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Spontaneous Regression of a Pancreatic Metastasis of a Renal Cell Carcinoma
Despite the passage of nearly a century, William Osler's words "[that spontaneous remissions of cancer metastases] are among the most remarkable events which we witness in the practice of medicine,"1 still ring true today. While Osler was describing patients with metastatic breast cancer in spontaneous remission, work since then, starting with Bumpus'2 1928 case report, has determined that metastases from renal cell carcinomas (RCCs) are among the most frequent to spontaneously regress.2-5 Unfortunately, even metastases from RCCs regress in less than 1% of cases.3, 5 The most commonly reported site of a spontaneously regressing metastasis from an RCC has been the lungs ( 75%); however, spontaneous regressions from other sites such as liver and brain have been reported.3 We report a case, the first to our knowledge, of spontaneous remission of a metastasis of an RCC to the pancreas, following surgical resection of another RCC metastasis to the right lower lobe of the lung. The case reported is of interest for the scientific issues raised by the regression of the pancreatic metastasis, and the decisions made by the patient in a family practice setting during the course of the illness.
In April 1995, a 71-year-old woman presented with cough, fatigue, and malaise. The patient had a right-sided nephrectomy in 1981 because of RCC. The patient was otherwise healthy, taking only conjugated estrogens (Premarin), aspirin, and vitamins. A chest x-ray film in July (Figure 1, A) showed a vague nodular density of greatest diameter 1.5 cm over the proximal aspect of the 10th rib. The patient underwent a right lung lower lobectomy. Pathologic findings showed metastatic RCC (Figure 1, B). A preoperative abdominal computed tomographic scan in August 1995 had shown no abdominal masses, but a postoperative follow-up computed tomographic scan showed a mass in the body of the pancreas, that had increased in size by November 1995 (Figure 2, A). A needle biopsy of the mass demonstrated the presence of metastatic RCC (Figure 2, B). The patient was offered both surgery and chemotherapy but declined any treatment. The patient's condition did not worsen, and an abdominal computed tomographic scan in October 1996 showed that the mass in the pancreas had regressed (Figure 2, C). The patient continues to be in good health.
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Figure 1. A, Chest x-ray film shows a nodule in the lower lobe of the right lung (arrow). B, Metastatic renal cell carcinoma in the lung.
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Figure 2. A, Follow-up computed tomographic scan in November 1995 after right lung lower lobectomy demonstrates a mass in the body of the pancreas (arrow). B, Metastatic renal cell carcinoma in the pancreas. C, Computed tomographic scan in October 1996 shows that the mass in the pancreas is no longer present.
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There are many theories to explain spontaneous regression of metastases, including an enhanced immune response, removal of a prometastatic factor by resection of the primary tumor, or even apoptosis by recapitulation of some latent developmental program.5 If successful cancer vaccines can be developed, given the naturally occurring, slightly increased propensity of metastases of RCCs to spontaneously regress, nephrectomy patients may be good candidates for a prophylactic vaccine. Renal cell carcinoma may be a good cancer through which to study prometastatic or endogenous antiangiogenic factors. The case reported is noteworthy for the regression of a pancreatic metastasis following both recent resection of a lung metastasis and distant resection of the primary RCC. This raises an important treatment issue, because if a patient declines surgery on an inaccessible organ, as our patient did, resection of metastases at other more accessible sites may be of the greatest therapeutic value. Without doubt the spontaneous regression itself, in a family practice setting, is the most remarkable and important aspect of this case and well illustrates Osler's point that "the uncertainty of prognosis and the truth of the statement that no condition, however desperate, is quite hopeless."1
AUTHOR INFORMATION
We thank Maria C. Savoia, MD, Jay Grimaldi, MD, and Nina Buckwalter, MD, for helpful discussions.
Eric Lewin Altschuler, PhD
La Jolla, Calif
Albert Ray, MD
San Diego, Calif
1. Osler W. The medical aspects of carcinoma of the breast, with a note on the spontaneous disappearance of secondary growths. Am Med. 1901;17-19:63-66.
2. Bumpus HC. The apparent disappearance of pulmonary metastasis in a case of hypernephroma following nephrectomy. J Urol. 1928;20:185-191.
3. Kavoussi LR, Lavine SR, Kadmon D, Fair WR. Regression of metastatic renal cell carcinoma: a case report and literature review. J Urol. 1986;135:1005-1007.
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4. Edwards MJ, Anderson JA, Angel JR, Harty JI. Spontaneous regression of primary and metastatic renal cell carcinoma. J Urol. 1996;155:1385.
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5. Papac RJ. Spontaneous regression of cancer. Cancer Treat Rev. 1996;22: 395-423.
Arch Fam Med. 1998;7:516-517.
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