The patient is a 52 year‐old man with a history of alcohol abuse, occasional cocaine use, and recent NSAID use who presents with symptomatic anemia. Two days prior to admission he presented to an outside clinic complaining of fatigue, fever, chills, and dizziness. He also had nausea, vomiting and pain with melena. Lab work showed hemoglobin of 6.5 g/dL and microcytosis. On presentation patient was tachycardic up to 117 bpm with otherwise stable vitals. On physical exam the patient was pale in appearance, abdomen was tender to palpation in RUQ and liver margin was palpable 6 cm below the costal margin, trace lower‐extremity edema and jugular venous distention with hepatojugular reflux was present. Repeat hemoglobin and hematocrit were 5.7 g/dL and 18.1%, respectively. Two units of blood were transfused and proton pump inhibitor and somatostatin analogue drips were started. Esophagogastroduodenoscopy was performed and a 5 cm friable ulcerated mass was found in the duodenum. CT scan revealed an invasive necrotic mass 12.6 × 7.3 × 12.2 cm that originated from the kidney invading the duodenum. Pathology report of the duodenal biopsy showed sarcomatoid renal cell carcinoma.
Small bowel tumors are most commonly metastases than primary tumors. The metastatic spread can occur by 3 possible mechanisms: (1) intraperitoneal seeding, (2) hematogenous spread, or (3) direct invasion. Pathology related to intraperitoneal seeding is usually mucinous tumors of the ovary, appendix or colon. Hematogenous metastases usually arise from renal cell carcinoma, bronchogenic carcinoma, breast carcinoma or melanoma. Invading tumors typically arise from the colon, pancreas, biliary tract. This case highlights another rare and unique cause of invasive pathology related to sarcomatoid carcinoma from the kidney. Unfortunately, sarcomatoid renal cell carcinoma treatment is limited to systemic therapy that has shown only moderate benefit. This form of renal cell carcinoma has the worst prognosis with medial survival of 4‐9 months after diagnosis. With more advanced molecular techniques, sarcomatoid renal cell carcinoma is no longer considered separate tumor type since it can occur in conjunction with any histologic subtype. In a recent article by Shuch and colleagues, they estimate that the sarcomatoid variant could be involved in up to one in six cases of advanced renal cell carcinoma.
Hospitalists will encounter patients similar to this case presentation during initial hospitalization for invasive diagnostic workup and for progression of advanced sarcomatoid renal cell carcinoma. As molecular techniques continue to improve, the sarcomatoid variant will be increasingly identified. Understanding the prognosis associated with the sarcomatoid variant can lead to more informed discussion with the patient regarding prognosis.
To cite this abstract:Shah C, Megan E. You Found My Kidney in My Intestines?. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 461. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/you-found-my-kidney-in-my-intestines/. Accessed March 29, 2020.