肾细胞癌胰腺转移的诊断和治疗

Diagnosis and treatment of pancreatic metastasis from renal cell carcinoma

目的探讨肾细胞癌（RCC）根治性手术后胰腺转移的诊断、治疗和预后。方法回顾性分析3例RCC根治性切除后发生胰腺转移的特点，对首次手术情况、转移时间、再次手术或第3次手术处理情况进行了探讨，并对患者的生存期进行了分析，术后随访192个月。结果第1次手术至柱现胰腺转移的时间为14～144个月，平均79个月。病理分期为T2NOM02例，T3NOM01例。肿瘤发生在右肾2例，左肾1例。3例患者的临床表现均不同，1例无症状，1例表现为上腹隐痛、体重下降、皮肤黄染瘙痒和大便颜色变浅，1例表现为不规则低热、体重下降和黄疸。胰腺病灶的CT影像学均为动脉期高强化肿瘤表现，胰腺孤立转移瘤者1例，2个转移瘤者1例，多发转移瘤伴肝转移者1例。3例患者中，保留幽门的胰十二指肠切除2例，其中1例加部分胰尾切除，1例胰十二指肠切除后30个月发生腹腔内转移，行第3次手术；1例行介入灌注化疗。行手术治疗的2例患者分别存活103个月和192个月；行介入治疗的1例患者在11个月后死于胰腺和肝脏广泛转移。结论RCC术后多年也会发生胰腺转移。临床医师对于胰腺占位患者，如既往有RCC病史，应不除外胰腺转移癌可能；在处理上应考虑积极手术，患者可能会获得较长的生存机会。

Objective Pancreatic metastasis from renal cell carcinoma （RCC） is a rare event and has not been reported in our country. We report a series of 3 patients with metastatic RCC to the pancreas after radical nephrectomy at our institution. The published reports in the literature were reviewed, and the diagnosis, treatment as well as prognosis of this rare event were discussed. Methods The data of 3 RCC patients with metastasis to the pancreas were reviewed retrospectively, including radical nephrectomy, metastatic interval, the second and third surgical removal. Survival of the three patients was analyzed and the reports in the literature were compared as well. Results The average interval from radical nephrectectomy to the comfirmed pancreatic metastasis was 6.6 years （range, 1.2 to 12 years）. The pathological stage revealed T2N0M0 （ n =2） or T3N0M0 （ n = 1 ）, with right-sided tumor in 2 patients and left side in 1. One patient was asymptomatie, while the other two cases were symptomatic at presentation, including upper abdominal pain, weight loss, slight xanthochromia of the skin and titillation, clay stool （n = 1 ） ; irregular fever, weight loss and jaundice （ n = 1 ）. All pancreatic metastases were hypervascular on arterial stage of CT imaging. One patient had only a solitary pancreatic metastasis （ n = 1 ） , the another showed two metastatic lesions （ n = 1 ） , the third one had multiple lesions （ n = 1 ）. Surgical removal was accomplished in 2 patients： including pylorus-preserving panereatieoduodenectomy in one, and pylorus-preserving pancreaticoduodenectomy together with partial tail resection in another one. The third one only received interventional therapy due to widespread extrapanereatic metastasis, and died of disseminated disease 11 months after the therapy. One of the above two surgically treated patients underwent the second removal due to local recurrence 2.5 years after the first removal of pancreatic metastasis. These two patients were still alive after follow-up of 8. 6 years and 16.1 years, respectively. Conclusion Renal cell carcinoma is an unpredictable tumor that may demonstrate very delayed metastasis even from early-stage of the disease. The pancreas is a rare site of metastasis from renal cell carcinoma. We advocate careful long-term follow-up of patients with a history of RCC. Aggressive surgical management of pancreatic metastatic lesions may provide a chance of long-term survival.