renal cell cancer is likely to hematogenously metastasize to the lung , bone , or liver , but metastasis to the esophagus is very rare . we report a patient with esophageal and mediastinal lymph node metastases that were treated surgically 10  years after the resection of primary renal cancer . patient : a 65-year - old man . presenting complaint : difficulty in swallowing . in 2002 , histopathological examination revealed clear cell carcinoma ( g2  >  g3 , pt3a , pn0 , m0 , and pstage iii ) . postoperative adjuvant therapy was performed with natural interferon alpha ( dainippon sumitomo pharma , osaka , japan ) at a dose of 6 million units 3 times a week from 2002 to 2005 , with no evidence of recurrence . present illness : in march 2012 , the patient complained of dysphagia . because upper gastrointestinal endoscopy detected a pedunculated polypoid tumor in the mid - esophagus and biopsy revealed clear cell carcinoma , he was referred to our hospital with a diagnosis of esophageal metastasis of renal cancer . findings on admission : the patient was 159  cm tall and weighed 51.8  kg . his temperature was 36.6  c , blood pressure was 108/60  mmhg , and pulse rate was 77/min ( regular ) . there was an upper abdominal scar from the transverse incision for his old right nephrectomy . hematology and biochemistry tests : there were no abnormal findings ( table  1).table  1examination on admissionwbc : 6,460/lalb : 4.1  g / dlrbc : 417    10/lt - bil : 0.5  mg / dlhb : 13.3  g / dlast : 15  iu / lht : 39.8  % alt : 17  iu / lplt : 23.4    10/lalp : 247  iu / lcea : 3.2-gtp : 42  iu / lca19 - 9 : 1.2bun : 15.5  mg / dlpt : 79.1  % cr : 1.05  mg / dlpt(inr ) : 1.08crp : 0.63  mg / dl examination on admission upper gastrointestinal endoscopy : a pedunculated polypoid tumor was noted on the anterior wall of the esophagus at 2935  cm from the incisors ( fig .  1 ) . 1upper gastrointestinal endoscopy shows a type 0-ip pedunculated tumor on the anterior wall at 2935  cm from the incisors upper gastrointestinal endoscopy shows a type 0-ip pedunculated tumor on the anterior wall at 2935  cm from the incisors thoracoabdominal ct : a a tumor was seen in the mid - thoracic esophagus , and a lymph node adjacent to the right main bronchus was enlarged ( fig . 2contrast - enhanced thoracoabdominal ct reveals a tumor in the mid - esophagus , and an enlarged lymph node adjacent to the right main bronchus contrast - enhanced thoracoabdominal ct reveals a tumor in the mid - esophagus , and an enlarged lymph node adjacent to the right main bronchus upper gastrointestinal contrast radiography : a pedunculated polypoid tumor was identified in the mid - thoracic esophagus ( fig . 3upper gastrointestinal contrast radiography shows a pedunculated tumor in the mid - esophagus upper gastrointestinal contrast radiography shows a pedunculated tumor in the mid - esophagus positron emission tomography / ct : uptake was noted at the mid - thoracic esophagus and in a lymph node adjacent to the right main bronchus . based on these findings , a diagnosis of esophageal metastasis and mediastinal lymph node metastasis of renal cancer was made , and esophagectomy via right thoracotomy was performed with reconstruction using a posterior mediastinal stomach tube . endoscopic treatment was not indicated for the esophageal metastasis because of its invasion of the submucosal layer and associated obstruction . a midline incision was made in the upper abdomen and a thin stomach tube was fashioned on the side of the greater curvature . the patient was then placed in the left lateral decubitus position , and thoracotomy was performed at the right 5th intercostal space . the thoracic duct was preserved . after dissecting the azygos vein and right bronchial artery , an enlarged lymph node ( right main bronchus lymph node ) was adherent to the cartilage of the right main bronchus , so this node was dissected free . the operating time was 6  h and 59  min and the blood loss was 234  ml . histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm were noted ( fig .  4 ) . the diagnosis was clear cell carcinoma . because histopathological examination at the time of right nephrectomy in 2002 also revealed proliferation of tumor cells with clear cytoplasm ( fig . 4histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm can be seenfig . 5histopathological findings : substantial proliferation of tumor cells with clear cytoplasm histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm can be seen histopathological findings : substantial proliferation of tumor cells with clear cytoplasm postoperative course : although suture dehiscence occurred , the patient s condition improved with conservative treatment ( enteral and central venous hyperalimentation ) and he was discharged from hospital 27  days postoperatively . histopathological examination revealed clear cell carcinoma ( g2  >  g3 , pt3a , pn0 , m0 , and pstage iii ) . postoperative adjuvant therapy was performed with natural interferon alpha ( dainippon sumitomo pharma , osaka , japan ) at a dose of 6 million units 3 times a week from 2002 to 2005 , with no evidence of recurrence . present illness : in march 2012 , the patient complained of dysphagia . because upper gastrointestinal endoscopy detected a pedunculated polypoid tumor in the mid - esophagus and biopsy revealed clear cell carcinoma , he was referred to our hospital with a diagnosis of esophageal metastasis of renal cancer . findings on admission : the patient was 159  cm tall and weighed 51.8  kg . his temperature was 36.6  c , blood pressure was 108/60  mmhg , and pulse rate was 77/min ( regular ) . there was an upper abdominal scar from the transverse incision for his old right nephrectomy . hematology and biochemistry tests : there were no abnormal findings ( table  1).table  1examination on admissionwbc : 6,460/lalb : 4.1  g / dlrbc : 417    10/lt - bil : 0.5  mg / dlhb : 13.3  g / dlast : 15  iu / lht : 39.8  % alt : 17  iu / lplt : 23.4    10/lalp : 247  iu / lcea : 3.2-gtp : 42  iu / lca19 - 9 : 1.2bun : 15.5  mg / dlpt : 79.1  % cr : 1.05  mg / dlpt(inr ) : 1.08crp : 0.63  mg / dl examination on admission upper gastrointestinal endoscopy : a pedunculated polypoid tumor was noted on the anterior wall of the esophagus at 2935  cm from the incisors ( fig .  1 ) . 1upper gastrointestinal endoscopy shows a type 0-ip pedunculated tumor on the anterior wall at 2935  cm from the incisors upper gastrointestinal endoscopy shows a type 0-ip pedunculated tumor on the anterior wall at 2935  cm from the incisors thoracoabdominal ct : a a tumor was seen in the mid - thoracic esophagus , and a lymph node adjacent to the right main bronchus was enlarged ( fig . 2contrast - enhanced thoracoabdominal ct reveals a tumor in the mid - esophagus , and an enlarged lymph node adjacent to the right main bronchus contrast - enhanced thoracoabdominal ct reveals a tumor in the mid - esophagus , and an enlarged lymph node adjacent to the right main bronchus upper gastrointestinal contrast radiography : a pedunculated polypoid tumor was identified in the mid - thoracic esophagus ( fig . 3upper gastrointestinal contrast radiography shows a pedunculated tumor in the mid - esophagus upper gastrointestinal contrast radiography shows a pedunculated tumor in the mid - esophagus positron emission tomography / ct : uptake was noted at the mid - thoracic esophagus and in a lymph node adjacent to the right main bronchus . based on these findings , a diagnosis of esophageal metastasis and mediastinal lymph node metastasis of renal cancer was made , and esophagectomy via right thoracotomy was performed with reconstruction using a posterior mediastinal stomach tube . endoscopic treatment was not indicated for the esophageal metastasis because of its invasion of the submucosal layer and associated obstruction . a midline incision was made in the upper abdomen and a thin stomach tube was fashioned on the side of the greater curvature . the patient was then placed in the left lateral decubitus position , and thoracotomy was performed at the right 5th intercostal space . the thoracic duct was preserved . after dissecting the azygos vein and right bronchial artery , an enlarged lymph node ( right main bronchus lymph node ) was adherent to the cartilage of the right main bronchus , so this node was dissected free . the operating time was 6  h and 59  min and the blood loss was 234  ml . histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm were noted ( fig .  4 ) . the diagnosis was clear cell carcinoma . because histopathological examination at the time of right nephrectomy in 2002 also revealed proliferation of tumor cells with clear cytoplasm ( fig . 4histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm can be seenfig . 5histopathological findings : substantial proliferation of tumor cells with clear cytoplasm histopathological findings : small alveolar proliferations of atypical cells with clear cytoplasm can be seen histopathological findings : substantial proliferation of tumor cells with clear cytoplasm postoperative course : although suture dehiscence occurred , the patient s condition improved with conservative treatment ( enteral and central venous hyperalimentation ) and he was discharged from hospital 27  days postoperatively . the mechanism of metastasis can be divided into direct invasion into adjacent organs ( such as the lungs , trachea / bronchus , thyroid , larynx , hypopharynx , and stomach ) or hematogenous / lymphogenous invasion of distant organs such as the uterus or liver . they reported that metastatic esophageal cancer accounted for 6.1  % ( 112 patients ) and the site of the primary tumor was as follows : lung in 51 cases , breast in 14 cases , and stomach in 13 cases . also reported that the frequency of hematogenous / lymphogenous metastasis to distant organs was only 11.3  % . it has been reported that metastasis is detected in approximately 30  % of renal cancer patients at the first hospital visit and the relative ranking of the site involved is lung  >  bone  >  regional lymph node  >  liver  >  virchow s node  >  brain . however , esophageal metastasis of renal cell carcinoma is extremely rare . when we searched pubmed using keywords such as  renal cell carcinoma  and  esophageal metastasis .   reported on a 62-year - old woman who underwent nephrectomy for right renal cancer 3  years before receiving transhiatal esophagectomy plus posterior mediastinal lymphadenectomy for esophageal metastasis ( a polypoid tumor ) . followed up on a 76-year - old woman who had esophageal metastasis of right renal cancer ( a sessile polypoid tumor ) at 5  years after nephrectomy , and reported that the patient survived for 10  months without surgical intervention . in our patient , esophageal metastasis occurred at 10  years after right nephrectomy for renal cancer , so the time interval until metastasis was longer than in the other cases reported so far . our renal cell carcinoma had an intermediate grade ( grade 2 ) ; this is part of the reason why he had a long recurrence - free time . according to the fuhrman classification , nuclear grade was the most significant prognostic criterion . surgical treatment of metastatic renal cancer usually has the advantage of a good performance status and prolongation of survival can be expected if the metastasis is in the lungs or adrenals . according to the national comprehensive cancer network guidelines ( version 2 , 2011 ) , surgical treatment is indicated when the primary tumor is in the kidney and the patient has a resectable solitary metastasis ( synchronous or metachronous ) . surgery was selected in our patient , because he had a resectable solitary esophageal tumor and a single mediastinal lymph node metastasis as well as a good performance status . however , it might become more common in the future , because renal cancer is a slow growing tumor and survival is likely to become longer with improvement of therapeutic strategies . in fact , in recent years there have been occasional reports of metastasis of renal cancer to the pancreas , although this used to be rare . the 5-year survival rate after pancreatectomy for pancreatic metastasis of renal cancer was reported to be 72.6  % for 321 resected patients and 14  % for 73 non - resected patients . there is a strong possibility that the incidence of both pancreatic and esophageal metastasis of renal cancer will increase in the future . if resection is possible , endoscopic or surgical resection is the treatment of first choice . if the tumor is unresectable , multidisciplinary treatment ( including molecular - targeting therapy ) will be needed . in conclusion , it will be necessary to conduct further studies in a larger number of patients to develop more appropriate treatments for esophageal metastasis of renal cancer .
the patient was a 65-year - old man , who had undergone right nephrectomy for renal cancer in 2002 . at that time 
 , histopathological examination revealed clear cell carcinoma ( pt3a , pn0 , m0 , and pstage iii ) . 
 postoperatively , he received natural interferon alpha ( 6 million units 3 times a week ) from november 2002 to february 2005 , and showed no evidence of recurrence . 
 however , he noticed dysphagia in march 2012 . 
 endoscopy revealed a pedunculated polypoid tumor in the mid - esophagus and biopsies were taken showing a clear cell carcinoma . 
 contrast - enhanced thoracoabdominal ct scanning identified a pedunculated polypoid tumor in the mid - thoracic esophagus and enlargement of a lymph node adjacent to the right main bronchus . with a diagnosis of esophageal and lymph node metastases of renal cancer , the patient underwent esophagectomy with right thoracotomy with reconstruction by a posterior mediastinal stomach tube . 
 postoperative histopathological examination revealed clear cell carcinoma . because esophageal metastasis of renal cancer is extremely rare , this case 
 is reported here together with discussions of the relevant literature .