renal cell carcinoma ( rcc ) has a potential to metastasize to almost any site . in descending order of frequency , the most common sites of metastasis are the lung , lymph nodes , liver , bones , adrenal glands , kidneys , brain , heart , spleen , intestine , and skin . it can involve any part of the bowel and accounts for 7.1% of all metastatic tumors to the small intestine . duodenal metastasis from rcc is very uncommon and only few cases have been described in the literature ( table 1 ) . also duodenal metastasis generally occurs when there is widespread nodal and visceral involvement and evidence of metastatic disease elsewhere in the body . commonly , renal cell metastases present many years after initial treatment , with recurrences reported up to 17.5 years after initial surgery . most cases of duodenal metastasis from rcc present with upper gastrointestinal bleeding or obstructive symptoms , and sequelae may include anemia , melena , fatigue , and early satiety . these include a variety of surgical and interventional therapy options that have been shown to provide effective survival benefits . here we report on a patient with solitary duodenal metastasis who presented with gastrointestinal bleeding 13 years after nephrectomy . a 66-year - old male presented with progressively worsening shortness of breath , fatigue and generalized weakness for the last 3 weeks . he also complained of loss of appetite and 15 pounds unintentional weight loss over the last few weeks . his past medical history was significant for hypertension , bilateral rcc status post right nephrectomy and partial left nephrectomy done 13 years earlier , ileocolectomy for perforated cecal diverticulitis , and prostate cancer treated with radiation . he had a 50 pack year history of smoking , but denied any alcohol use . on physical exam laboratory investigations on admission were significant for microcytic hypochromic anemia with hemoglobin 5 g / dl , hematocrit 16.8% , mcv 72 fl and mch 21.7 esophagogastroduodenoscopy showed an actively bleeding , 4 cm irregular , polypoid , ulcerative mass in the second portion of the duodenum , adjacent to but not involving the papilla ( fig . biopsies were obtained from this mass , following which the patient started having severe bleeding from the lesion . visceral angiography was done which demonstrated no extravasation or pseudoaneurysm in the duodenal vascular distribution or pancreaticoduodenal arcade . however , empiric angiographic embolization of the gastroduodenal artery was performed . despite these endoscopic and radiologic embolization attempts , bleeding continued , requiring another endoscopic procedure when the lesion was treated with argon plasma coagulation with successful control of the bleeding . the patient received a total transfusion of 11 units of packed red blood cells during his hospital course . further investigations included a computed tomography scan of the abdomen which showed an ill - defined mass measuring 5.4  3.3 cm at the junction of the second and third portion of the duodenum , adjacent to but not involving the head of the pancreas ( fig . 2 ) . there was no evidence of liver or visceral metastasis , and the visceral vessels and lymph nodes appeared normal . ultrasound of the abdomen showed normal pancreaticobiliary system with no common bile duct dilatation suggestive of obstruction . subsequently , the patient underwent exploratory laparotomy which revealed a 7  4 cm mass in the second portion of the duodenum . there was no evidence of malignant ascites , carcinomatosis , omental implants , or involvement of the pancreas or liver . he underwent pylorus - sparing pancreaticoduodenectomy , choledochojejunostomy , handsewn pancreaticojejunostomy and gastrojejunostomy with removal of the mass . postoperatively , the patient 's hospital course was complicated by leakage of the pancreaticojejunostomy fistula and sepsis , and he died two weeks later . gross examination of the surgical specimen revealed a 2.0  1.5  0.8 cm tan - red polypoid , pedunculated tumor protruding into the duodenum approximately 0.5 cm away from the ampulla of vater . the tumor appeared confined grossly to the mucosa and submucosa of the duodenum and did not appear to extend into or through the muscularis . eight lymph nodes were identified in the resection specimen , and all were negative for metastatic tumor with successful excision of all involved structures with clear margins and with no lymph node involvement . microscopically , the tumor was composed of clear cells arranged in a trabecular and alveolar pattern ( fig . immunohistochemically the tumor was positive for vimentin , cd10 , ae1/ae3 and epithelial membrane antigen and negative for ck7 , ck20 and pnra ( fig . 4 ) . histopathological features and immunostaining findings were compatible with a diagnosis of metastatic rcc of clear cell type . small bowel involvement by metastatic tumors is rare and has been reported in only 12% of autopsy cases [ 2 , 4 ] . common metastatic malignancies known to involve the small bowel are melanomas , lung cancer , cervical carcinomas , rccs , thyroid carcinomas , hepatomas and merkel cell carcinomas . solitary duodenal metastasis from rcc is exceedingly rare and most frequently involves the periampullary region or the duodenal bulb [ 6 , 7 ] . we have included patients with the bulk of the gross tumor in the duodenal or ampullary regions , distinct from pancreatic involvement . the majority of patients were found to have metastasis within 1 year after nephrectomy though it could be seen even after several years . the mean duration post nephrectomy to diagnosis of these solitary duodenal metastases was 7.9  4.7 years ( median 8 years ) . the range was 0 to 13 years , with one patient presenting with a synchronous metastasis . males were more commonly affected ( male : female ratio 3:1 ) and the incidence of metastasis increased with age . mean age at diagnosis of duodenal metastasis was 60.7  14 years ( median age 63 years , range 1686 years ) . disease eradication and cure are possible after nephrectomy ; however , there is also the possibility of a long period of disease latency , followed by recurrence of metastatic disease at unsuspected anatomic locations . rcc can metastasize via the lymphatic or hematogenous route , as well as by peritoneal dissemination or direct invasion into adjacent anatomic structures . the duodenum is an exceptionally rare site of metastasis in rcc , which is perhaps counterintuitive given its retroperitoneal proximity to the right kidney , though a majority ( around 70% ) occur from the right kidney . the most common clinical presentation of gastrointestinal metastases of rcc is gastrointestinal bleeding , resulting from the invasion of intestinal vessels by the neoplastic disease and/or intestinal obstruction [ 7 , 9 ] . most of the patients with solitary duodenal rcc metastasis present with gastrointestinal bleeding ( 69% ) , anemia and fatigue , whereas others present with early satiety , bowel obstruction , abdominal pain or jaundice from biliary obstruction [ 4 , 7 , 10 , 11 ] . patients post nephrectomy for rcc presenting with gastrointestinal symptoms should undergo complete diagnostic work - up with both endoscopic and radiologic evaluation , for detection and evaluation of the extent of metastatic disease . on endoscopy the lesion can be seen as a submucosal mass with ulceration of the tip , multiple nodules of varying sizes or raised plaques . endoscopic biopsy of suspicious lesions provides tissue for histologic diagnosis of metastasis and helps to distinguish primary gastrointestinal malignancy from metastatic disease . the treatment options in a case of solitary duodenal rcc metastasis depend upon the extent and location of the lesion and therapy must be individually tailored . procedures ranging from classic pancreaticoduodenectomy ( whipple procedure ) to interventional embolization have been reported ( table 1 ) . any patient with solitary metastatic rcc to the duodenum should be considered a candidate for complete surgical excision if medically and technically feasible , both for palliation of symptoms and because it provides the opportunity for meaningful disease - free survival . a curative role for pancreaticoduodenectomy in patients with solitary duodenal metastasis has been reported and has been shown to improve survival [ 11 , 13 , 14 , 15 , 16 ] . hemostasis of gastrointestinal bleeding occurring due to metastasis or invasion of malignant tumor is hard to manage endoscopically , and data on endoscopic therapy of bleeding from these duodenal lesions are limited . in selected cases , intractable gastrointestinal bleeding can be treated with arterial embolization of tumor - supplying arteries that has been reported to control gastrointestinal bleeding effectively , but there are no long - term follow - up data [ 17 , 18 , 19 ] . however , embolotherapy is only palliative while the tumor develops other collateral vessels and has potential for re - bleeding . also , in these cases , the physician should keep in mind that embolization for control of hemorrhage in the small bowel carries a significant risk of bowel infarction . for disseminated malignancy , treatment is mainly supportive and palliative , in the form of palliative surgery , radiotherapy , chemotherapy or immune - stimulating agents ( interleukin-2 ) [ 10 , 21 , 22 ] . patients with metastatic disease have poor survival despite the above treatment . the average survival is about 4 months and only 10% of them survive for 1 year . this case report highlights the importance of vigilance and high index of suspicion in post nephrectomy patients upon presentation of new clinical symptoms . appropriate awareness , recognition and aggressive work - up of gastrointestinal symptoms in patients post nephrectomy for rcc are of paramount importance . all authors declare that there are no potential conflicts ( financial , professional , or personal ) relevant to this paper .