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Case report

  1. Top of page
  2. Case report
  3. Comment
  4. References

A 60-year-old man presented with RCC of the left kidney and was treated successfully by a transperitoneal nephrectomy in 1989. The histopathological examination revealed a small (2 cm in the greatest dimension) well differentiated, clear-cell type RCC with microscopic vein involvement. The tumour was resected radically; furthermore, no regional lymph nodes or distant metastases were found. Over a follow-up of 8 years there was no evidence of local recurrence or metastatic disease. The patient began to experience unpredictable episodes of hunger associated with sweating and dizziness in October 1997. During these episodes his blood glucose levels were decreased by up to 300 mg/L. Ultrasonography showed two hypoechoic lesions in the pancreas and subsequent CT of the abdomen showed two hypervascularized well-circumscribed tumours in the body (1.5 cm) and in the tail (2.3 cm) of the pancreas (Fig. 1). However, insulin and C-peptide levels were in the normal range. In January 1998 the patient was admitted to the Department of Surgery. A distal pancreatectomy with splenectomy, combined with a tumour enucleation, was performed after intraoperative ultrasonography. An accurate tumour classification from the intraoperative frozen section was not possible, but the surgical margins were free of tumour. The definitive histopathological specimens revealed two metastases of a clear-cell type RCC (Fig. 2); near these lesions some islet cells showed a moderate hyperplasia. The postoperative course was uneventful. During a 4-month follow-up the patient had no hypoglycaemic attacks and his blood glucose levels remained within the normal range.

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Figure 1. . Helical CT of the pancreas (slice thickness 3 mm) in the arterial phase. a, Focal lesion in the pancreatic tail (2.3 cm in diameter), with perifocal hypervascularity and an avascular centre (arrow). b, Tumour in the body of the pancreas (1.5 cm in diameter), causing a bulge in the anterior pancreatic contour (arrow).

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Figure 2. . Histological specimen of the pancreas, showing a metastasis of clear-cell renal carcinoma (arrow). Haematoxylin and eosin.×20.

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Comment

  1. Top of page
  2. Case report
  3. Comment
  4. References

Pancreatic metastases of RCC are extremely rare [1]. The present patient presented with Whipple’s triad (symptoms of hypoglycaemia, low blood glucose levels and rapid alleviation of symptoms after glucose administration). After surgery, these signs resolved and we attribute the symptoms to a paraneoplastic effect. The moderate hyperplasia of the islet cells near the metastases was notable; despite this, no pathological levels of insulin and C-peptide were detectable. We omitted preoperative CT-guided needle biopsy because Whipple’s triad and the findings on CT supported the diagnosis of an insulinoma, because surgery is the treatment of choice for any malignancy of exocrine and endocrine pancreatic tissue, as it is for solitary metastases [2]. The possibility of metachronous metastases, even after a long asymptomatic period [3], requires a careful, life-long follow-up after nephrectomy for RCC.

References

  1. Top of page
  2. Case report
  3. Comment
  4. References
  • 1
    Hirota T, Tomida T, Iwasa M, Takahashi K, Kaneda M, Tamaki H. Solitary pancreatic metastasis occurring eight years after nephrectomy for renal cell carcinoma. A case report and surgical review. Int J Pancreatol 1996; 19: 14553
  • 2
    Stankard CE, Karl RC. The treatment of isolated pancreatic metastases from renal cell carcinoma: a surgical review. Am J Gastroenterol 1992; 87: 165860
  • 3
    Onishi T, Ohishi Y, Iizuka N et al. Clinical characteristics of 7 renal cell carcinoma patients developing a solitary pancreatic metastasis after nephrectomy. Nippon Hinyokika Gakkai Zasshi 1995; 86: 153842