual or new tumor growth as evidenced
by imaging, biochemical and clinical follow-
up exams.
Case 2
In 1985, a 54-year-old woman underwent a
left nephrectomy for renal cell carcinoma
(pT1 N0 M0) at another hospital. Because of
a new RCC lesion in the right kidney (also
pT1 N0 M0), the patient had a partial right
nephrectomy in 1993. In November 2002, the
patient underwent a second kidney-preserving
Figure 1. A computed tomography scan of the
abdomen showing the tumor in the head of the
pancreas. Quick contrast mean absorption was
incorrectly interpreted as indicative of a tumor of
neuroendocrine origin.
Figure 2. Somatostatin receptor
scintigraphy showing a pathol-
ogical uptake in the head of the
pancreas, the upper right arm,
and the right side of the thyroid
gland.
Figure 3. Surgical specimen of the Whipple operation
demonstrating a 5.5x6x5 cm tumor in the head of the
pancreas.

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JOP. Journal of the Pancreas – http://www.joplink.net – Vol. 6, No. 4 – July 2005. [ISSN 1590-8577]
341
partial right nephrectomy for recurrent RCC
at another institution. In February 2004, the
patient presented at our hospital with a mass
in the right kidney remnant and a 2.7 cm
lesion in the tail of the pancreas. Informed
consent addressing the risks of the surgery
was obtained, with special emphasis on the
need for lifelong hemodialysis. A remnant
right nephrectomy and distal pancreatectomy
without splenectomy were performed (Figure
4). A Cimino-shunt was constructed in the left
forearm two weeks later. The patient remains
recurrence-free 8 months postoperatively.
DISCUSSION
The pancreas is an unusual but occasionally
favored site for metastases, notably from
carcinomas of the kidney and lung. In a
clinical series of patients with pancreatic
tumors, 4.5 % of cases were found to be
metastatic lesions. That figure increased to
42% among patients with previously
diagnosed malignancies and solitary lesions in
the pancreas [1]. Pancreatic metastases of
RCC origin represented between 0.25 and 3%
of all resected pancreatic specimens in a
recent large series [2, 3]. Among patients who
had resections of RCC and survived for 10
years, more than 10% had late metastases [4].
The median interval from nephrectomy to
diagnosis of solitary pancreatic metastases
was reported to be 11 years [5]. Cases of a
long-term disease-free interval between a
nephrectomy and pancreatic metastases have
been reported, the longest one being 28 years
[6, 7, 8].
The mode of spread of RCC to the pancreas
remains controversial. It may be
hematogenous, along the draining collateral
veins from a hypervascular primary tumor, or
lymphatic by retrograde flow through
retroperitoneal nodes [9].
The current literature contains no data
supporting medical treatment of patients with
isolated RCC metastases, even though there is
some evidence that patients who do not
undergo resection still have a reasonable long
survival rate [3, 10]. Spontaneous regression
of pancreatic metastasis of RCC has also been
reported [11]. The effectiveness of adjuvant
therapy with alpha-interferon for RCC
metastases in the pancreas has not yet been
proven [10, 12].
Some authors consider pancreatectomy for
metastatic disease as long as the pancreas is
the only site of metastasis [1]. However, the
slow metastatic pattern of RCCs could justify
pancreatic resections even in cases where
another metastatic lesion is simultaneously
identified. In a retrospective analysis of 151
patients with metastatic RCC involving, for
the most part, the lungs, bone and lymph
nodes, but not the pancreas, 111 patients with
multifocal metastases and 40 patients with
solitary metastases underwent surgical
resection. No survival benefit was observed
for those with solitary metastases, but survival
was found to be significantly higher after a
R0 resection, independent of the number of
tumor lesions [13]. Kavolius et al., in a
retrospective study of 278 cases of metastastic
RCC (mostly in the lungs and the brain),
showed a 5-year survival rate of 44% after R0
resections as opposed to 14% after palliative
or incomplete resections. Five-year survival
was also better for patients with solitary as
opposed to multifocal metastases (54% vs.
29%, respectively) [14].
Cases of both synchronous and asynchronous
bilateral RCC with late pancreatic metastases
have been observed in the past. Carini et al.
reported a case of solitary pancreatic
metastases 13 years after a left radical
nephrectomy and right lower polar resection
Figure 4.
Surgical specimen of the distal
pancreatectomy.

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342
for bilateral simultaneous RCC, successfully
treated with a pancreaticoduodenectomy [15].
Gohji et al. reported a case of asynchronous
bilateral renal cell carcinoma with pancreatic
metastasis treated with distal pancreatectomy
more than 6 and 2 years after a left
nephrectomy and right renal tumor
enucleation, respectively. The patient was
alive without disease after being treated with
alpha-interferon for 12 months after distal
pancreatectomy [12].
Solitary pancreatic metastases are considered
to be more frequent than multifocal ones [2].
Standard pancreatic resections are adopted in
the surgical therapy of pancreatic metastases
of RCC: pancreaticoduodenectomy for tumors
in the head, neck or uncinate process, distal
pancreatectomy with or without splenectomy
for tumors in the body or tail, total
pancreatectomy for multifocal lesions, or
atypical tumor resection in other cases. Bassi
et al., based on a morbidity rate of 83% and a
recurrence rate of 50% after atypical
resections, recommended standard pancreatic
resections in cases of RCC metastases [16].
Given that many studies report no pancreatic
lymph node involvement in the surgical
specimens [3, 17], radical lymph node
dissection does not seem to be mandatory [3].
Kierney et al. reported a 5-year survival rate
of 31% in 41 cases of intrathoracic,
intracranial, intraabdominal, or extrapleural
chest wall soft tissue metastatic RCC
undergoing resection. Single lesions were
found in 64% of the cases, and complete
tumor removal was achieved in 88% of cases
[18]. A 5-year survival rate of approximately
70% has been noted in some recent reports [6,
19]. Thompson and Heffess reported a series
of 21 patients who underwent pancreatic
resection for RCC metastases with an 81% 5-
year survival rate. Mean overall survival from
the date of nephrectomy was 19.8 years, and
mean overall survival from the date of
diagnosis of pancreatic metastasis was 6.2
years [2].
An obvious limitation of our report is the
short follow-up, especially in the second case.
However, as mentioned above, long term
survival after surgical therapy of pancreatic
metastases of RCC is well-documented in the
literature [2, 6, 19].
Surgical therapy in both of our cases could be
characterized as extreme. In the first case,
tumor infiltration of the portal vein required a
technically demanding pancreaticoduodenect-
omy with partial resection and reconstruction
of the portal vein. Metastases in the upper
right arm and in the thyroid gland were also
addressed surgically. Similar aggressive
surgical therapy was reported in the series of
Law et al., where 3 patients underwent
resection of brain, lung, and adrenal gland
metastases from RCC prior to pancreatic
resection [20]. In our second case, a remnant
nephrectomy led to renal insufficiency
requiring lifelong hemodialysis. However, the
strong desire of the patients to achieve 'tumor-
free' situations together with the encouraging
reports in the literature encouraged us to
proceed with the above-mentioned therapies.
Received March 9th, 2005 - Accepted May 4th,
2005
Keywords Carcinoma, Renal Cell; Neoplasm
Metastasis; Pancreatectomy; Pancreatic
Diseases
Abbreviations RCC: renal cell carcinoma
Correspondence
Georgios C Sotiropoulos
Department of General Surgery and
Transplantation
University Hospital Essen
Hufelandstr. 55
D-45122 Essen
Germany
 
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