Accepted: 21 February 2002Published online: 13 April 2002© Springer-Verlag 2002

Abstract Background and aims:Metastatic spread of a distant tumorto the rectum is extremely rare. Toour knowledge, there have been nopublished reports of hematogenicmetastasis from a renal cell carcino-ma to the rectum. Patients and methods: A patient with a renal cellcarcinoma was initially treated by aradical right nephrectomy. Results: Nine months after the sur-gery he started to have multiple epi-sodes of hematochezia. Colonoscopyshowed a nodular lesion located in

the distal rectum, and biopsy re-vealed an undifferentiated carcino-ma. The patient then underwent ab-dominoperineal resection of the rec-tum, and histological examinationshowed metastatic renal clear cellcarcinoma. Conclusion: This caserepresents an exceedingly rare condi-tion, which has never been reportedbefore.

Keywords Renal cell carcinoma ·Hematogenic metastasis · Rectum ·Clear cell carcinoma

Int J Colorectal Dis (2002) 17:359–361DOI 10.1007/s00384-002-0401-z C A S E R E P O RT

Mário A. RositoDaniel C. DaminAnderson R. LazzaronAndré CartellGilberto Schwartsmann

Metastatic renal cell carcinoma involving the rectum

Introduction

Metastatic spreading of a distant malignant tumor to therectum represents an exceedingly rare event; melanomaand breast cancer are the most common primary tumorsthat disseminate to this organ [1]. Renal cell carcinoma(RCC) is a neoplasm with unpredictable biological be-havior. It tends to metastasize to numerous sites, particu-larly the lungs, lymph nodes, bones, liver, and brain. Wehave found only four reported cases of clinically signifi-cant hematogenic metastasis from RCC to the colon [2,3, 4, 5]. In contrast, despite an extensive literature searchwe have found no report of metastasis from RCC in therectum. We present a case of a renal clear cell carcinomaproducing a symptomatic hematogenic metastasis to therectum and discuss choices of treatment.

Case report

A 55-year-old white man presented with a poorly controlled sys-temic arterial hypertension without associated hematuria or pain.During the preceding 6 months he had lost 7 kg in weight. On ex-

amination a painless palpable mass in the right abdominal flankwas noted. The other aspects of the physical examination, includ-ing the digital rectal examination, were unremarkable.

Ultrasound examination of the abdomen revealed a markedlyabnormal right kidney containing a solid mass measuring15×10 cm in the upper pole. The left kidney was normal. Comput-ed tomography of the abdomen confirmed the ultrasound resultsand demonstrated capsular extension of the tumor, which was con-fined in the Gerota's fascia. There was no adrenal involvement,and the liver parenchyma was normal. Complementary excretoryurography showed the good function of the left kidney. Chest radi-ography and liver function tests were normal.

After the investigation the patient underwent radical right ne-phrectomy by the flank approach. He experienced a satisfactorysurgical recovery. Histologically the surgical specimen revealed aRCC with capsular invasion. Nine months after the surgery h start-ed to have multiple episodes of anal bleeding, resulting in severeanemia (hemoglobin 7.2 mg/dl) along with evacuatory discomfortwhich he interpreted as hemorrhoidal symptoms. Digital examina-tion and colonoscopy showed a 3-cm nodular lesion located in therectum, just above the dentate line. Biopsy revealed an undifferen-tiated carcinoma. Chest radiography and computed tomography ofthe abdomen were normal.

Considering the location and the undifferentiated histology ofthe tumor, the patient was treated by abdominoperineal resectionof the rectum. The surgical specimen showed an irregular nodulewith sharply defined borders and tan surface located near the mu-cocutaneous transition (Fig. 1). Microscopic analysis showed clear

M.A. Rosito · D.C. Damin (✉ )A.R. Lazzaron · A. CartellG. SchwartsmannDepartments of Coloproctological Surgery,Pathology, and Oncology, Hospital de Clínicas de Porto Alegre, Federal University of Rio Grande do Sul,Porto Alegre, Brazile-mail: damin@zaz.com.brTel.: +55-51-33416816Fax: +55-51-33285168

cells proliferation with tenuous to moderate cellular atipias pre-dominating in the submucosal layer of the rectum, without mucos-al invasion (Fig. 2a). The neoplasia displayed the clear-cell typewith evident vascularization and trabecular grow pattern (cordlike)around blood vessels (Fig. 2b). These features were consideredstrongly consistent with metastatic RCC. The patient had a goodsurgical recovery, but 1 year after the latter surgery he presentedagain with multiple disseminated skeletal and lung metastasis,which progressed to death in 6 months. Although the bone in-volvement was multiple, he was treated by radiotherapy to controla dominant and painful bone metastasis in the right femur. There-after only supportive treatment was provided.

Discussion

RCC represents 85% of the parenchymal renal cancers inadults. The predominant histological presentation is the

clear-cell type. In the United States about 30,000 casesand 11,000 deaths occur yearly due to this type of can-cer. It occurs mainly in the sixth and seventh decades oflife and is twice as common in men. RCC is easily rec-ognized by its tendency to early dissemination, beingable to compromise a great variety of organs. Not rarely,the first clinical manifestation of the RCC is a metastaticlesion [6, 7]. Although there are few reports of colonicmetastasis from RCC, we have found no report of rectalmetastasis from this kind of neoplasia in the indexed lit-erature.

There are only four reported cases of clinically signif-icant metastasis from the RCC to the colon. The majorityof these patients presented with hematochezia. Autopsystudies have revealed intestinal metastasis in a largernumber of patients with RCC, but these lesions had noclinical significance [2, 3, 4, 5]. In the presented case theinitial manifestation was also anal bleeding, and this rep-resented the first sign of metastatic disease. The lesionwas located 4 cm from the anal verge and was accessibleto the digital rectal examination. In spite of the unpre-dictable outcome a radical resection of the rectum wasperformed, due mainly to the clinical repercussion of theanal bleeding. In addition, the preoperative rectal biopsyshowed an undifferentiated carcinoma, which precludesany possibility of local resection of the tumor.

The diagnosis of metastatic RCC was determined on-ly after histological analysis of the surgical specimen.Although the search of expression of the cytokeratin8,18 by the tumor could be a valuable test to confirm thisdiagnosis, it was considered unnecessary by the patholo-gy team since the histological features were extremelyconsistent with RCC.

The rectum rarely receives metastasis from distant tu-mors. The prognosis of these lesions is variable, and sur-

360

Fig. 1 Surgical specimen showing an ulcerate nodule located nearthe mucocutaneous transition. Arrow Dentate line

Fig. 2 a Histological examina-tion showing clear-cell prolifer-ation predominating in the sub-mucosal rectum layer withoutmucosal invasion. b Clear cellswith evident vascularizationand trabecular grow patternaround blood vessels

vival after the metastasis resection is unpredictable. Theprognosis of a rectum metastasis has not been deter-mined because of the few number of cases reported,which describe different types of tumors. Survival seemsto depend on the presence of metastasis in other organsand the type of primary tumor [1]. Likewise, the out-come of a patient with colonic metastases from RCC hasnot yet been documented since the few published reportspresent only limited information about the disease pro-gression [2, 3, 4, 5].

The mean survival rate with metastatic RCC is12–24 months and depends on several factors, the pa-tient's performance status being the best predictive pa-rameter. Of the approximately 30% of patients with RCCwho present with metastases, fewer than 4% have soli-tary lesions [8, 9]. Patients with a solitary metastasissynchronous with a primary lesion have shorter survivalthan those who develop metastasis after the primary tu-mor is removed [8, 10, 11].

Surgical resection is recommended in selected pa-tients with metastatic RCC. Some authors suggest thatpatients with RCC and a solitary metastatic lesion at pre-sentation can be treated by nephrectomy and excision ofthe metastasis; these have the same prognosis as thosewithout metastatic disease [11]. According to Wirth [12],successful resection of a solitary metastasis increases 3-year survival (20–60%), particularly if the resected me-tastasis is pulmonary. In a study of 59 patients with RCC

who underwent surgical resection for a solitary metasta-sis 45% had a 3-year survival, and 34% survived 5 years[9].

About 20% of patients with metastatic RCC presentalso with bone metastasis [8, 13]. Palliative radiotherapy,even with higher doses than usual, for patients withsymptomatic osseous metastasis is successful in fewerthan 50% of the cases. Solitary brain metastasis can betreated by surgery, but multiple brain metastasis are bet-ter treated with radiotherapy [8].

RCC responds poorly to cytotoxic chemotherapy;medical treatment for widespread metastatic RCC focus-es on the combination of interferon-α and interleukin-2.However, several major questions remain unresolvedabout their administration as the factors that predict du-rable responses in a minority of patients have not beenelucidated [12]. Some clinical trials with interleukin-2report response rates around 16% in the treatment ofRCC [14]. Some responders never relapsed, even withmore than 10 years of follow-up. In the largest studiesthe response rates using interferon-α to treat RCCranged between 0% and 29%, with few complete re-sponses [15].

In conclusion, the case presented here represents anextremely rare clinical condition which has never beenreported before. Its description contributes to the under-standing of the biological behavior of the RCC and toknowledge about metastasis involving the rectum.

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