1. Benjamin R. Hart, Mazen El Atrache, Ashish Zalawadia
A Rare Case of Simultaneous Metastatic Disease of Renal Cell Carcinoma to the Stomach, Bone, and Lungs
Benjamin R. Hart, Mazen El Atrache, Ashish Zalawadia
Introduction
Clinical Images
Discussion continued
Gastric Metastatic disease is a relatively uncommon occurrence happening in 0.2 to 0.7% of cases1,2. The most common sources of gastric metastatic disease are derived from Lung, Breast, Melanoma, and Esophageal cancers2. Renal cell carcinoma (RCC) accounts for 3% of all cancers % of RCC presents at an advanced state with metastatic disease most often presenting with spread to lung, liver, bone, soft tissue, and brain. The occurrence of RCC with metastatic disease to the stomach has been documented in 50 cases in the literature prior to
Gastric RCC typically presents with a solitary bulky mass in the gastric body and are typically of a clear cell etiology6.
Treatment options are unclear however total or partial gastrectomy are common, endoscopic resection, chemotherapy including sorafenib, temsirolimus, and bevacizumab have also been attempted1,7 For cases of bleeding, resection and subsequent hemostasis can be considered by embolization or endoscopic approaches3. .
Conclusion
Case
79 year old male patient with past medical history of stage 4 renal cell carcinoma status post nephrectomy and radiation presented with melena. His vital signs were normal upon presentation. Physical exam was unremarkable except for mild left sided abdominal pain without guarding or rebound. He was found to have a hemoglobin of 5.9g/dL from a baseline of 9g/dL, 2 months ago. Upper endoscopy showed a non bleeding non ulcerated vessel in the second portion of the duodenal bulb. This was consistent with a Dieulafoy’s lesion.  It was treated with epinephrine injection and one hemoclip.  In stomach we noted two ulcerated friable masses (3 cm and 4 cm).  Biopsy showed Clear Cell carcinoma consistent with renal origin. Antral biopsy was remarkable for gastritis with reactive changes and H. pylori positivity. 
Imaging was performed to rule out further metastatic disease. CT showed numerous pulmonary metastatic nodules, a lesion in the right kidney, a lesion in the acetabulum with large destructive metastasis, and multiple abdominal lymph nodes and small enhancing peritoneal nodules with concern for metastatic disease.  He represented three weeks later with hypoxia secondary to a pulmonary embolus treated with Enoxaparin which was discontinued after he developed melena, requiring 2 units pRBCs and was discharged to rehab. Seventeen days later he returned with additional GI bleeding with Hb of 7.2g/dL requiring 2 units PRBCs and was enrolled in hospice care.
This shows that RCC remains unpredictable in its pattern of spread. Oncologists should anticipate any pattern of presentation of RCC metastasis, and this report emphasizes the importance of close follow- up and a high suspicion for odd areas of metastasis.
References
1. Sakurai K, Muguruma K, Yamazoe S, et al. Gastric metastasis from renal cell carcinoma with gastrointestinal bleeding: a case report and review of the literature. Int Surg 2014;99:86-90.
2. Namikawa T, Munekage M, Kitagawa H, Okabayashi T, Kobayashi M, Hanazaki K. Metastatic gastric tumors arising from renal cell carcinoma: Clinical characteristics and outcomes of this uncommon disease. Oncol Lett 2012;4:631-6.
3. Akay E, Kala M, Karaman H. Gastric metastasis of renal cell carcinoma 20 years after radical nephrectomy. Turk J Urol 2016;42:104-7.
4. Kongnyuy M, Lawindy S, Martinez D, Parker J, Hall M. A Rare Case of the Simultaneous, Multifocal, Metastatic Renal Cell Carcinoma to the Ipsilateral Left Testes, Bladder, and Stomach. Case Rep Urol 2016;2016:
5. Kim MY, Jung HY, Choi KD, et al. Solitary synchronous metastatic gastric cancer arising from t1b renal cell carcinoma: a case report and systematic review. Gut Liver 2012;6:
6. Xu J, Latif S, Wei S. Metastatic renal cell carcinoma presenting as gastric polyps: A case report and review of the literature. Int J Surg Case Rep 2012;3:601-4.
7. Chibbar R, Bacani J, Zepeda-Gomez S. Endoscopic Mucosal Resection of a Large Gastric Metastasis from Renal Cell Carcinoma. ACG Case Rep J 2013;1:10-2.
Figures: Gastric Mass
Discussion
Renal cell carcinoma can metastasize to multiple organs. The most common sites are the liver, brain, bones, and lung. Metastatic disease to the stomach is very rare (0.2–4%)1,4.  Our patient had metastatic disease in both of these organs as well as bone and lungs. Common presentations of gastric metastisis of RCC can often occur late average 7 years after initial diagnosis, and often presents with bleeding 83-65%, anemia 35%, abdominal pain 13% and dysphagia 3%, and some patients are asymptomatic 9%1,5,6.
Presenting author: Bronwyn Small, MD
Conflict of interest: None
Funding support: None