腸阻塞表現之轉移性腎細胞癌合併小腸侵犯：案例報告與文獻回顧

蘇奕瑋、張東平、薛又仁、賴昱維、黃建榮、蕭毅君、李淑文、邱文祥

台北市立聯合醫院仁愛院區外科部泌尿科

Metastatic renal cell carcinoma with small intestine invasion presenting as bowel obstruction: a case report and literature review

Yi-Wei Su, Tung-Ping Chang, Thomas Y. Hsueh, Yu-Wei Lai, Andy C. Huang, Yi-Chun Hsiao, Shu-Wen Li, Allen W. Chiu

Division of Urology, Department of Surgery, Taipei City Hospital Renai branch

Introduction:

Renal cell carcinoma (RCC) is the most often seen tumor at renal parenchyma. Metastatic RCC mostly involved lymph nodes, lungs, liver, and bone. However, RCC with intestine invasion is a rare condition and only sporadically reported around the world. The symptoms may lead to abdominal pain, abdominal distention, nausea and vomiting which make the treatment of such cases become more complicated. We are presenting a 52-year-old man who had RCC with small intestine invasion and underwent laparoscopic nephrectomy with small bowel resection and anastomosis.

Case presentation: 

A 52-year-old man with a past medical history of hepatitis B carrier, hypertension and hyperlipidemia. He visited our General surgery (GS) outpatient department (OPD) with the complaint of epigastric pain for one week and start nausea and vomiting for one day. Physical examination (PE) disclosed distended abdomen with diffuse tenderness and bowel sound decreasing. Ileus and acute abdomen were suspected. Thus, abdominal computed tomography (CT) scan was arranged which revealed a lobulated mass (6.0x5.9cm) with segmental renal vein extension at anteroinferior aspect of right kidney. Besides, ascites and two lobulated masses (6.8x5.0cm and 4.7x4.3cm) at left lower abdomen with jejunum invasion causing bowel obstruction was discovered. Renal cell carcinoma with small bowel metastasis were suspected.Under the stable vital sign, NPO with TPN supplement was applied and pre operative prepare was arranged. GS and Urology (GU) combined surgery (Laparoscopic nephrectomy with small intestine resection and anastomosis) were performed then. Pathologic report showed clear cell renal cell carcinoma with renal vein and small intestine invasion, stage 4, pT3aNxM1. Based on Memorial Sloan-Kettering Cancer Center (MSKCC) score, he was classified into intermediate risk group. According to current NCCN guideline, further immunotherapy was scheduled.   

Conclusion:

        Renal cell carcinoma with small intestine invasion is a rare condition. Since metastatic renal cell carcinoma has poor prognosis, those complicated with small bowel invasion and ileus may even worsen the condition as small bowel obstruction affects the nutrition system and increases the risk of intra-abdominal infection. Treatment plan has to be made comprehensively and case by case when initially approach these patients. Further immunotherapy and follow up is crucial.