Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2013  |  Volume : 24  |  Issue : 1  |  Page : 100--104

Metastatic renal cell carcinoma of gall bladder


Deepali Jain, Prem Chopra 
 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India

Correspondence Address:
Prem Chopra
Consultant, Department of Pathology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi
India

Abstract

Renal cell carcinoma (RCC) is well known for its propensity to metastasize to unusual sites. Metastasis to the gall bladder (GB) has been reported in the literature rarely. We herein report an interesting case of metastatic RCC, which presented with cholecystitis. Gall bladder is a rare site of metastasis of RCC. Polypoid lesions of the GB in patients who have a synchronous or a prior history of RCC should be considered as metastatic lesions. It needs to be differentiated from primary clear cell carcinoma of the GB with the help of immunohistochemistry.



How to cite this article:
Jain D, Chopra P. Metastatic renal cell carcinoma of gall bladder.Saudi J Kidney Dis Transpl 2013;24:100-104


How to cite this URL:
Jain D, Chopra P. Metastatic renal cell carcinoma of gall bladder. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2021 Oct 27 ];24:100-104
Available from: https://www.sjkdt.org/text.asp?2013/24/1/100/106301


Full Text

 Introduction



Renal cell carcinoma (RCC) has a high metastatic potential associated with synchronous or metachronous metastatic disease. The lesion is known to metastasize to the lung, bone, liver, and brain. [1] Approximately 30% of patients present with metastatic disease at the time of presentation. [2] Involvement of the gall bladder (GB) in patients with RCC is extremely rare, being present in less than 0.6% of autopsies. [3] We present a 49-year-old woman with metastasis of metachronous RCC to the GB.

 Case Report



A 49-year-old female presented in the year 2003 with swelling all over the body, eyes, and face. Her past history was unremarkable except for essential hypertension, which was controlled with medications. She was non-diabetic. Contrast-enhanced computerized tomography (CECT) of whole abdomen showed a well-defined mass measuring 5 × 5 × 5.2 cm in the middle and lower pole of the left kidney. Renal scintigraphy revealed bilateral compromised renal cortical function. Within two weeks of presentation, left radical nephrectomy was performed. The entire kidney was removed without disruption. The specimen revealed an intact 5 × 5 cm tumor located in the mid-portion of the kidney. The tumor was near, but did not invade the renal pelvis. No invasion of the renal vein was noted. Microscopically, the tumor was a clear cell type of RCC without involvement of the renal capsule, pelvis, hilar vessels, or lymph nodes. However, lymphatic invasion was present. The remaining portion of the kidney showed features of benign nephrosclerosis. A scheduled follow-up with abdominal-pelvic CT scan was performed one year later. There was no evidence of recurrent tumor. In the year 2005, the patient underwent live related renal allograft transplant due to chronic renal failure. Over the next four years of follow-up, the patient reported no evidence of recurrence.

Six years after resection of the primary renal neoplasm, the patient presented with right upper quadrant abdominal pain. Abdominal ultrasonography (USG) showed calculi and a single polypoidal lesion (14.5 × 10 mm) in the fundus of the GB. A clinical diagnosis of reactive lesion was considered. Cholecystectomy was performed subsequently and the specimen was sent for histopathology. On gross examination, the GB was 8 cm in length. A polypoidal structure measuring 2 × 1.8 × 0.5 cm was identified on the mucosal aspect of the fundus [Figure 1]A. The GB including the fundal polyp was entirely processed.{Figure 1}

Histologic examination showed a lesion present within the lamina propria [Figure 1]B. It revealed surface ulceration focally that was covered by acute necrotizing inflammatory exudate. The lesion was composed of tightly placed groups and nests of cells separated by thin and delicate fibrovascular septae. Individual tumor cells were large and polyhedral, and contained abundant amount of clear/vacuolated cytoplasm. Few groups of cells showed eosinophilic granular cytoplasm [Figure 1]C. The nuclei were round and hyperchromatic with finely granular chromatin. There was mild nuclear pleomorphism. Macrocysts, areas of fresh hemorrhage, and myxoid degeneration were also observed amidst the tumor cells. The remaining portion of the GB revealed papillary hyperplasia of the mucosal lining epithelium with chronic inflammation and fibrosis of the wall. The GB mucosal cells had no atypia.

Immunohistochemistry was performed for pancytokeratin, vimentin, and CD10. The tumor cells showed diffuse positivity for pancytokeratin and vimentin. CD10 was focally, although strongly, positive in few groups of tumor cells [Figure 1]D-F.

In view of morphological and immunohistochemical findings, a diagnosis of metastatic RCC in the GB was made.

 Discussion



Despite the great propensity of RCC for metastasizing synchronously and/or metachronously to different anatomic sites, metastasis to the GB is extremely rare. Twenty-three cases of GB metastasis of RCC have been reported in the literature [Table 1]. [4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25] There is a striking male predominance in the reported cases, although our patient is a female. Latent distant metastasis is characteristic of RCC and manifests more than ten years after nephrectomy in about 10% of patients. [26] The time interval of metastasis ranged from three months to 27 years in metachronous RCC. The present case developed metastasis six years after a diagnosis of RCC. It is evident from the review that longer interval is associated with better survival.{Table 1}

The presumed mode of GB involvement from kidney follows the hematogenous route which initially occurs as a small flat nodule below the mucosal layer and then it grows as a pedunculated nodule. [10] Therefore, the tumor had polypoid appearance in majority of the reported cases. [10],[15],[24] In very rare cases, RCC can metastasize to the GB, mimicking acute cholecystitis on clinical examination. [25] In the present case, cholecystectomy was performed for chronic cholecystitis. However, on gross inspection, an incidental polypoidal mass was seen at the fundus. CECT scan or endoscopic USG can reveal hypervascular polypoid lesions in the GB. However in the present case, CECT scan was not performed and plain USG could not detect hypervascularity. Furukawa and Mizuguchi [13] recommended that patients with hypervascular polypoid lesion in the lumen of the GB, who have a synchronous or a prior history of RCC should be considered as metastatic lesion regardless of the presence or absence of signs or symptoms. Although in the present case the tumor was clearly present in the lamina propria and the mucosa showed no dysplasia, primary clear cell carcinoma of the GB should be excluded. The distinction of metastatic RCC from primary clear cell carcinoma of the GB is especially difficult when the metastatic solitary deposit is the first manifestation of an RCC. Clear cell carcinomas of the GB usually have a component of conventional adenocarcinoma that allows distinction from metastatic RCC with H&E stain. [27] In view of the prior history of clear cell RCC and immunohistochemical findings, we established the final diagnosis of metastatic RCC. Our patient was on immunosuppressive drugs that might have been the accelerating factor for the metastasis.

It is generally agreed that if a solitary metastatic lesion is detected, excision should be considered as it is associated with increased survival. Survival is better after resection of a metachronous metastasis than in patients presenting with synchronous primary tumor and metastasis. Although in our case the lesion was completely resected, the patient needs to be followed up regularly for any other metastasis. The patient was referred to oncologist for further management.

References

1Saitoh H. Distant metastasis of renal adenocarcinoma. Cancer 1981;48:1487-91.
2Lokioch J, Harrison JH. Renal cell carcinoma: Natural history and chemotherapeutic experience. J Urol 1975;114:371-4.
3Weiss L, Harlos JP, Torhorst J, et al. Metastatic patterns of renal carcinoma: An analysis of 687 necropsies. J Cancer Res Clin Oncol 1988;114:605-12.
4Botting AJ, Harrison EG Jr, Black BM. Metastatic hypernephroma masquerading as a polypoid tumor of the gallbladder and review of metastatic tumors of the gallbladder. Proc Staff Meet Mayo Clin 1963;38:225-32.
5Fullarton GM, Burgoyne M. Gallbladder and pancreatic metastases from bilateral renal carcinoma presenting with hematobilia and anemia. Urology 1991;38:184-6.
6Golbey S, Gerard PS, Frank RG. Metastatic hypernephroma masquerading as acute cholecystitis. Clin Imaging 1991;15:293-5.
7Satoh H, Iyama A, Hidaka K, Nakashiro H, Harada S, Hisatsugu T. Metastatic carcinoma of the gallbladder from renal cancer presenting as intraluminal polypoid mass. Dig Dis Sci 1991;36:520-3.
8Nagler J, McSherry CK, Miskovitz P. Asymptomatic metachronous metastatic renal cell adenocarcinoma to the gallbladder. Report of a case and guidelines for evaluation of intraluminal polypoid gallbladder masses. Dig Dis Sci 1994;39:2476-9.
9Coþkun F, Cetinkaya M, Cengiz O, Adsan O, Kulaçoðlu S, Eroðlu A. Metastatic carcinoma of the gallbladder due to renal cell carcinoma in the ectopic kidney. Acta Chir Belg 1995; 95:56-8.
10Pagano S, Ruggeri P, Franzoso F, Brusamolino R. Unusual renal cell carcinoma metastasis to the gallbladder. Urology 1995;45:867-9.
11King DH, Centeno AS, Saldivar VA, Sarosdy MF. Renal cell carcinoma metastatic to the gall bladder or prostate: Two case reports. Urology 1995;46:722-5.
12Lombardo FP, Hertford DE, Shanahan EM, Kazam E. Color Doppler ultrasonographic evaluation of renal cell carcinoma metastasis to the gallbladder. J Ultrasound Med 1996;15: 725-8.
13Furukawa H, Mizuguchi Y, Kanai Y, Mukai K. Metastatic renal cell carcinoma to the gallbladder: Color Doppler sonography and CT findings. AJR Am J Roentgenol 1997;169: 1466-7.
14Sparwasser C, Krupienski M, Radomsky J, Pust RA. Gallbladder metastasis of renal cell carcinoma. A case report and review of the literature. Urol Int 1997;58:257-8.
15Celebi I, Guzelsoy M, Yorukoglu K, Kirkali Z. Renal cell carcinoma with gallbladder metastasis. Int J Urol 1998;5:288-90.
16Kechrid M, Malik GH, Al-Mohaya S, et al. Renal cell carcinoma of contralateral kidney with secondaries in gallbladder eight years after nephrectomy. Saudi J Kidney Dis Transpl 2000;11:587-92.
17Aoki T, Inoue K, Tsuchida A, et al. Gallbladder metastasis of renal cell carcinoma: Report of two cases. Surg Today 2002;32:89-92.
18Limani K, Matos C, Hut F, Gelin M, Closset J. Metastatic carcinoma of the gallbladder after a renal cell carcinoma. Acta Chir Belg 2003; 103:233-4.
19Park JS. Metastatic renal cell carcinoma of the gallbladder. Yonsei Med J 2003;44:355-8.
20Andoh H, Kurokawa T, Yasui O, Shibata S, Sato T. Resection of a solitary pancreatic metastasis from renal cell carcinoma with a gallbladder carcinoma: Report of a case. Surg Today 2004;34:272-5.
21Ishizawa T, Okuda J, Kawanishi T, Kitagawa T, Yakumaru K, Sekikawa T. Metastatic renal cell carcinoma of the gallbladder. Asian J Surg 2006;29:145-8.
22Pandey D, Kane SV, Shukla PJ, Shrikhande SV, Tongaonkar HB. Isolated gall bladder metastasis from renal cell carcinoma. Indian J Gastroenterol 2006;25:161-2.
23Hellenthal NJ, Stewart GS, Cambio AJ, Delair SM. Renal cell carcinoma metastatic to gall-bladder: A survival advantage to simultaneous nephrectomy and cholecystectomy. Int Urol Nephrol 2007;39:377-9.
24Nojima H, Cho A, Yamamoto H, et al. Renal cell carcinoma with unusual metastasis to the gallbladder. Hepatobiliary Pancreat Surg 2008; 15:209-12.
25Sand M, Bechara FG, Kopp J, Krins N, Behringer D, Mann B. Gallbladder metastasis from renal cell carcinoma mimicking acute cholecystitis. Eur J Med Res 2009;14:90-2.
26McNichols DW, Segura JW, De Weerd JH. Renal cell carcinoma: Long term survival and late recurrence. J Urol 1981;126:17-23.
27Vaíllo A, Rodríguez-Recio FJ, Gutiérrez-Martín A, Ballestín C, Ruiz-Liso JM. Fine needle aspiration cytology of clear cell carcinoma of the gallbladder with hepatic infiltration: A case report. Acta Cytol 2004;48:560-4.