Radiology Page

Inferior Vena Cava Tumor Thrombus (Renal Cell Carcinoma)

Extending Into Hepatic Veins

A 56-year-old white male presented with complaints offatigue, weight loss, edema in the lower extremities,shortness of breath and several bouts of transientgross hematuria during the last 2 months. Physicalexamination revealed grade 1 pitting edema of thelower extremities and the liver was tender to palpation.

Laboratory findings at hospital admission re-vealed red blood cell count 4.1 million, white bloodcell count 6,400, hematocrit 38, hemoglobin 11.2,alkaline phosphatase 73, serum glutamic-oxalo-acetic transaminase 16, bilirubin 0.7, creatinine 3.8mg/dl, blood urea nitrogen 42 mg/dl, serum albumin3.6 and serum globulin 3.8. Urinalysis showed aslightly turbid urine with a pH of 7.4, 15 red bloodcells per high power field, 1 to 2 white blood cells perhigh power field and clusters of bacteria.

The arterial phase of enhanced multidetector comput-erized tomography revealed a 4.8 cm enhancing tumor inthe right kidney with neovascularity extending into theperinephric space. An arterialized tumor thrombus wasseen in the right renal vein extending into the intrahe-patic segment of the inferior vena cava (IVC). Tumorneovascularity extended into the hepatic veins and therewas contiguous invasion of liver parenchyma sector V(see figure). In addition, there was a small 1 ½ cm neg-ative defect in the IVC segment above the obvious tumorthrombus reflecting an adherent bland thrombus. Tumorneovascularity was also seen in the renal hilar nodes (8to 10 mm in size) and nodes at the level of the portahepatis. Computerized tomography of the lungs andbrain as well as radionuclide bone scans showed no othermetastatic tumor.

Following superselective embolization of the re-nal cell carcinoma and the arterialized tumor throm-bus (augmented by adrenaline flow modulation)with 355 mc embologold spheres the primary neo-plasm was removed with radical nephrectomy. Em-bolization had resulted in slight retraction of thetumor thrombus in the IVC, facilitating its removal.The intrahepatic tumor extension was managed us-ing segmental hepatectomy. The patient survivedwith a cancer-free status as ascertained by followup

computerized tomography for 11 months, and then

0022-5347/11/1854-1475/0THE JOURNAL OF UROLOGY®

© 2011 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION AND RESEARCH, INC.

died of sepsis and pneumonia. An autopsy was notperformed.

While the tumor in the liver in our patient was due tocontiguous extension from an arterialized tumor throm-bus in the IVC and hepatic veins, surgical treatment, iesegmental resection, was the same as for metastatic liverlesions.1 Similarly, extraction of the tumor thrombusfrom the intrahepatic segment of the IVC, including re-section of infiltrated wall segments of the IVC, can im-prove cancer-free specific survival.2

Erich K. Lang, Amer Hanano and Quan Nguyen

Department of RadiologySUNY Downstate Medical School

Brooklyn, New York

1. Staehler MD, Kruse J, Haseke N et al: Liver resection for metastatic diseaseprolongs survival in renal cell carcinoma: 12-year results from a retrospectivecomparative analysis. World J Urol 2010; 28: 543.

2. Manassero F, Mogorovich A, Di Paola G et al: Renal cell carcinoma with cavalinvolvement: contemporary strategies of surgical treatment. Urol Oncol 2009;

Epub ahead of print.

Vol. 185, 1475, April 2011Printed in U.S.A.

DOI:10.1016/j.juro.2011.01.009

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