Metastatic Renal Cell Cancer and a Gastric Mass: An Unusual Finding

Abstract

Renal cell cancer (RCC) accounts for approximately 3% of all adult malignancies. RCC has a metastasis rate of approximately 25%, which is most commonly to the lungs (>50%). On the contrary, RCC metastasis to the gastrointestinal tract (excluding the liver) is very uncommon and ranges from 0.2 to 0.7%. Thus, a gastric cancer in a patient with known metastatic RCC would most likely be secondary to metastasis. We present the first reported case of a metastatic RCC coexisting with a new-onset primary gastric cancer and a review of management using guidelines from metastatic RCC to the stomach. An 82-year-old African American male with papillary RCC status post left nephrectomy with recurrence of liver metastasis presented with failure to thrive shortly after his third cycle of chemotherapy despite stable disease by imaging studies. He had received 7 chemotherapy cycles of Gemzar, Nexavar, and Avastin prior to admission. He subsequently had a drop in his hemoglobin and was found to have hemoccult positive stool in the setting of recent Avastin. Endoscopic evaluation showed a 3 cm ulcerated mass in the cardia which was biopsied. The biopsy showed invasive and poorly differentiated gastric adenocarcinoma unrelated to his RCC. The patient subsequently underwent partial gastrectomy with loop gastrojejunostomy for resection of his stage 1 primary gastric adenocarcioma. The surgery also facilitated future chemotherapy (Avastin), which could not be given prior to surgery due to its side effect of bleeding. The patient did not receive adjuvant chemoradiation for his gastric cancer due to his comorbidities at the time and was doing well at a one month follow-up. Metastatic RCC and primary gastric cancer can coexist, especially when there is an overlap of risk factors such as smoking or nitrosamines. The management of a gastric cancer in the setting of metastatic RCC is similar to the management of solitary primary gastric carcinoma. Treatment of the primary gastric cancer can facilitate future chemotherapy such as Avastin, which has been recently approved for the treatment of metastatic RCC.

Fig. 1

Photomicrograph of liver biopsy illustrating a metastatic papillary renal cell carcinoma. Immunohistochemical staining revealed PAX-2 positivity and Mucin negativity. A PAX-2 positive stain is highly specific for RCC. A Mucin negative stain suggests against gastric cell carcinoma.

Fig. 2

Superior EGD view discovering a 3 cm mass in the gastric cardia.

Fig. 3

Horizontal EGD view showing a friable, ulcerated mass with an umbilicated center with central depression.

Fig. 4

On EGD, the mass bled on contact prior to biopsy.

Fig. 5

Photomicrograph of EGD biopsy, which showed classic signet ring morphology.

Fig. 6

Photomicrograph of EGD biopsy is consistent with invasive and poorly differentiated gastric cell carcinoma.