Sabato 27 ottobre 2012 - Pacini Editore

376
frequency of the reference allele and q the frequency of the variant).
Genotype and allele frequencies between case and controls
were compared with Fisher’s exact test, using 2x2 contingency
tables. Only p values G polymorphism
with hepatocellular carcinoma risk: a meta-analysis. Arch Med Res
2011;42:149-55.
A solitary polypoid gastric metastasis in renal cell
carcinoma: an event to be considered
M. Onorati, P. Uboldi, G. Petracco, S. Romagnoli * , F. Di Nuovo
Pathology Unit, Garbagnate Milanese, AO “G. Salvini” Garbagnate Milanese,
Italy.
* Department of Health Sciences, AO S. Paolo, University of Milan, Medical
School, Italy
Introduction. The incidence of gastric metastases is 2,6%. Their
most common endoscopic appearance is a “volcano-like” polypoid
mass covered by normal mucosa that may show a central
ulceration. Although all primary neoplasms can metastasize to
the stomach, most of them originate from melanoma or breast and
lung cancer. Metastases from primary neoplasms of the kidney,
have also been describe. Renal cell carcinoma (RCC) is known
to spread hematogenously and isolated metastasis to the stomach
is a rare event. In this report, we describe a gastric recurrence of
clear-cell renal carcinoma in a patient who underwent nephrectomy
19 years ago. The case shows that metastatic involvement
of the stomach should be suspected in any patient with a previous
history of RCC, presenting with gastrointestinal symptoms,
although many years after nephrectomy for neoplasm. We also
pursued a brief review of the literature to update the number of
cases described until now.
Methods and results. We report an unusual case of a patient with
gastric polipoyd metastasis from a RCC. A 82 year-old man was
admitted to our hospital in Garbagnate Milanese with persisting
CONGRESSO aNNualE di aNatOmia patOlOGiCa SiapEC – iap • fiRENzE, 25-27 OttOBRE 2012
rectal bleeding. On admission severe anaemia was present. He had
a history of weight loss, epigastric pain and weakness. Because
of the symptoms and signs, the patient underwent a colonoscopy
and a gastroscopy. While colonoscopy was negative, gastroscopy
showed a 30 mm, irregular, polypoid bleeding lesion with superficial
erosions in the upper part of the corpus near the lesser curvature.
The lesion was snared with loop biopsy because they did not
suspect his histological nature and to prevent post-polipectomy
bleeding. The excision biopsy of the lesion was fixed in formalin
and stained with Haematoxilin and Eosin. Microscopically, the
polypoid lesion, covered by ulcerated mucosae, revealed nests
of neoplastic cells with a solid pattern of growth. The neoplastic
population showed a peculiar cytological characteristic represented
by cells with abundant clear cytoplasm. The nuclei were
round, hyperchromatic with prominent nucleoli. In the absence of
clinical information cytokeratin-7 was performed to exclude/confirm
a gastric origin. Subsequently clinicians informed us that the
patient had a past medical history of left nephrectomy for a clearcell
RCC in 1992 and a colic resection for a poorly differentiated
adenocarcinoma of the rectum in 1997. A second set of antibodies
were tested (CD10, EMA, Vimentin, CK20, and CDX2) on the
basis of recent clinical information. The neoplastic cells were
strongly stained with CD10, Cam 5.2 and EMA and Vimentin.
The diagnosis was consistent with metastasis from clear-cell RCC
also on the basis of the clinical notice. Endoscopic margins were
free of disease. CT scan of the chest, abdomen and pelvis showed
no evidence of other metastatic sites.
Conclusion. RCC account for 3% of all adult malignancy and
it is more than twice as common in males than females with the
majority of cases occurring in the sixth decade of life. Although
the localizing findings of hematuria, pain and a flank mass are the
classic triad of presenting symptoms, many patients with renal cell
carcinoma lack any of these and have systemic symptoms such as
fever, malaise or anemia. Metastases at the time of diagnosis occur
in 25%-33% of patients since this neoplasm is frequently presenting
as metastasis of unknown primary site, sometimes in unusual
sites. The extent of spread of RCC is notoriously unpredictable
with well-documented cases of spontaneous regression of metastases,
prolonged course and recurrence 10 years or more after nephrectomy
in more than 10% of patients who survive so long. Gastric
metastases from RCC following radical excision of the primary
tumour is extremely rare. Despite the strong potential for hematogenous
metastases of RCC and due to its rarity, stomach metastases
are often not suspected as a cause of gastrointestinal bleeding. This
case highlights the importance of clinical information to better
treat the patients with metastases. Investigation for such metastatic
tumors should be performed routinely in the follow-up of patients
who have been treated for RCC. To date about 53 cases of gastric
metastases from RCC, included the present one, have been reported.
The most complete article was published in 2011 by Eslick
et al describing 44 cases. They argue that in their series females
are younger than males and that overall patients age is younger
than that previously reported in other case series (66 years vs 73
years). Moreover they argue that on average there is a long interval
between nephrectomy and presentation with gastric metastases.
They confirmed, as Greendike et al stated, that in 25% of new
patients with renal cell carcinoma, there is radiologic evidence of
metastases at presentation. They highlighted that, although RCC is
resistant to chemotherapy and the prognosis of patients with remote
metastasis is extremely poor, more recent developments have occurred
in the treatment of gastric cancer; therefore the distinction
between the two entities is fundamental. Our case demonstrates
how important is the dialogue between clinicians and pathologists
in order to obtain a rapid and accurate diagnosis of lesions
which don’t show any apparent unusual presentation (a gastric
polyp in the present case), but are histopathologically unlikely to
be primitive in origin. Although the nature of polypoid mass was
unknown, the choice of the endoscopic polipectomy seemed to be