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Abdomen » Adult Renal
Renal cell carcinoma (RCC)
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Author(s) :
Leandro Fernandez, MD
 
Presentation This 53 year old male with hematuria and mild right flank pain for two months duration was referred for an ultrasound examination.
 
 
 
Caption: Sagittal view of the right upper quadrant.
Description: A large homogeneous solid mass with well defined margins is visualized inferior to the liver. A normal right kidney is not identified. These findings are most consistent with a renal tumor.
 
 
 
Caption: Transverse scan through renal hilum
Description: Color Doppler imaging (CDI) demonstrates flow in the right renal artery entering the renal hilum. Flow in the right renal vein is not detected. The renal architecture is distorted and the kidney is enlarged. These findings are consistent with a renal malignancy with invasion of the right renal vein.
 
 
 
Caption: Transverse view obtained from a subzyphiod approach
Description: This sonogram demonstrates a solid appearing mass immediately posterior to the gall bladder. The lumen of the aorta is visualized to the left of the solid mass but the inferior vena cava (IVC) is not visualized. The mass represents the IVC which is distended with tumor thrombus.
 
 
 
Caption: Longitudinal color Doppler image slightly to right of midline
Description: CDI demonstrates small channels of flow through what appears to be the inferior vena cava. These flow signals represent minimal recannalization of flow through the IVC which is distended with tumor thrombus. These findings support a diagnosis of a right renal malignancy with tumor thrombus extending into the renal vein and IVC.
 
Differential Diagnosis Lymphoma
Hepatic mass
Renal mass
 
Final Diagnosis Renal cell carcinoma (RCC)
 
Discussion

Solid renal tumors are predominantly malignant (>90%). Renal cancer comprises approximately 3% of all cancers in the United States (ratio 2:1 males:females) with approximately 12,000 deaths per year. This disease is most common in patients between the ages of 50 and 70 but may be identified in any age group. Renal cell carcinoma (RCC) is the most common form of renal malignancy in adults. RCC is also known as adenocarcinoma or hypernephroma. The tumor can be focal (confined to one region of the kidney) or extend throughout the organ (as seen in this case) . The tumor may be located entirely within the kidney or present as a mass bulging from the renal capsule. 
When a solid renal mass is identified by sonography it is important to extend the examination to include the renal vein and inferior vena cava to evaluate these vessels for the presence of tumor thrombus. If present, tumor thrombus will be identified as a space-occupying mass of medium echogenicity within the vessel. The presence of tumor thrombus increases the probability of metastases to other parts of the body. It is important to indicate to the referring physician whether or not there is tumor thrombus as this will impact the therapeutic management including the surgical approach used to treat the patient.

 
Case References 1. Cochlin DL. Urinary tract. In: Diagnsotic Ultrasound: A logical approach. McGahn JP and Goldberg BB Eds. Lippencott - Raven. Philadelphia, PA 1998. 

2. Bolton DM, Wong P, Lawrentschuk N. Renal cell carcinoma: imaging and therapy.Curr Opin Urol. 2007 Sep;17(5):337-40.
 
Technical Details ATL HDI 5000 ultrasound system with a C5-2 (5 to 2 Mhz) curved linear transducer.  P4-2 phased array transducer was used for CDI to obtain improved penetration.
 
Follow Up This patient had surgery and the ultrasound findings were confirmed.
 
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