Gastric Metastasis From Renal Cell Carcinoma Causing Upper Gastrointestinal Bleeding 18 Years After Curative Tumor Resection: A Case Report and Review of the Literature

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Case Report: Our patient was an 83-year-old male with a prior history of renal cell carcinoma (RCC) treated with a radical nephrectomy and chemotherapy 18 years prior. He was reported to be in full clinical remission at the time of presentation. He presented to our emergency department with complaints of one day of lightheadedness and melena. His triage vital signs were significant for orthostatic hypotension. His physical exam was notable for melena. Hemoglobin was 12.9 gms from a prior baseline of 14. A proton pump inhibitor infusion was initiated and he was admitted to the hospital ward. He underwent upper endoscopy that revealed a 1.5 cm irregular shaped and inflammatory appearing polyp on the lesser curve. Further inspection revealed an area of ulceration on the posterior aspect and evidence of recent bleeding. The gastric polyp was lifted with saline injection and poylpectomy was performed. The mass was retrieved and the margins were grossly inspected. The remainder of his hospital course was uneventful and he was discharged within 48 hours of the procedure. The pathology from the polyp revealed morphologic features of clear cell RCC with a clear margin of resection. When compared to stored kidney tissue from the 1995 resection the cytological characteristics of the gastric polyp closely matched the original tumor. A body CT scan was performed and revealed a small lesion in the inferior pole of the left kidney resembling metachronous RCC, as well as a concerning mass in the pancreatic tail. He was subsequently referred for evaluation by our oncology specialists who initiated chemotherapy with pazopanib (a selective tyrosine kinase inhibitor).

Discussion: Renal cell carcinoma (RCC) can metastasize to a variety of locations including most frequently the lung, liver, bone and brain. Metastatic RCC to the stomach is rare with an estimated incidence of 0.2-3.1% of all gastric metastatic lesions. Moreover, the timeframe for recurrence of metastatic disease is typically significantly closer to the initial resection. There are reports of RCC metastasizing to the gastrointestinal (GI) tract several years after the primary tumor has been successfully resected. The estimated interval from the time of surgical resection of the primary RCC to noting the gastric metastasis was roughly 7 years in one series. In a larger series of 22 patients the average interval to gastric metastasis was 6.3 years. In our case, the time interval was over 18 years making it one of the latest presentations in the current literature.