Small-intestinal bleeding due to metastatic renal cell cancer

A 68-year-old man who presented with obscure occult gastrointestinal bleeding was referred to our department to undergo capsule endoscopy. He had a history of clear-cell renal carcinoma (pT2NxM0EII), for which he had undergone a radical nephrectomy 1 year before. No adjuvant radiation or chemotherapy was administered. At 5 days before capsule endoscopy was due to be performed, he developed melena and required blood transfusion. Laboratory data revealed an iron deficiency anemia, with a hemoglobin level of 7.8 g/dL.

Capsule endoscopy of the small bowel revealed an active hemorrhage due to an ulcerated mass at the proximal jejunum ([Fig. 1]).

Fig. 1 Endoscopy capsule view of an active hemorrhage due to an ulcerated mass.

Enteroscopy confirmed the bleeding tumor, which was excised immediately ([Video 1]).

Video 1 Enteroscopy showing the small-bowel tumor.

The pathology was consistent with clear-cell renal metastases to the small bowel.

Secondary tumors of the gastrointestinal tract are unusual but are probably more common than clinically suspected. The most common primaries include melanoma, lung, breast, and ovarian carcinomas, and choriocarcinomas.

Intraluminal small-bowel metastases from metastatic renal cancer are not commonly seen, but based on autopsy data the incidence may be 0.7 % – 14.6 % [1] [2] [3] [4]. The interval from initial nephrectomy to presentation of intestinal metastases is reported to range from 3 months to 20 years, and appears to correlate with overall disease-specific survival. Intestinal metastases occur equally in the jejunum and the ileum, and usually present with intestinal bleeding due to tumoral invasion of intestinal vessels [5].

This current case is of interest because its demonstrates the clinical and endoscopic characteristics of an unusual small-bowel tumor. Capsule endoscopy allowed not only the detection of the site of active bleeding but also the diagnosis of the intestinal mass. The early use of this device shortened the patient’s diagnostic work-up and subsequent management.

Endoscopy_UCTN_Code_CCL_1AC_2AC

References

• 1 Pavlakis G M, Sakorafas G H, Anagnostopoulos G K. Intestinal metastases from renal cell carcinoma: a rare cause of intestinal obstruction and bleeding.  Mt Sinai J Med. 2004;  71 127-130
• 2 Merino C, Moles J R, Rodrigo A et al. [Uncommon etiology of gastrointestinal bleeding: duodenal metastases from renal cell carcinoma.]  Gastroenterol Hepatol. 2005;  28 221-224
• 3 Weiss L, Harlos J P, Torhorst J et al. Metastatic patterns of renal carcinoma: an analysis of 687 necropsies.  J Cancer Res Clin Oncol. 1988;  114 605-612
• 4 Pezzoli A, Matarese V, Boccia S et al. Gastrointestinal bleeding from gastric metastasis of renal cell carcinoma, treated by endoscopic polypectomy.  Endoscopy. 2007;  39 (Suppl 1) E52
• 5 Sridhar S S, Haider M A, Guindi M, Moore M J. A case of small bowel obstruction due to intraluminal metastases from metastatic renal cell cancer.  Oncologist. 2008;  13 95-97