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Retroperitoneum » Kidneys, Ureters
Renal cell carcinoma invading the renal vein
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Author(s) :
Pamela T. Johnson, MD
 
Presentation This 60 year old man presented with macroscopic hematuria and left flank pain. On urinalysis, he was found to have proteinuria as well.
 
 
 
Caption: Transverse sonogram of the lower pole of the left kidney
Description: Hypoechoic, solid mass arising from the lower pole of the left kidney.
 
 
 
Caption: Transverse sonogram, medial to left kidney.
Description: The left renal vein is expanded with hypoechoic, solid material (thrombus).
 
 
 
Caption: Transverse sonogram, medial to left kidney.
Description: Color Doppler confirms the intraluminal location of the solid mass of thrombus within the left renal vein. The thrombus is non-occlusive, with flow peripheral to it. The expansile nature is typical of tumor thrombus.
 
 
 
Caption: Transverse sonogram, medial to left kidney.
Description: Color Doppler confirms the intraluminal location of the solid mass of thrombus (arrows) within the left renal vein. The thrombus is non-occlusive, with flow peripheral to it. The expansile nature is typical of tumor thrombus.
 
Differential Diagnosis Renal cell carcinoma with bland thrombus in the renal vein.
Renal cell carcinoma with tumor thrombus in the left renal vein.
 
Final Diagnosis Renal cell carcinoma with tumor thrombus in the renal vein.
 
Discussion Renal cell carcinoma is one of a subset of tumors with a propensity for vascular invasion. Spread into the renal vein is proported to occur in 4-25% of cases, and extension into the inferior vena cava occurs in 5-10%.

The detection of venous thrombus impacts the staging.  The classic staging of renal cell carcinoma is as follows:
Stage I: confined to the renal capsule
Stage II: extending into the perinephric fat, but confined to Gerota’s fascia
Stage III: invasion of the renal vein or regional lymph nodes, with or without perinephric extension or IVC extension
Stage IV: distant metastases or involvement of contiguous visceral structures

However, recent data has demonstrated that patients with renal vein and/or IVC involvement who do not have lymph node or perinephric extension have outcomes similar to those with Stage I disease, following nephrectomy and thrombectomy. Nonetheless, of patients with no metastatic disease or macroscopic vein invasion, those with microscopic vascular invasion have significantly worse survival at 5 years. In another series, patients with tumors confined to the kidney which extended into the vein had a signficantly worse prognosis than those without tumor thrombus. 

Patients with renal cell carcinoma invading the renal vein and/or IVC may have symptoms related to the vascular invasion, including lower extremity edema, a new right or left sided varicocele, dilated abdominal wall veins, pulmonary embolism and proteinuria. While the extent of thrombus does correlate with the patient’s symptoms, the literature states that the extent of thrombus does not necessarily correlate with the outcome.

On ultrasound, evaluation of the renal vein is imperative if a solid renal mass is detected. Sonograms will demonstrate hypoechoic solid material within the lumen of the vein. It may be occlusive, or partially occlusive as in this case, with some color flow around it. In addition, the inferior vena cava should be imaged to exclude thrombus extension if venous thrombus is identified. Tumor thrombus can be vascularized, which may be apparent with power Doppler or contrast enhancement. 

Ct and MRI are typically performed for staging, to guide the treatment. The treatment for these patients without metastatic disease is thrombectomy and nephrectomy; for those with metastatic disease, treatment includes cytoreductive nephrectomy, thrombectomy and immunotherapy.
 
Case References 1. Swierzewski PJ, Swierzewski MJ, Libertino JA et al. Radical nephrectomy in patients with renal cell carcinoma with venous, vena cava and atrial extension. Am J Surg 994; 168(2): 205-209.
2.  Van Poppel H, Vandendriesschett H, Boel K et al. Microscopic vascular invasion is most relevant prognosticator after radical nephrectomy for clinically nonmetastatic renal cell carcinoma. J Urology 1997; 158(1): 45-9.
3.  Ljungberg B, Stenling R, Osterdahl B et al. Vein invasion in renal cell carcinoma: impact on metastatic behavior and survival. J Urology 1995; 154: 1681.
4.  Zisman A, Pantuck AJ, Chao DH et al. Renal cell carcinoma with tumor thrombosis: is cytoreductive nehprectomy for advanced disease associated with and increased complication rate? J Urology 2002; 168(3): 962-7.
 
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