Metastatic Renal Cell Carcinoma To The Stomach Presenting As Upper Gastrointestinal Bleeding

A 65-year-old male with a history of metastatic renal cancer was admitted to the hospital for weakness, hematemesis and melena. Physical examination revealed a pale man with anicteric sclera. His abdomen was soft, non-tender, non-distended without organomegaly or ascites. He was tachycardic on admission with stable vital signs except tachycardia of 126. On admission, his labs revealed a hemoglobin of 4.4 gm/dL, hematocrit of 14.7% and normal white cell count (10.7 THOUSAND/mcl) and platelets (308 THOUSAND/mcl). He had elevated blood urea nitrogen of 76 mg/dL and creatinine of 1.71 mg/dL. He had a mild troponin leak of 0.10 with a normal ECG. The patient was transfused two units of packed red blood cells and remained hemodynamically stable throughout admission. The patient had an endoscopy one year ago that revealed a gastric ulcer with no active bleeding, and pathology then was negative for malignancy. On this hospitalization, an endoscopy done the next day revealed a normal appearing esophagus and a medium-sized, non-bleeding, clean-based ulcer found on the greater curvature of the gastric body. The ulcer appeared to be raised from the sub mucosal layer, suggesting metastatic disease (Image 1). Multiple biopsies were obtained from the site, which showed fragments of gastric mucosa with ulceration and a focus of metastatic RCC (Image 2 and 3). The ulcer was too large for a hemo-clip and was injected with epinephrine at multiple sites with no further bleeding noted. The duodenal bulb was normal in appearance. Due to the extent of his disease the patient decided to pursue palliative measures and was discharged home in stable condition. The patient passed away approximately 10 months later. We present a case of a renal cell carcinoma (RCC) metastasis found as a gastric ulcer. To our knowledge there are only 23 reported cases of gastric metastases from RCC as of 2014. Approximately 3% of adult malignancies are due to RCC, and direct complication from the distant metastasis is usually the cause of death. Metastases to the stomach are an infrequent finding, and the incidence in autopsy series varies between 0.2% to 0.7% with lung, breast and malignant melanoma being the most common. This case illustrates the importance of considering metastatic renal cell cancer as a cause of upper gastrointestinal bleeding in a patient with a renal mass or history of renal cell cancer.Figure 1Figure 2Figure 3