Treatment of Bleeding Secondary to Gastric Metastases from Renal Cell Carcinoma Primary

Abstract

Journal of SurgeryGastrointestinal bleeding IntroductionGastric metastases from primary renal cell carcinoma (RCC) are considered rare. However, there are nearly 50 cases described in the literature. We present two cases of patients presenting with clinically significant bleeding from gastric RCC metastasis; utilising lessons learnt from these cases, and from a literature review, we propose a model of treatment for gastrointestinal (GI) bleeding secondary to metastases from RCC. Case 1A 68-year-old Caucasian lady (Ms DA) was referred to the emergency department (ED) by her general practitioner following a collapse. She complained of fatigue, anorexia and weight loss of around 1.5 stone over 6 months. Blood tests revealed a microcytic anaemia (haemoglobin = 51 grams/litre, mean corpuscular volume (MCV) = 71 femtolitres).Past medical history was significant for left-sided clear cell renal cell carcinoma 21 years prior to this presentation, for which she underwent a nephrectomy. Her drug history included levothyroxine, aspirin and prochlorperazine. Ms DA lived with her partner, was a non-smoker and consumed no alcohol. Physical examination at the time of presentation did not reveal anything of note.Initial treatment involved resuscitation and transfusion of 3 units of packed red cells and an infusion of vitamin B complex. Her haemoglobin levels returned to normal parameters following this.A computerised tomography (CT) scan showed an elevated soft tissue lesion arising from the posterior wall of the central stomach with no evidence of metastatic disease.Ms DA subsequently underwent a gastroscopy which showed 2 ulcerated, sessile polyps, the largest measuring 20 millimetres, and a submucosal polyp on the greater curvature of the stomach. All lesions were biopsied. A colonoscopy was attempted but was limited by melaena.A positron emission tomography CT scan and a nuclear medicine bone scan were performed, neither of which showed metastatic disease.Histological examination of the biopsies showed clear cell RCC metastasis. Her case was discussed at a multi-disciplinary meeting (MDM), where it was decided that a laparoscopic gastric wedge resection would be most appropriate for her. This procedure was performed successfully without post-operative complications.Histology of the resected specimen showed a well circumscribed 15 millimetre nodule in the submucosa with ulceration into the mucosa, no spread into stomach muscle and clear surgical margins.Since this, Ms DA has annual surveillance gastroscopies which have not shown any evidence of recurrence (Figure 1). AbstractGastric metastases from primary renal cell carcinoma (RCC) are uncommon, but not as rare as once thought. These metastases frequently present with upper gastrointestinal (UGI) bleeding. We report two such cases, and utilising lessons learnt from them, and from a literature review, propose a model of treatment for UGI bleeding secondary to metastases from RCC primaries.Both patients presented with clinically significant UGI bleeding secondary to RCC metas...