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SILENT METASTASIS: A CASE OF RENAL CELL CARCINOMA PRESENTING AS GI BLEEDING AND SMALL BOWEL OBSTRUCTION
Lan Nguyen
*, Matthew J. Hudson
University at Buffalo, Buffalo, NY
IntroductionRenal cell carcinoma (RCC) is the most common renal tumor and can metastasize years after initial treatment. Small bowel metastases from RCC are rare and often present with gastrointestinal (GI) symptoms such as bleeding, intussusception, or bowel obstruction. This case emphasizes the need for a comprehensive GI evaluation in patients with RCC who presents with new GI symptoms to ensure early detection and effective management of metastatic disease.
Case PresentationA 74-year-old male with a history of hypertension, hyperlipidemia, and RCC treated with nephrectomy in 2014 and immunotherapy in 2020, presented with one week of bright red blood per rectum. He had recently undergone a small bowel resection for distal ileo-ileal intussusception, with pathology confirming metastatic RCC. Video capsule endoscopy (VCE) was recommended but not performed. Upon presentation, his vital signs were stable, and physical examination was unremarkable. Lab tests were significant for a hemoglobin level of 5.4 g/dL, and computed tomography angiography (CTA) identified active extravasation within a loop of small bowel. After blood transfusions, the patient was monitored, and endoscopic procedures were deferred due to recent surgeries. VCE later revealed blood in the distal small bowel, but the exact bleeding source was obscured due to debris (figure 1). Three weeks later, he returned with abdominal bloating and vomiting. A computed tomography (CT) scan revealed small bowel obstruction caused by recurrent intussusception. Surgical exploration identified a mass causing the obstruction (figure 2). The patient underwent another small bowel resection, with pathology confirming metastatic RCC (figure 2).
DiscussionAccounting for 90% of renal solid tumors, RCC has an asymptomatic course which often delays its diagnosis. With an unpredictable metastatic pattern, RCC can recur at any time following nephrectomy or immunotherapy. Small bowel metastases are rare with incidence rate of only 0.7% and present with GI bleeding, intussusception, or obstruction. Imaging (CT and CTA) and endoscopy are essential for the diagnostic process. By offering both visualization and biopsy capabilities, double-balloon enteroscopy is a key tool for diagnosing RCC metastasis to the small bowel. Surgical resection is preferred for isolated metastases and is associated with improved survival. For non-surgical candidates, targeted therapies or palliative care should be prioritized.
ConclusionSmall bowel metastases from RCC, though rare, can present with GI symptoms. Early detection through imaging and endoscopy is crucial for improving patient outcomes. This case highlights the importance of maintaining a high index of suspicion in RCC patients with new GI symptoms for timely detection and effective management of metastatic disease.
Figure 1. Video capsule endoscopy findings: (a) Bleeding is identified in the ileum. (b) A blood clot was identified in the ileum (arrow)
Figure 2. (a) An obstructing mass measuring 7.5 x 5 x 3 cm located in the distal small bowel. (b) Classic histological findings of renal clear cell carcinoma, including clear cytoplasm with distinct cell boundaries (black arrow) and network of thin-walled, "chicken-wire" vasculature (white arrow). Magnification 400x
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