A Solitary Hematogenous Metastasis to the Gastric Wall From Renal Cell Carcinoma Four Years After Radical Nephrectomy

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The incidence of tumor metastasis to the stomach is very rare (0.2%-0.7%) in autopsy studies (1,2). Gastric metastatic tumors have been reported to result mainly from primary breast cancers, lung cancers, and melanoma (1-3). Metastatic tumor from renal carcinoma is very rare (4-8). There are two kinds of proliferation in renal carcinoma: slow and rapid growth (6,9). In our patient, the examinations of various organs were performed every year after surgical resection, but there were no abnormal findings for 4 years. An elevated lesion in the stomach was found for the first time by gastric endoscopy 4 years after resection. However, a precise diagnosis using biopsy specimens was not made for 1 year, although the examinations were performed every 6 months.We present and discuss a rare case of gastric metastatic tumor from left renal carcinoma.CASE REPORTIn a 55-year-old man, who was diagnosed with a clear cell carcinoma of the left kidney by abdominal ultrasonography for health examination, a tumor was radically resected in June 1990, and he was administered 6 million units of interferon-α after surgical resection. According to TNM classification, the tumor was T2a, N0, M0, V0 and stage 1, and its histologic evaluation was clear cell subtype grade 1. No metastatic tumors in other organs were found, although we investigated annually, even with gastrointestinal endoscopy.A small elevated lesion with central ulceration was detected for the first time by gastrointestinal endoscopy in the lesser curvature of the upper body of the stomach in November 1994. Biopsy specimens obtained from the top of the lesion showed no specific finding. Therefore, endoscopic examination and the evaluation of biopsy specimens were repeated every 6 months. There was little change in the shape and size of the tumor, but the central ulceration seemed to be larger. Biopsy specimens obtained 12 months later showed clear cell carcinoma, just as the specimens of renal cancer resected surgically showed. Endoscopic ultrasonography showed that the relative hypoechoic lesion existed mainly in the first and second layers and partially in the third (Fig. 1). These findings suggested that the tumor was expected to lie mainly in the mucosa and partially in the submucosa, although its growth was slow. No other metastatic lesions in other organs were found as far as we examined, including by barium enema, systemic computed tomography scan, abdominal ultrasonography, barium scintigraphy, and bone scintigraphy. Laboratory data of blood, urine, and feces showed no abnormal values except a slightly high value of immunosuppressant acid protein (561 mg/ml). Total gastrectomy and regional lymphadenectomy were performed in December 1995. Histologic findings revealed grade 1 clear cell subtype. The size of this lesion was 15 mm by 13 mm, and macroscopic findings corresponded correctly with the image from endoscopic ultrasonography (Fig 2). No other lesions in the stomach were found during surgery. The postoperative diagnosis was a metachronous, hematogenous, solitary gastric tumor metastasized from the left renal cell carcinoma. No additional metastasis or recurrence has been detected 17 months after discharge from our hospital.DISCUSSIONMetastatic tumor in the stomach is very rare (1,2). In general, many patients have nonspecific clinical problems such as primary gastric cancer, but a few are at the onset of metastic gastric tumor with perforation or bleeding during chemotherapy for a primary lesion (10). As for the metastatic process, tumors metastasized hematogenously implant in the submucosa forming circumscribed plaque.

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