- A 65-year-old male presented with a left iliac fossa mass and changes in bowel habits. CT and examination revealed a large sigmoid colon and rectal mass. He underwent exploratory laparotomy and Hartmann's procedure with resection of the mass and nodes. Pathology found a clear cell carcinoma. - Follow up CT found no evidence of recurrence but a stationary small renal mass. Options for the renal mass include radical nephrectomy or modifying the incision for access. Restoring bowel continuity may be considered with possible loop ileostomy protection. - Renal cell carcinoma is known for its varied presentations and unpredictable behavior, sometimes presenting as unusual metastases that require individualized management even for solitary or

1. Case Presentation
Ihab Samy
Lecturer of Surgical Oncology
National Cancer Institute
Cairo University
2012

2.  65 years old male patient presented with left
iliac fossa mass since 2 weeks of gradual
onset and progressive course. Change in
bowel habits and drops of blood with
defecation since then.
 No previous history of
operations,medications nor hospitalizations.
 Examination revealed palpable lt. iliac fossa
mass about 7X5 cm. PR  NAD
 Labs were normal apart from Hgb. 10gm/dl
and serum Albumin 3gm./dl CXR Free.

3.  CT Abdomen and pelvis with contrast revealed large
sigmoid colon and upper rectal mass about 11x8
cm. +lt. lower pole small renal mass about 2x2 cm.
 Inspite this large colonic mass , he was not
obstructed and passed stools patched with irregular
amouts of blood.
 Patient was scheduled for Lower GI endoscopy and
prescribed a regimen of Konakion , Kapron and
Dicynone till the day of Colonoscopy.

4. Chest X-ray PA view

9.  However before the time of Colonoscopy he
developed acute attack of bleeding per rectum
which turned the case to be an emergency.
 Exploratory laparotomy was done after an
adequate short course of rehydration and
electrolytes stabilization at the ICU.
 Exploration through a lower midline incision
revealed large mass involving from the mid-
descending, sigmoid and upper rectum with large
inf. Mesenteric LNs.

10.  The mass was resected along with the inf.
Mesenteric nodes.
 Hartmann’s procedure with terminal lt.
hypochondrial colostomy was done.
 The patients passed through a smooth PO course
with good recovery and early ambulation without
any detectable morbidities.
 Discharged on the 7th PO day for follow up a week
later

13. Pathology Report
 Gross: Specimen 48 cm. long on opening showed a
polypoid fungating whitish mass 12x10x4cm.
Submucosal and muscle wall infiltation along the
segment sparing in most parts the mucosa.
 Microscopic: clear vacuolated multi-nucleated cells
separated by fibrovascular stroma. CK and Vimentin
+ve S-100 negative. However vimentin staining is more
intense and profuse than CK. 13 from 13 Nodes
showed reactive hyperplasia. SM –ve.

14. Clear Cell Carcinoma
Uncertain whether primary or secondary

15.  Follow-up CT Abdomen and pelvis 3 weeks
later  Noevidence of local tumor residue or
recurrence. Stationary course of the
previously noted lower pole Lt. renal mass.
 Bone Scan  Free CXR and CT chest
Free
 Labs Normal

19. ?
 Putting in mind that the patient does not complain of any
urinary tract symtoms.
 Should we proceed for Lt Radical nephrectomy?
 Putting in mind the position of the terminal colostomy
 Should we release the terminal colostomy to have access to
the Lt. Kidney? What type of incision should be done?
 Putting in mind the (Hartmann’s)
 Should we restore the bowel continuity)?
 Should we protect the anastomosis with a loop ileostomy?

20. Uncommon sites of
Metastases from RCC

21.  Solitary Pancreatic Metastasis of Renal Cell
Cancer Treated by Pancreaticoduodenectomy:
A Case Report
E.E. Piccinini, MD; G. Ugolini, MD; G. Rosati, MD; N.C.M. Salfi, MD(*); S. Marroccu, MD; M. Del Governatore,
MD; and A. Conti, MD;
of the Istituto di Clinica Chirurgica III (*I Servizio di Anatomia Patologica), Policlinico Santa'Orsola,
Universita degli Studi di Bologna, Italy.
 Isolated RCC metastasis to the head of the pancreas detected six
weeks after a left radical nephrectomy that was successfully treated
by pancreaticoduodenectomy.
 An adjuvant treatment with vinblastine plus alpha-interferon was
prescribed. The patient is alive with no evidence of disease at 16
months of follow-up.

22.  A 51 year old man presented
 Upper and lower gastrointestinal endoscopy showed polypoid
gastric masses in the cardia, fundus, and antrum.
 Biopsies revealed the pathology described below.
 CT scan additionally demonstrated an enlarged lymph node in the
gastrohepatic ligament.
 The patient had a subsequent gastrectomy, esophagojejunostomy.
 Diagnosis: Metastatic Renal Cell Carcinoma, clear cell type

23.  Renal cell carcinoma (RCC), with
metastases in the maxillary sinus
extending to the oral cavity with
mediastinal lymphadenopathy.
Jain V, Shergill GS, Gupta K, Bhandari RK. Case report: Renal cell carcinoma:
Unusual metastases. Indian J Radiol Imaging 2000;10:249-51
Renal cell carcinoma is the third most frequent primary
infraclavicular tumor after lung and breast carcinoma to
metastasize to the head and neck.
it is the most frequent infraclavicular primary tumor to
metastasize to the nasal cavity and paranasal sinuses (40-50%)

24.  Rt. Renal cell carcinoma with
secondaries in the opposite suprarenal.
Deodhar SD, Mehendale VG, Bhave GG. Renal cell carcinoma with
unusual metastases (A case report). J Postgrad Med 1978;24:55-7
 The left suprarenal was markedly enlarged, 10 cm
x 7.5 cm, well capsulated, having a variegated
consistency.
 Cut surface showed greyish white lobulated
tumour deposit completely replacing the normal
suprarenal tis-sue (Autopsy)

25.  Renal Cell Carcinoma Presenting as Metastasis
to Scrotum and Spermatic Cord
Panda P, Sharma S, Chandel UK, Jaswal KS, Jhobta A, Bhatia V. Renal Cell
Carcinoma Presenting as Metastasis to Scrotum and Spermatic Cord. Online J
Health Allied Scs. 2012;11(1):21
 Skin is a rare site of metastasis compared to other
organs.
 Cutaneous metastasis of RCC implies poor prognosis.
 Metastatic tumor of the spermatic cord from RCC
usually presents as a painless mass or swelling.

26.  Thus renal cell carcinoma is characterized by
its varied presentation and variable clinical
course.
 It is the most unusual and unpredictable
cancer. Like tuberculosis and syphilis, it is one
of the great mimics in clinical medicine.
 Recognizing the unusual presentation and
natural history of an RCC can have a profound
effect on patient management.

27. Unusual Metastases in Renal Cell Carcinoma: A Single Institution
Experience and Review of Literature
Cynthia Villarreal-Garzaa, b, Sandra I. Perez-Alvareza, Ivan R. Gonzalez-Espinozaa, Eucario Leon-Rodrigueza
 Background: To report location and management of atypical metastases from renal cell carcinoma (RCC) in the
Instituto Nacional de Ciencias Medicas e Investigacion Salvador Zubiran (INCMNSZ) in Mexico City.
 Methods: Between 1987 to 2009, 545 patients with RCC were retrospectively identified at the INCMNSZ. Patients with
unusual metastases confirmed by histopathology were analyzed. Epidemiological, clinical, diagnosis, treatment and
outcome data were reviewed.
 Results: Sixty patients developed 98 unusual metastases secondary to RCC. The group was comprised of 35 men
(58.3%), with a median age of 60 years at diagnosis. Metachronous unusual metastases with primary renal cancer
were observed in 37 individuals (61.7%). Median time from primary RCC diagnosis to the first unusual metastasis was
16.5 months. Median survival from diagnosis of the first unusual metastasis to death was 5.0 months (CI 95%: 2.8-7.2
months). Patients with an initial solitary metastatic lesion in an unusual site (28.3%) had a better survival compared to
patients who primarily presented with multiple metastases, 17.0 (CI 95%: 6.1-27.9) Vs 3.0 months (CI 95%: 0.9-5.1), p
= 0.001. Unusual metastasis resection (21 patients) improved survival, 25.0 (CI 95%: 5.1-44.9) Vs 3.0 months (CI
95%: 0.8-5.2), p < 0.0001. No survival difference was observed between localization of unsual metastases (p = 0.72).
 Conclusions: In patients with advanced RCC we suggest an individual diagnostic and surgical approach to achieve
complete resection with disease-free margins, even in the presence of unusual metastatic sites, multifocality, or history
of metastasectomy. These strategy might provide not only palliation for symptoms, but an opportunity for meaningful
disease free and overall survival.

28. Thank You