Case Report

A 46-year-old woman with a past medical history of clear cell renal cell carcinoma, who underwent left nephrectomy in April 2024 with negative surgical margins, presented to the emergency department in September 2025 with progressive asthenia. Severe iron-deficiency anemia was identified, with a hemoglobin level of 4.9 g/dL, and no clinical evidence of an active bleeding source.

Initial imaging evaluation included abdominopelvic computed tomography, which revealed a hypodense nodular lesion located in the pancreatic body, measuring approximately 30 mm in its greatest diameter. In addition, multiple bilateral pulmonary nodular lesions compatible with metastatic disease were identified.

An upper digestive endoscopic ultrasound was subsequently performed for further evaluation. The exam demonstrated a solid nodular lesion adjacent to the pancreatic head/isthmus region. The lesion was hypoechoic, markedly heterogeneous and had irregular and poorly defined margins, measuring 40 × 37 mm, with intense vascularization on doppler study (figure 1). This lesion showed invasion of the duodenal wall (figure 2). The remaining pancreatic parenchyma showed no relevant abnormalities.

Figure 1. (A)Endoscopic ultrasound image showing a neoplastic lesion. (B) Intense vascularization observed on Doppler study.

 

Figure 2. Invasion of the duodenal wall by the neoplasm.

Endoscopic ultrasound-guided fine-needle biopsy was performed using a 22G needle for histological characterization (figure 3).

Figure 3. Fragment of the neoplasm composed of cells with clear cytoplasm [A] (H&E, 20×). The neoplasm shows a pattern of small solid nests, more evident after immunohistochemical staining with CK8/18 [B] (20×). In the remaining immunohistochemical study, the neoplastic cells showed expression of PAX8 [C] (20×), carbonic anhydrase IX (box-like membranous staining pattern) [D] (20×), and CD10 [E] (20×). CD34 highlighted a prominent network of blood capillaries, typical of this neoplasm [F] (10×).

What is the most likely diagnosis?

Submeter

Histopathological examination confirmed a pancreatic metastasis from previously diagnosed and treated clear cell renal cell carcinoma. Additionally, histological confirmation of pulmonary metastatic involvement was obtained.

Discussion

Secondary pancreatic tumors, although rare, represent a relevant entity in the differential diagnosis of pancreatic masses. They may result from distant hematogenous metastasis, direct invasion from adjacent organs, or, more rarely, originate from tissues not normally present within the pancreas. ¹˒² Pancreatic metastases from clear cell renal cell carcinoma (CCRCC) are one of the most frequently reported.

Pancreatic metastases from CCRCC have a poorly understood metastatic mechanism and may occur several years after resection of the primary tumor. ² Clinical presentation is variable, ranging from asymptomatic disease to non-specific symptoms, gastrointestinal bleeding, or obstructive jaundice. These manifestations and imaging findings can be similar to other pancreatic nodular lesions, which makes differentiation from pancreatic ductal adenocarcinoma or pancreatic neuroendocrine tumors challenging. ³

Endoscopic ultrasound (EUS) is essential for the characterization of these lesions, which typically appear as solid, well-circumscribed, often lobulated masses with marked hypervascularity on doppler imaging. ⁴˒⁵ While histological and cytology assessment can be challenging even for experienced pathologists, definitive diagnosis relies on histology. Therefore, endoscopic ultrasound–guided fine-needle biopsy represents a reliable method for diagnosing pancreatic metastases from renal cell carcinoma.⁴ Pancreatic metastasectomy in selected patients is associated with prolonged survival. ⁵

 

References

1. Harish Lavu, and Charles J Yeo. “Metastatic Renal Cell Carcinoma to the Pancreas.” Gastroenterology & Hepatology, vol. 7, no. 10, Oct. 2011, p. 699, pmc.ncbi.nlm.nih.gov/articles/PMC3265016/?utm_source=chatgpt.com. Accessed 18 Jan. 2026.
2. Cheng, Shaun Kian Hong, and Khoon Leong Chuah. “Metastatic Renal Cell Carcinoma to the Pancreas: A Review.” Archives of Pathology & Laboratory Medicine, vol. 140, no. 6, June 2016, pp. 598–602, pubmed.ncbi.nlm.nih.gov/27232353/, https://doi.org/10.5858/arpa.2015-0135-RS.
3. Shin, Teak Jun, et al. “Metastatic Renal Cell Carcinoma to the Pancreas: Clinical Features and Treatment Outcome.”Journal of Surgical Oncology, vol. 123, no. 1, Jan. 2021, pp. 204–213, pubmed.ncbi.nlm.nih.gov/33047324/, https://doi.org/10.1002/jso.26251.
4. Zignani, Nunzio, et al. “Endoscopic Ultrasound Features of Pancreatic Solid Lesions: Descriptive and Predictive Analysis on a Multicenter Sample.” World Journal of Gastrointestinal Endoscopy, vol. 17, no. 11, Winter 2025, p. 112487, pubmed.ncbi.nlm.nih.gov/41256295/, https://doi.org/10.4253/wjge.v17.i11.112487.
5. Rahul Pannala, et al. “Endoscopic Ultrasound-Guided Fine Needle Aspiration Cytology of Metastatic Renal Cell Carcinoma to the Pancreas: A Multi-Center Experience.”Cytojournal, vol. 13, 13 Oct. 2016, pp. 24–24, https://doi.org/10.4103/1742-6413.192191. Accessed 6 July 2023.

Authors

Inês Abreu Marques ^1,2,3  Joana Magalhães ^1,2,3  Francisca Dias Castro ^1,2,3 Cláudia Macedo ^1,2,3  José Cotter ^1,2,3

1 – Gastroenterology Department, Hospital da Senhora da Oliveira, Guimarães, Portugal;

2 – Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal;

3 – ICVS/3B’s – PT Government Associate Laboratory, Braga/Guimarães, Portugal