|IMAGES IN ONCOLOGY
|Year : 2021 | Volume
| Issue : 4 | Page : 619-620
Infrarenal extensive tumor thrombus in renal cell carcinoma: A rare presentation
Satish K Ranjan, Rudra P Ghoarai, Sunil Kumar
Department of Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
|Date of Submission||27-May-2020|
|Date of Decision||01-Jun-2020|
|Date of Acceptance||02-Sep-2020|
|Date of Web Publication||31-Dec-2021|
Department of Urology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Ranjan SK, Ghoarai RP, Kumar S. Infrarenal extensive tumor thrombus in renal cell carcinoma: A rare presentation. Indian J Cancer 2021;58:619-20
Inferior vena cava (IVC) thrombus can occur in a wide variety of malignancy viz., adult renal cell carcinoma (RCC), transitional cell carcinoma of upper tract, adrenocortical carcinoma, angiosarcoma, and hepatocellular carcinoma. RCC only accounts for about 18% of all malignancies causing venous thrombi, of which 17% are suprarenal and <1% are infrarenal. The presence of thrombus changes the clinical stage hence significantly affecting treatment and prognosis.
A 40-year-old man presented with pain in the right flank, progressive swelling of both legs, and hematuria for the last 7 days. He was anemic with bilateral pitting pedal edema and a palpable abdominal lump on the right side. There were dilated veins over the anterior abdominal wall. Contrast-enhanced computed tomography of chest, abdomen, and pelvis showed 15 × 12 × 10 cm heterogeneously enhancing right renal mass with infiltration into segments V, VI, and VII of the liver [Figure 1]. IVC was dilated up to 2.8 cm in diameter with a 15 cm long heterogeneously enhancing content in it extending from the infrahepatic part to bilateral common iliac and right external iliac vein suggestive of tumor thrombus [Figure 2]. Multiple enhancing pleural-based soft-tissue nodules were seen in both lungs with the largest 1 × 1.2 × 1.26 cm nodule in the posterior basal segment of the left lower lobe. An ultrasonography-guided biopsy from renal mass showed clear cell RCC. The patient was having Karnofsky performance (0-100%), Hemoglobin (13-17 g/dl), platelet count (150-450 L), neutrophil count (4-12 L), corrected serum calcium (9-11 mg/dL), and metastatic disease at presentation. According to International Metastatic RCC Database Consortium (IMDC), the risk model patient had four adverse prognostic factors, rendering him into a poor-risk group with a median survival of 7.8 months. Cytoreductive nephrectomy was also not a feasible option because he was not surgically fit. The case was discussed in the institutional tumor board and the prognosis was explained to the patient. With a shared decision, pazopanib 800 mg once daily was started but the patient expired in follow-up after 3 months.
|Figure 1: Heterogeneously enhancing soft tissue mass lesion completely replacing the right kidney|
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|Figure 2: Enhancing tumor thrombus extending from infrahepatic inferior vena cava to right common iliac vein|
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The clinical and pathological stage has proved to be the most important prognostic factor for RCC along with other factors like histological type and nuclear grade. The reported 5-year survival of localized RCC, RCC with IVC thrombus, and metastatic disease is 60–90%, 40–60%, and 0–10%, respectively. For nonmetastatic RCC with IVC thrombus, radical nephrectomy with thrombectomy is the most appropriate therapy. In the case of complete IVC blockage by tumor or bland thrombus, options available are IVC ligation, segmental resection followed by reconstruction. Mootha et al. have reported a case of RCC with infrarenal IVC tumor thrombus without metastasis, which was managed by radical nephrectomy along with ligation and resection of the infrarenal IVC. After ligation of IVC, drainage of venous flow from the lower extremity is possible because of ascending lumbar veins communicating iliac veins to suprarenal IVC, azygous, and hemizygous venous system. According to the IMDC risk model, Karnofsky performance status <80%, neutrophilia, thrombocytosis, elevated corrected calcium, low hemoglobin, and <1 year from diagnosis to vascular endothelial growth factor (VEGF)-targeted therapy are adverse prognostic factors. Patients with 0, 1–2, and 3–6 adverse prognostic factors have 43.2, 22.5, and 7.8 months of median overall survival, respectively. Our patient had four adverse prognostic factors namely poor performance status, neutrophilia, anemia, and less than one year from diagnosis to initiation of tyrosine kinase inhibitor (TKI) and hence carried poor risk and dismal survival. For metastatic RCC cytoreductive nephrectomy is preferred in good risk patients and can be offered to intermediate and poor risk patients, but recent studies have shown TKI alone is not inferior to nephrectomy (CARMENA trial). Because the patient belonged to the poor risk category according to the IMDC risk model, he was not suitable for cytoreductive nephrectomy; hence, TKI was chosen for treatment. Generic statements like this are preferablly avoided. There are generic options available for other TKIs. Please dont discuss the finances when science is focus of case report. Metastatic RCC with extensive IVC tumor thrombus is rare and is usually associated with advanced disease. It carries a very poor prognosis, and survival is less as compared to metastatic disease without IVC thrombus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Dr. Shivcharan Navriya gave the idea to draft the manuscript.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]