Simple Summary A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed that these are characterised by not only the exclusive occurrence of PM and a good prognosis but a lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. As an explanation for all these peculiarities, a strong acting seed and soil mechanism can serve, which allows metastases settlement only in the pancreas, but prevents them definitively or for years in all other organs. Genetic studies revealed specific changes in cases of PM of RCC and a lack of loss of 9p and 14q, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC, however this is still unclear. Abstract A meta-analysis of 1470 isolated pancreatic metastases of renal cell carcinoma revealed, that, in addition to the unusual exclusive occurrence of pancreatic metastases and the favourable treatment results, the isPMRCC is characterised by further peculiarities of the clinical course: The lack of prognostic significance of volume and growth rate dependent risk factors and the independence of treatment results from standard or local resections. As an explanation for all these peculiarities, according to today’s knowledge, a strong acting seed and soil mechanism can serve, which allows embolized tumour cells to grow to metastases only in the pancreas, and prevents them definitively or for years in all other organs. The good prognosis affects not only isolated PM, but also multi-organ metastases of the RCC, in which the additional occurrence of PM is also associated with a better prognosis. Genetic studies revealed specific changes in cases of PM of RCC: Lack of loss of 9p21.3 and 14q31.2, which are otherwise specific gene mutations at the onset of generalization, a low weight genome instability index, i.e., high genetic stability, and a low rate of PAB1 and a high rate of BPRM1 alterations, which signal a more favourable course. The cause of pancreatic organotropism in isPMRCC is still unclear, so only those factors that have been identified as promoting organotropism in other, more frequent tumour entities can be presented: Formation of the pre-metastatic niche, chemokine receptor–ligand mechanism, ability to metabolic adaptation, and immune surveillance.

/pdf/isolated-pancreatic-metastases-of-renal-cell-carcinoma-350f3jzt.pdf

Isolated Pancreatic Metastases of Renal Cell Carcinoma—Clinical Particularities and Seed and Soil Hypothesis

Metastasis to the pancreas represents a small proportion of all pancreatic malignancies. Among primary tumors that metastasize to the pancreas, renal cell carcinoma (RCC) is one of the most common causes of metastatic pancreatic lesions. We herein report a case series of three patients with pancreatic metastasis from RCC. The first is a 54-year-old male with a history of left nephrectomy for RCC, in whom an isthmic pancreatic mass suggestive of a neuroendocrine lesion was found during oncological follow-up. Endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) identified pancreatic metastasis of RCC and the patient was referred for surgery. The second case is a 61-year-old male, hypertensive, diabetic, with left nephrectomy for RCC six years previously, who complained of weight loss and was found with a hyperenhancing mass in the head of the pancreas and a lesion with a similar pattern in the gallbladder. EUS-FNB from the pancreas proved to be a metastatic pancreatic lesion. Cholecystectomy and treatment with tyrosine kinase inhibitors were recommended. The third case is a 68-year-old dialysis patient referred for evaluation of a pancreatic mass, also confirmed by EUS-FNB, who was started on sunitinib treatment. We report a literature summary on epidemiology and clinical features, diagnosis and differential diagnosis and treatment and outcomes in pancreatic metastasis of RCC.

/pdf/metastatic-renal-cell-carcinoma-to-pancreas-case-series-and-1ka68aao.pdf

Metastatic Renal Cell Carcinoma to Pancreas: Case Series and Review of the Literature

Isolated pancreatic metastases of renal cell carcinoma (IsPMRCC) are a rare manifestation of metastatic, clear-cell renal cell carcinoma (RCC) in which distant metastases occur exclusively in the pancreas. In addition to the main symptom of the isolated occurrence of pancreatic metastases, the entity surprises with additional clinical peculiarities: (a) the unusually long interval of about 9 years between the primary RCC and the onset of pancreatic metastases; (b) multiple pancreatic metastases occurring in 36% of cases; (c) favourable treatment outcomes with a 75% 5-year survival rate; and (d) volume and growth-rate dependent risk factors generally accepted to be relevant for overall survival in metastatic surgery are insignificant in isPMRCC. The genetic and epigenetic causes of exclusive pancreatic involvement have not yet been investigated and are currently unknown. Conversely, according to the few available data in the literature, the following genetic and epigenetic peculiarities can already be identified as the cause of the protracted course: 1. high genetic stability of the tumour cell clones in both the primary tumour and the pancreatic metastases; 2. a low frequency of copy number variants associated with aggressiveness, such as 9p, 14q and 4q loss; 3. in the chromatin-modifying genes, a decreased rate of PAB1 (3%) and an increased rate of PBRM1 (77%) defects are seen, a profile associated with a favourable course; 4. an increased incidence of KDM5C mutations, which, in common with increased PBRM1 alterations, is also associated with a favourable outcome; and 5. angiogenetic biomarkers are increased in tumour tissue, while inflammatory biomarkers are decreased, which explains the good response to TKI therapy and lack of sensitivity to IT.

Genetic and Epigenetic Characteristics in Isolated Pancreatic Metastases of Clear-Cell Renal Cell Carcinoma

Recurrent isolated pancreatic metastasis from Renal Cell Carcinoma (RCC) after pancreatic resection is rare. The purpose of our study is to describe a series of cases of relapse of pancreatic metastasis from renal cancer in the pancreatic remnant and its surgical treatment with an repeated pancreatic resection, and to analyse the results of both overall and disease-free survival. Multicenter retrospective study of patients undergoing pancreatic resection for RCC pancreatic metastases, from January 2010 to May 2020. Patients were grouped into two groups depending on whether they received a single pancreatic resection (SPS) or iterative pancreatic resection. Data on short and long-term outcome after pancreatic resection were collected. The study included 131 pancreatic resections performed in 116 patients. Thus, iterative pancreatic surgery (IPS) was performed in 15 patients. The mean length of time between the first pancreatic surgery and the second was 48.9 months (95 % CI: 22.2–56.9). There were no differences in the rate of postoperative complications. The DFS rates at 1, 3 and 5 years were 86 %, 78 % and 78 % vs 75 %, 50 % and 37 % in the IPS and SPS group respectively(p = 0.179). OS rates at 1, 3, 5 and 7 years were 100 %, 100 %, 100 % and 75 % in the IPS group vs 95 %, 85 %, 80 % and 68 % in the SPS group (p = 0.895). Repeated pancreatic resection in case of relapse of pancreatic metastasis of RCC in the pancreatic remnant is justified, since it achieves OS results similar to those obtained after the first resection. 

Repeated pancreatic resection for pancreatic metastases from renal cell Carcinoma: A Spanish multicenter study (PANMEKID)

Laparoscopic total gastrectomy results in more internal hernias than open surgery. However, there are few reports of incarcerated hiatal hernia after laparoscopic total gastrectomy. Here, we report a case of a 79-year-old male who underwent urgent surgical intervention for a strangulated intestinal obstruction due to an incarcerated hernia through the esophageal hiatus following laparoscopic total gastrectomy. In this case, an esophageal hiatal hernia was present before gastrectomy, but was not repaired. Additionally, the patient experienced significant weight loss after gastrectomy. Preoperative hiatal hernia and marked postoperative weight loss may pose risks.

Strangulated Bowel Obstruction Due to Hiatal Hernia After Laparoscopic Total Gastrectomy

https://doi.org/10.1016/j.ijscr.2022.107022

Repeat pancreatic resection for metachronous pancreatic metastasis from renal cell carcinoma: A case report

Abstract Background Esophageal hiatal hernia (EHH) presenting after gastrectomy for carcinoma is a type of internal hernia and very rare. There have been no published reports on the use of hand-assisted laparoscopic surgery (HALS) for the treatment of an incarcerated EHH that presented after a gastrectomy. Herein, we report a rare case of HALS performed for an incarcerated EHH presenting after a laparoscopic gastrectomy. Case presentation This case report presents the case of a 66-year-old man who underwent hernia repair for an incarcerated hernia that presented after he underwent a laparoscopic proximal gastrectomy with double-tract reconstruction for cancer in the esophagogastric junction. Emergency laparoscopic hernia repair was performed and herniation of the transverse colon into the left thoracic cavity through a hiatal defect was confirmed. Since it was difficult to return the transverse colon into the abdominal cavity using forceps, the procedure was converted to HALS and the transverse colon was pulled back into the abdominal cavity. The hernia defect was closed using a non-absorbable suture. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. Conclusions The HALS approach provides the tactile experience of an open surgery combined with the benefits of a laparoscopic procedure such as good visualization and low invasiveness. In this case, when the transverse colon that had herniated into the left hemithorax was returned to the abdominal cavity, damage to the transverse colon was avoided by using the hand. Hence, HALS was safely performed to repair an incarcerated EHH after gastrectomy. 

/pdf/hand-assisted-laparoscopic-surgery-for-an-esophageal-hiatal-1ddk526q.pdf

Hand-assisted laparoscopic surgery for an esophageal hiatal hernia with incarcerated transverse colon presenting after laparoscopic gastrectomy: a case report

Abstract The Pfizer‐BioNTech coronavirus disease 2019 (COVID‐19) vaccine is extensively used worldwide, and its safety has been proven. Herein, we report a case of an acute necrotic disorder in the small intestine post‐COVID‐19 vaccination. The patient developed severe abdominal pain the day after the first vaccination. Contrast‐enhanced computed tomography showed extensive ileum wall thickening and ascites. Colonoscopy revealed a ring‐shaped ulcer and stricture in the terminal ileum. Ileocecal resection was performed, and the patient did not have further episodes of a necrotic disorder in the small intestine. Although it is unknown if this event is associated with vaccination, and this occurrence also does not outweigh the efficacy and safety of the Pfizer‐BioNTech COVID‐19 vaccine, gastroenterologists need to be aware of this rare case, given its noteworthy timing.

Acute necrotic disorder of the small intestine post‐coronavirus disease‐2019 vaccination

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Repeat pancreatic resection for metachronous pancreatic metastasis from renal cell carcinoma: A case report

Hand-assisted laparoscopic surgery for an esophageal hiatal hernia with incarcerated transverse colon presenting after laparoscopic gastrectomy: a case report

Acute necrotic disorder of the small intestine post‐coronavirus disease‐2019 vaccination