Surg TodayJpn J Surg (2000) 30:94–97

Reprint requests to: C. Volpe(Received for publication on Dec. 15, 1998; accepted on July13, 1999)

Pancreaticoduodenectomy for Metastatic Renal Cell Carcinoma:Report of a Case

Nikhil Mehta, Carmine Volpe, Timothy Haley, L. Balos, Edward L. Bradley III, and Ralph J. Doerr

State University of New York at Buffalo School of Medicine and Biomedical Sciences, Department of Surgery, Buffalo General Hospital,100 High Street, Buffalo, NY 14203, USA

geon to be confronted with a solitary metastasis in thehead of the pancreas and therefore, the role of surgicalresection in this setting is poorly defined and difficultto substantiate. A review of the literature revealedthat only 17 pancreaticoduodenectomies have beenperformed for metastatic renal cell carcinoma. Herein,we report the 18th patient to undergo pancreaticoduo-denectomy for metastatic renal cell carcinoma, aftertumor surveillance, including positron emission tomog-raphy (PET), suggested a solitary malignancy in thehead of the pancreas, 19 years after a nephrectomy forrenal clear cell carcinoma of the right kidney.

Case Report

A 58-year-old man presented to our hospital with symp-toms of malaise and vague epigastric abdominal painwhich was dull in nature and not related to meals or achange in position. His past medical history was signifi-cant in that renal clear cell carcinoma of the right kidneyhad been diagnosed in 1978 and treated with a rightradical nephrectomy. No adjuvant therapy had beenadministered at that time. A right thoracotomy hadbeen carried out 12 years later to remove a solitarynodule of the right upper lobe of the lung, which provedto be metastatic renal cell carcinoma. Physical examina-tion revealed a well-nourished, nonicteric man who ap-peared his stated age. There was no adenopathy on neckexamination, his chest was clear to auscultation, and hisabdomen was nontender with no palpable masses.Laboratory studies, including liver function tests, car-cinoembryonic antigen, and carbohydrate antigen 19-9levels, were within normal limits. A computed tomogra-phy (CT) scan identified enlargement of the head of thepancreas without a discrete mass, and a dilated mainpancreatic duct (Fig. 1). Celiac angiography showed nostenosis or occlusion of the peripancreatic vessels. PETscanning demonstrated a discrete area of increased

Abstract: Metastasis to the pancreas from a distant primarycancer is uncommon, most cases being detected in the ad-vanced stages of disease, often multiple in number, and dif-fusely displayed beyond surgical salvage. A solitary metastasisin the head of the pancreas is rarely encountered and althoughpotentially amenable to surgical resection, surgeons are hesi-tant to perform pancreaticoduodenectomy for metastaticdisease. Renal cell carcinoma is one malignancy with a pro-pensity to metastasize to the pancreas. We report herein thecase of a solitary pancreatic metastasis from renal cell carci-noma successfully treated by pancreaticoduodenectomy in amiddle-aged man. A discussion on the indications and effec-tiveness of performing pancreaticoduodenectomy for meta-static renal cell carcinoma is also presented.

Key Words: Whipple procedure, solitary pancreaticmetastasis

Introduction

The surgical resection of visceral metastases, particu-larly in the liver and lung, is a well-accepted method oftreatment.1,2 In fact, survival rates of 30%–40% havebeen achieved following complete resection of hepaticmetastases from a colon or rectal primary.3,4 On theother hand, surgeons are reluctant to perform pan-creaticoduodenectomy to completely excise metastaticlesions in the head of the pancreas. Metastatic tumors ofthe pancreas are rare, accounting for less than 5% of allpancreatic malignancies, and the majority originatefrom primary tumors of the large bowel, lung, breast,and kidney.5 In most cases, pancreatic metastases implyincurability and palliative measures are the most appro-priate form of treatment. It is extremely rare for a sur-

metabolic activity in the head of the pancreas consistentwith a malignant process and/or inflammation (Fig. 2).Endoscopic retrograde cholangiopancreatographyconfirmed the finding of main pancreatic duct obstruc-tion, previously identified on the CT scan. The preop-erative differential diagnoses included primarypancreatic adenocarcinoma, chronic pancreatitis, muci-nous ductal ectasia (MDE), and metastasis from renalcell carcinoma.

At laparotomy, a 3-cm mass, firm to palpation,was found in the head of the pancreas. No othermasses were felt in the remainder of the pancreasand abdominal exploration revealed no evidence ofmetastatic disease. Based on the finding of an isolatedsolitary mass in the head of the pancreas, the decisionwas made to proceed with a pancreaticoduodenec-tomy. There were no postoperative complicationsand the patient remains disease-free 6 months after hisoperation.

Pathology

Gross FindingsSections of the pancreas revealed a poorly circum-scribed, firm, white nodular mass measuring 3 3 3.5 32.4 cm. On cut section, a separate, cylindrical plug ofbrownish tissue was identified in the lumen of thepancreatic duct, but was not attached to the wall(Fig. 3). The remainder of the pancreatic tissue main-tained its lobular architecture and the rest of the speci-men appeared grossly normal.

Microscopic FindingsSections showed an infiltrating epithelial neoplasmwithin the pancreas and pancreatic duct. There wasdense fibrosis and chronic inflammation with markedacinar atrophy in areas surrounding the tumor. The cellcytoplasm was predominantly clear, but a few cells hadgranular cytoplasm (Fig. 4). The nuclei were round,central, or eccentric with prominent nucleoli. Immuno-histochemical staining was positive for low- andhigh-molecular-weight keratin and vimentin, beingconsistent with origin from a renal primary.

Discussion

Pancreaticoduodenectomy is the treatment of choicefor localized periampullary malignancies, which include

Fig. 1. Computed tomography scan of the abdomen demon-strated diffuse enlargement of the head of the pancreas with adilated main pancreatic duct

Fig. 2. Positron emission tomography scan image. The coro-nal view showed increased uptake of the isotope 18-FDG inthe area of the head of the pancreas (arrow)

N. Mehta et al.: Pancreatic Metastasectomy 95

tumors of the distal common bile duct, ampulla, duode-num, and head of the pancreas. This is based on thesurvival advantage afforded to patients able to undergopancreatic resection, compared with those who undergobypass alone, or no surgery at all.6,7 Yeo et al. recentlyreported a 5-year actual survival rate of 28% for pa-tients undergoing pancreaticoduodenectomy for peria-mpullary adenocarcinoma.8 Fortunately, as the survivalhas improved, so has the morbidity and mortality asso-ciated with pancreaticoduodenectomy. In fact, high-volume centers in the 1990s currently report operativemortality rates approaching 0%.9,10 Prolonged survivalat a minimal risk has fueled the idea of liberalizing theuse of pancreaticoduodenectomy beyond its curativerole.

With this in mind, Lillemoe et al. has advocated theuse of palliative pancreaticoduodenectomy combinedwith postoperative chemoradiation for the treatment ofpatients with pancreatic carcinoma and local residualdisease.11 Likewise, Harrison and Brennan recentlyreported the cases of seven patients who underwent

pancreaticoduodenectomy for a metastatic tumor in thehead of the pancreas.12 The most common metastatictumor in their series was renal cell carcinoma, found inthree of these seven patients. The median survival timeof these seven patients was 40 months, with a 2-yearsurvival rate of 70%.

A recent collective review of pancreatic resectionsfor solitary pancreatic metastasis from renal cell carci-noma cited 37 pancreatic resections, 17 of which (46%)were pancreaticoduodenectomies.12–15 Metastases weremetachronous in 28 patients (76)%, and nearly twothirds of the patients remained disease-free for 10 yearsor longer. The head of the pancreas was the metastaticsite in 20 of the 37 patients (54%), the mean tumor sizewas 5.3cm, and the mean survival after resection was14 months, with a range of 2–60 months. This comparesfavorably to the median survival of 8.7 months reportedfor metastatic periampullary lesions treated conserva-tively at the Mayo Clinic.5 Other studies also reportimproved survival following resection of solitary meta-stasis from renal cell carcinoma with 3-year survivalrates ranging from 19% to 43%.16

The incidence of solitary metastasis from renal cellcarcinoma is low, at around 1%–3%.13 In general, pan-creatic metastases are often multiple, associated withwidespread disease, and observed in terminal patients.However, in the subset of patients with a solitary me-tastasis confined within the pancreas, resection can ren-der patients disease-free and prolong their survival.

In conclusion, pancreaticoduodenectomy is rarely in-dicated for metastasis to the pancreas from renal cellcarcinoma; however, surgery is an option for patientswith a long, disease-free interval after nephrectomy, asolitary metastasis requiring less than a total pancreate-ctomy to achieve complete resection, and the absenceof widely disseminated disease. Such patients who have

Fig. 3. Low-power microscopy demonstrated a nest of tumorcells within the lumen of the pancreatic duct (340)

Fig. 4. High-power microscopy illustrates malignant clearcells (3100)

96 N. Mehta et al.: Pancreatic Metastasectomy

undergone resection should have a prognosis at leastequal to that expected for patients with a primaryperiampullary carcinoma.

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12. Harrison LE, Merchant N, Cohen AM, Brennan MF (1997)Pancreaticoduodenectomy for nonperiampullary primary tumors.Am J Surg 174:393–395

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