Late solitary pancreatic metastasis from clear-cell renal cell carcinoma: A case report

ABSTRACT

Solitary pancreatic metastasis from renal cell carcinoma (RCC) is uncommon and may present decades after nephrectomy. We report an unusually late (17-year) solitary pancreatic metastasis from clear-cell RCC treated with curative resection. A 66-year-old man with a prior right nephrectomy 17 years earlier presented with 3 months of unintentional weight loss. Contrast-enhanced computed tomography (CECT) demonstrated an 8.0 × 5.0 cm hypervascular exophytic mass in the pancreatic neck body. Tumor markers (CEA, CA19-9) were within normal limits. Because of lesion vascularity, preoperative percutaneous biopsy was deferred. The patient underwent distal pancreatectomy with splenectomy. Gross and histology showed sheets of polygonal clear cells with prominent vasculature; immunohistochemistry was positive for CD10 and PAX8 and negative for synaptophysin and chromogranin, confirming metastatic clear-cell RCC. Resection margins were negative (R0). The patient declined adjuvant systemic therapy and remains disease-free at 36 months post-surgery. This case illustrates the potential for extremely late solitary pancreatic metastasis from RCC and underscores the importance of lifelong surveillance in RCC survivors. In selected patients, complete surgical resection can achieve durable disease control, even in the absence of adjuvant therapy.

Introduction

Renal cell carcinoma (RCC) is a malignant epithelial tumor accounting for 2–3% of adult cancers and is characterized by an unpredictable clinical course, including the potential for late recurrences many years after nephrectomy. Common metastatic sites include the lungs (50–60%), bones (30–40%), liver (30–40%), and brain (5%). In contrast, pancreatic metastases are exceedingly rare, representing approximately 0.3% of all pancreatic tumors.[1,2]

This case highlights the value of considering metastatic RCC in the differential diagnosis of pancreatic masses, even decades after primary tumor treatment, and this case bridges a critical knowledge gap by demonstrating that late solitary pancreatic metastasis from clear-cell RCC is both diagnosable and curable. For practitioners, it refines diagnostic suspicion and surgical strategy; for patients, it provides optimism for long-term survival through vigilant follow-up and individualized care.[3]

Patient Information

A 65-year-old male, with a history of left radical nephrectomy for clear-cell RCC 17 years earlier, presented with progressive weight loss for three months. There was no jaundice, abdominal pain, or gastrointestinal (GI) bleeding. Physical examination was unremarkable, and routine laboratory tests, including tumor markers (CEA and CA19-9), were normal.

Clinical Findings and Diagnostic Workup

The patient was moderately built with an Eastern cooperative oncology group (ECOG) performance status of 0. Vital signs were stable, and physical examination revealed no pallor, icterus, lymphadenopathy, or edema. Abdominal examination showed healed nephrectomy and port scars, a soft, non-tender abdomen, and no palpable masses or organomegaly; other systemic findings were unremarkable.

Baseline laboratory investigations, including complete blood count, liver and renal function tests, were normal. Tumor markers CEA and CA19-9 were within reference limits. Contrast-enhanced computed tomography (CECT) of the abdomen demonstrated an 8 × 5 cm hypervascular, exophytic mass arising from the neck and extending into the distal body of the pancreas, showing peripheral arterial enhancement with central necrosis. The lesion was closely abutting the splenic vessels and the left hepatic lobe without infiltration. The right kidney and gallbladder were surgically absent from prior nephrectomy and cholecystectomy. Owing to the lesion’s vascularity and location, a preoperative biopsy was avoided to minimize hemorrhagic risk [Figures 1,2 and Table 1].

Figure 1.

Contrast-enhanced computed tomography (CECT) of the abdomen showing an 8 × 5 cm exophytic mass (red arrow) arising from the neck and extending to the distal body of the pancreas, with peripheral arterial enhancement and central necrosis. The mass is in close contact with the left lobe of the liver without infiltration. Absent right kidney (yellow arrow) and absent gallbladder were also noted

Figure 2.

Photograph showing a well-circumscribed, highly vascular mass (center) arising from the neck of the pancreas and extending into the body, closely abutting the splenic vessels without encasement

Table 1.

Clinical time line of events

Year/Month	Event	Details
2002	Open right nephrectomy	Reports not available
2009	Laparoscopic cholecystectomy	For symptomatic cholelithiasis
2002–2019	Disease-free period	No symptoms or clinical evidence of recurrence
2019 Year 17– Month 4+	Symptom onset	Significant unintentional weight loss for 3 months; no abdominal pain, jaundice, or GI symptoms
	Diagnostic workup	CECT abdomen revealed an 8×5 cm exophytic mass from the pancreatic neck to the body
	Surgical intervention	Exploratory laparotomy with distal pancreatectomy and splenectomy; histology confirmed metastatic clear-cell RCC to pancreas
2019–Till date	Follow-up	Disease-free on surveillance, ECOG performance status 0

CECT=Contrast-enhanced computed tomography, GI=Gastrointestinal, RCC=Renal cell carcinoma

Clinical Timeline

The preoperative differential diagnoses included primary pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, and metastatic tumor from a remote primary malignancy. The decision was made to proceed with surgical exploration for diagnosis and management.

Therapeutic Intervention

Exploratory laparotomy revealed a well-defined, highly vascular mass arising from the pancreatic neck and extending into the body, without invasion of adjacent structures. The splenic vessels were preserved though closely abutted. A distal pancreatectomy with splenectomy was performed (operative time ≈ 2.5 h; blood loss ≈ 350 mL).

Grossly, the specimen contained a 6 × 7 × 2 cm hemorrhagic, multinodular tumor with an additional 4 × 2 × 2 cm nodule. Microscopically, polygonal cells with clear cytoplasm and prominent vasculature were observed. Immunohistochemistry showed CD10 positivity and synaptophysin negativity, confirming metastatic clear-cell RCC; all margins were tumor-free. Postoperative recovery was uneventful. The patient was discharged on day 6 and recovered fully. Although adjuvant sunitinib was advised, the patient declined systemic therapy and remains under surveillance [Figures 3–5 and Table 2].

Figure 3.

Gross specimen of the distal pancreatectomy showing a multinodular, hemorrhagic, gray-white tumor involving the body and tail of the pancreas, measuring 6 × 7 × 2 cm

Figure 5.

(a and b) Immunohistochemical marker profile comparison between clear-cell renal cell carcinoma (CCRCC), clear-cell carcinoma of the pancreas (CCCP), and clear-cell pancreatic endocrine tumor (CCPET) (5a-Left). “+” = positive staining; “–” = negative staining; “U” = uncertain. The patient’s tumor profile (CD10 positive, synaptophysin negative) aligns with CCRCC, confirming the metastatic origin. (original magnification × 200) (5b-Right)

Table 2.

Summary of laboratory diagnosis

Test name	Result	Normal range	Interpretation
Hemoglobin (Hb)	13.1 g/dL	13.0–17.0 g/dL	Normal
Total leukocyte count (TLC)	8,500/mm3	4,000–11,000/mm3	Normal
Blood urea	23 mg/dL	10–40 mg/dL	Normal
Serum creatinine	1.1 mg/dL	0.6–1.3 mg/dL	Normal
Liver function tests	Within normal limits	—	Normal
Serum amylase	36 U/L	23–85 U/L	Normal
Serum lipase	79 U/L	0–160 U/L	Normal
CA 19-9	Normal	<37 U/mL	No elevation
CEA	Normal	<5 ng/mL	No elevation
CECT Abdomen	8×5 cm exophytic mass from the pancreatic neck to the distal body with peripheral enhancement, central necrosis, splenic vessel narrowing, and absent right kidney.	—	Highly suggestive of pancreatic neoplasm; differential included primary pancreatic cancer, neuroendocrine tumor, or metastasis.
Histopathology (H&E)	Clear cells with abundant cytoplasm, central nuclei, and prominent vasculature.	—	Features consistent with clear-cell carcinoma.
Immunohistochemistry	CD10 positive, synaptophysin negative.	—	Supports the diagnosis of metastatic clear-cell RCC.

CECT=Contrast-enhanced computed tomography

Figure 4.

Sheets of round to polygonal cells with abundant clear cytoplasm with a centrally placed nucleus and congested blood vessels (Photomicrograph of hematoxylin and eosin [H and E])

Follow-up and Outcomes

The patient has been under regular surveillance for three years following surgery. Follow-up assessments included periodic clinical evaluations and imaging, with no evidence of recurrence or new metastases. His ECOG performance status remains 0, and he reports good quality of life with no functional limitations.

Patient Perspective

“I had travelled 1200 kms to this tertiary care hospital for further evaluation and management. I was worked up by a multi-disciplinary team and was offered the best care possible. Postoperative course was smooth without any complications.”

Discussion

RCC exhibits unpredictable metastatic behavior and may recur many years after an apparently curative nephrectomy. While the lungs, bones, liver, and brain are typical metastatic sites, pancreatic involvement is rare, accounting for only about 0.3% of pancreatic tumors.[4] Isolated pancreatic metastases from RCC are clinically significant because they differ from primary pancreatic malignancies in biology, prognosis, and treatment response.

The latency period between nephrectomy and pancreatic recurrence can be remarkably long. Several series, including the clinicopathologic analysis by Thompson and Heffess involving 21 cases, documented disease-free intervals exceeding 10 years, with a median of 9.2 years.[5,6] In the present case, pancreatic metastasis was detected 17 years after nephrectomy, emphasizing the need for lifelong surveillance in RCC survivors, as dormant tumor clones may remain indolent for decades before reactivation.

A recently published report by Fujiwara et al.[7] described an isolated pancreatic metastasis from clear-cell RCC occurring 29 years post-nephrectomy, representing the longest latency period documented to date. Our case provides complementary evidence of a similarly prolonged interval (17 years), suggesting a common biological mechanism of tumor dormancy and late angiogenic escape. These findings reinforce that metastatic recurrence may arise decades after surgery and that late relapse does not necessarily reflect aggressive disease.

The multicenter analysis by Sellner et al. evaluated 51 surgically resected pancreatic RCC metastases, reporting a median interval of 10 years (range: 0.5–32) and excellent outcomes, with 5- and 10-year survival rates of 88% and 79%, respectively.[8] Collectively, these studies and our case confirm that pancreatic metastases from RCC represent a distinct, slow-evolving metastatic subset characterized by long latency, hypervascular imaging, clear-cell histology, and excellent post-surgical survival.

Radiologically, differentiation from primary pancreatic adenocarcinoma or pancreatic neuroendocrine tumor (PNET) is difficult.[9] In our patient, contrast-enhanced CT revealed a hypervascular, well-demarcated lesion, mimicking PNET. Immunohistochemistry was decisive, showing strong CD10 and PAX8 positivity with synaptophysin negativity, consistent with metastatic clear-cell RCC and excluding pancreatic primaries.

Management principles differ markedly from primary pancreatic cancer. Whereas pancreatic adenocarcinoma carries a poor prognosis despite resection, multiple studies report prolonged survival after complete (R0) resection of pancreatic RCC metastases, with 5-year survival rates between 43 and 75%.[10] Surgical choice depends on tumor location and includes distal pancreatectomy, pancreaticoduodenectomy, or enucleation. Our patient underwent distal pancreatectomy with splenectomy, achieving R0 margins and uneventful recovery.

The role of systemic therapy in isolated pancreatic RCC metastasis remains uncertain. Although targeted agents such as tyrosine-kinase inhibitors (e.g. sunitinib, sorafenib) and anti-VEGF antibodies (e.g. bevacizumab) are effective in disseminated disease, evidence supporting adjuvant use after complete resection is limited.[11] Our patient declined systemic therapy yet remains disease-free three years post-surgery, reinforcing that observation is reasonable when complete excision is achieved.

In summary, this case illustrates the rare but clinically significant phenomenon of late solitary pancreatic metastasis from RCC. When compared with earlier literature, our report demonstrates that complete resection can yield durable remission even after >15 years of dormancy. Lifelong follow-up and timely surgical intervention remain essential for optimizing outcomes in this uncommon metastatic pattern.

Conclusion

Solitary pancreatic metastasis from RCC is an uncommon clinical entity that may present decades after primary tumor resection. This case highlights the importance of maintaining a high index of suspicion for metastatic RCC in patients with hypervascular pancreatic masses and a remote history of nephrectomy. Definitive diagnosis requires histopathological confirmation with an appropriate immunohistochemical panel, particularly CD10 positivity and synaptophysin negativity. Complete (R0) surgical resection remains the cornerstone of treatment for isolated pancreatic metastasis and can provide durable disease control, as demonstrated by our patient’s three-year disease-free survival without adjuvant therapy. Lifelong follow-up is essential in RCC survivors to detect late recurrences, and timely surgical intervention can lead to excellent long-term outcomes.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and the accompanying images.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.