Medical Image of the Month: Renal Cell Carcinoma with Extensive Tumor Thrombus

Figure 1. CT of the abdomen with contrast (axial image) shows a large right large heterogeneous mass (red arrow), consistent with renal cell carcinoma.

Figure 2. A: CT of the abdomen with contrast (coronal image) shows a large right renal mass (green arrow) and tumor thrombus in the IVC (orange arrow). B: Sagittal image showing extension of the tumor thrombus from the inferior vena cava into the right atrium (blue arrow). C: Axial image showing evidence of tumor thrombus in the right atrium (pink arrow).

A 53-year-old man with a right-sided renal cell carcinoma (RCC) presented with nausea, vomiting, intolerance of oral intake and melena. A contrast enhanced CT of the abdomen and pelvis showed near complete replacement of the right kidney by a large heterogeneous mass, measuring 10 x 16 cm (Figure 1). The mass invaded the renal vein and inferior vena cava (IVC) with extension to the level of the inferior cavo-atrial junction (Figure 2). The mass compressed the duodenum, causing a bowel obstruction. Liver and lung metastases were also found. A duodenal stent was placed with significant improvement in his nausea and vomiting. He was not able to receive anticoagulation due to severe gastrointestinal bleeding. The patient discontinued disease modifying therapy and died four weeks after discharge from the hospital.

Tumor thrombus occurs when a tumor invades a blood vessel. It occurs in approximately 10% of patients with renal cell carcinoma, which is a highly vascular malignancy with a propensity to invade the venous system (1). Extension of the tumor from the inferior vena cava into the right atrium is very uncommon, seen in only about 1% of RCCs (1). The American Joint Committee on Cancer staging system for RCC differentiates between tumor thrombus involving the renal vein (T3a), IVC below the diaphragm (T3b) and IVC above the diaphragm (T3c) (1). The presence of tumor thrombus changes staging, prognosis and surgical options. Surgical treatment may be the approach to tumor thrombus in RCC without metastatic disease. The surgical approach is often complex and requires extensive surgical planning and expertise (2). Perioperative morbidity and mortality appear to be proportional to the height of tumor growth, and tumor thrombus extending above the diaphragm carries increased perioperative risk. Wagner et al. (3) retrospectively studied 1,192 cases, and found reduced long-term survival in patients with any venous involvement. However, they found no significant difference in long-term survival between patients with IVC tumor thrombus below (T3b) or above (T3c) the diaphragm. In this study, the most important prognostic factors in RCC included renal tumor size, the presence of perinephric fat invasion, lymph node involvement and distant metastatic lesions.

David Horn MD, Sue Cassidy ANP-BC and Linda Snyder MD

Departments of Internal Medicine and Pulmonary, Critical Care, Allergy and Sleep Medicine

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Wotkowicz C, Wszolek MF, Libertino JA. Resection of renal tumors invading the vena cava. Urol Clin N Am. 2008; 35: 657-71. [CrossRef] [PubMed]
2. Quencer KB, Friedman T, Sheth R, Rahmi O. Tumor thrombus: incidence, imaging, prognosis and treatment. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S165-77. [CrossRef] [PubMed]
3. Wagner B, Patard JJ, Méjean A, et al. Prognostic value of renal vein and inferior vena cava involvement in renal cell carcinoma. Eur Urol. 2009;55:452-9. [CrossRef] [PubMed]

Cite as: Horn D, Cassidy S, Snyder L. Medical image of the month: renal cell carcinoma with extensive tumor thrombus. Southwest J Pulm Crit Care. 2019;19(3):95-6. doi: https://doi.org/10.13175/swjpcc031-19 PDF 

Medical Image of the Week: Pulmonary Metastases of Rectal Cancer

Figure 1. CT scan of the chest shows bilateral masses (white arrows), left sided pleural effusion and endobronchial mass (black arrow).

Figure 2: Endobronchial mass (A) before and (B) after removal.

A 51-year-old woman with known rectal cancer currently receiving systemic chemotherapy presented with 2 weeks of worsening dyspnea on exertion. The day prior to admission she developed persistent inspiratory and expiratory wheeze. CT scan demonstrated right main stem endobronchial mass and a heterogeneous mass comprising the entire left hemithorax (Figure 1). Flexible bronchoscopy demonstrated a fungating mass at the carina extending down both main stems (Figure 2). The mass was snared and removed with cryotherapy and pathology was consistent with metastatic rectal adenocarcinoma.

Michael Insel MD, Naser Mahmoud MD and Afshin Sam MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center Tucson

Tucson, AZ USA

Cite as: Insel M, Mahmoud N, Sam A. Medical image of the week: pulmonary metastases of rectal cancer. Southwest J Pulm Crit Care. 2017;14(2):43-4. doi: https://doi.org/10.13175/swjpcc008-17 PDF 

Medical Image of the Week: Renal Cell Carcinoma Metastasis

Figure 1. Panel A: Axial CT image noncontrast showing small pulmonary nodules concerning for metastasis. Panel B: Axial CT image depicting 15 cm mass, originating from the right acetabulum and adjacent iliac bone. Panel C: Coronal CT image showing prominent left renal cyst measuring almost 40 mm. Panel D: Coronal CT image displaying femoral head intact but surrounded by abnormal soft tissue, concerning for neoplasm. There is bony destruction and lytic process in the anterior and posterior pillars of the right acetabulum.

A 65-year-old man was complaining of progressive weakness and right knee pain with limping since November 2014 was admitted recently to a local hospital and treated for chronic kidney disease related anemia, Klebsiella urinary tract infection and methicillin-sensitive Staphylococcus aureus wound infections. He was discharged to rehab, but continued to have progressive weakness, pain and limping. He was sent to our hospital for further evaluation and imaging.

CT of the abdomen and pelvis non contrast, due to decreased glomerular filtration rate, revealed a 15 cm mass originating from the right acetabulum and adjacent iliac bone with bony destruction and lytic processes (Figure 1). The femoral head is also surrounded by abnormal soft tissue (Figure 1D). There were also small pulmonary nodules (Figure 1A), small lymph nodes in the transverse mesocolon and retroperitoneum, and an enlarged left adrenal gland concerning for other metastasis.

CT guided biopsy of the lesion revealed a neoplastic process composed of atypical cells with centrally placed nuclei, abundant clear cytoplasm arranged in a vascular network. Immunohistochemical stains demonstrated positivity for the following: vimentin, low molecular weight keratin, CD10, RCCA, and PAX-8. These findings are consistent with metastatic renal cell carcinoma.

A total body bone scan with Tc-99m methylene diphosphonate, performed to locate other osseous metastasis, was negative for distant metastasis other than the large destructive lesion destroying the right ileum previously noted on CT.

Renal cell carcinoma (RCC) is a cortical tumor with malignant cells originating from the epithelial lining of the proximal tubules. Renal cancer is amongst the 10 most common cancers in both men and women, with RCC accounting for about 80% of the total incidence and mortality (1). RCC has been referred to as “the internist’s tumor” as it can cause systemic symptoms unrelated to the renal cancer. The classic triad of RCC (flank pain, hematuria, and a palpable abdominal renal mass) occurs in at most 9 percent of patients (1). Most cases of RCC are diagnosed incidentally on radiographic investigation done for other reasons. Unfortunately, many patients are asymptomatic until the disease is advanced. At presentation, approximately 25% of individuals either have distant metastases or advanced local disease (2). Biopsy is not usually required to diagnose RCC. Contrast-enhanced CT can be used to diagnosis and stage RCC. 

Stage IV disease has a median survival of about 12 months with systemic cytokine therapy and 28 months with targeted therapies, based on analyses from the International Metastatic RCC Database Consortium (IMDC) (1,3).

Erin Yen MS¹, Benjamin Rayikanti MD², Yunuen Valenzuela MD³, Jennifer Segar MD³

¹ Midwestern University Arizona College of Osteopathic Medicine, Phoenix

² Tucson Hospitals Medical Education Program

³ Department of Internal Medicine, Banner University Medical Center Tucson

Tucson AZ USA

References

1. American Cancer Society. Cancer Facts & Figures 2016. Atlanta, GA: American Cancer Society; 2016. Available at: http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2016/ (accessed 9/14/16).
2. DeKernion JB. Real numbers. In: Campbell's Urology, Walsh PC, Gittes RF, Perlmutter AD (Eds), WB Saunders, Philadelphia 1986. p.1294.
3. Heng DY, Choueiri TK, Rini BI, et al. Outcomes of patients with metastatic renal cell carcinoma that do not meet eligibility criteria for clinical trials. Ann Oncol. 2014 Jan;25(1):149-54. [CrossRef] [PubMed]

Cite as: Yen E, Rayikanti B, Valenzuela Y, Segar J. Medical image of the week: renal cell carcinoma metastasis. Southwest J Pulm Crit Care. 2016;13(3):135-6. doi: http://dx.doi.org/10.13175/swjpcc068-16 PDF

Medical Image of the Week: Metastatic Collecting Duct Carcinoma

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Figure 1. Transverse section of CT chest and abdomen shows enhancing pleural nodularity (yellow arrows) with a pleural effusion.

Figure 2.  Transverse section of CT abdomen shows heterogeneous enhancing mass in the right kidney (red arrow).

Figure 3. Coronal section of CT chest and abdomen showing a large right pleural effusion (yellow arrow) and atelectatic lung with mediastinal shift to the left. Red arrow points to the heterogeneous mass in the right kidney.

A 40-year-old woman home health nurse presented to the ED with intermittent right sided sharp chest pain and progressive dyspnea for 2 weeks. On admission she was found to be in respiratory distress. Chest x-ray revealed a massive right sided pleural effusion. Thoracic CT scan with contrast confirmed a large right pleural effusion with associated enhancing pleural nodularity also involving the diaphragmatic surface (Figure 1).  The visualized part of the abdomen revealed a mass in the midpole of right kidney (Figure 2). Subsequent CT scan of the abdomen with contrast revealed a heterogeneous enhancing mass in the right kidney suspicious for malignancy (Figure 3) and multiple paracaval lymph nodes. Thoracentesis revealed a hemorrhagic pleural effusion and during subsequent right video-assisted thoracoscopy showed disseminated tumorlets along the diaphragm and pleura. Pleural biopsy and fluid cytology was consistent with metastatic poorly differentiated collecting duct carcinoma of the kidney. The patient is currently getting outpatient chemotherapy. Collecting duct carcinoma of the kidney is an unusual variant of renal cell carcinoma and accounts for about 1% of all renal cell carcinomas (1). This variant has a poor prognosis and frequently metastasizes to the lung and liver.

Chandramohan Meenakshisundaram, MD

Nanditha Malakkla, MD

St. Francis Hospital.

Evanston, IL

Reference

1. Wang X, Hao J, Zhou R, Zhang X, Yan T, Ding D, Shan L, Liu Z. Collecting duct carcinoma of the kidney: a clinicopathological study of five cases. Diagn Pathol. 2013;8:96. [CrossRef] [PubMed]

Reference as: Meenakshisundaram C, Malakkla N. Medical image of the week: metastatic collecting duct carcinoma. Southwest J Pulm Crit Care. 2014;9(6):348-9. doi: http://dx.doi.org/10.13175/swjpcc160-14 PDF

Medical Image Of The Week: Metastatic Testicular Cancer

Figure 1.  Axial image of the abdomen demonstrating multiple hypodense hepatic lesions (orange oval) and a large left adrenal mass (green arrow).

Figure 2. Axial image of the abdomen with innumerable hepatic metastatic lesions and a mass arising from the left adrenal gland resulting in compression of the left kidney (red arrow) and lateral displacement of the spleen (blue arrow).

A 30 year-old man with metastatic embryonal testicular cancer was admitted to the hospital with severe abdominal pain. A contrast enhanced CT of the abdomen demonstrated large metastatic burden throughout the liver and the left adrenal gland (Figures 1 and 2). The mass arising from the left adrenal gland caused significant mass effect. The left kidney was compressed, though without hydronephrosis, and the spleen was displaced laterally. Renal and hepatic functions were preserved. His pain was controlled with opioids and oral steroids with significant improvement.

Michael Debo DO1, Linda Snyder MD2, S. Michelle Rhodes MD3.

1Department of Internal Medicine, Genesys Regional Medical Center; Grand Blanc, MI

2Departments of Medicine, Pulmonary and Critical Care and Palliative Medicine, University of Arizona Medical Center; Tucson, AZ

3Departments of Emergency Medicine, Geriatrics, Palliative and General Medicine, University of Arizona Medical Center; Tucson, AZ

Reference as: Debo M, Snyder L, Rhodes SM. Medical image of the week: metastatic testicular cancer. Southwest J Pulm Crit Care. 2014;8(6):354-5. doi: http://dx.doi.org/10.13175/swjpcc063-14 PDF

Medical Image of the Week: Parietal Mass

Figure 1. MRI of the head with contrast. Panel A: A 2.2 cm X 2.1 cm enhancing mass within the right precuneus with surrounding vasogenic edema. Panel B: Coronal view.

A 48 year old man presented to the emergency department with a witnessed tonic clonic seizure by family members and 1 week worsening headaches and gait ataxia. Non-contrast CT of the head showed a large right-sided parietal mass. MRI of the head was done to further evaluate the mass (Figure 1). CT chest/abdomen/pelvis showed bilateral pulmonary nodules, mediastinal lymphadenopathy, hepatic lesions, and thickening of the mid-distal esophagus. The patient was evaluated by neurology and started on dexamethasone and levetiracetam. Neurosurgery was consulted and performed a right-sided craniotomy and parietal mass resection. Later, an EGD was performed and biopsies were taken of the esophagus. The patient was found to have metastatic esophageal adenocarcinoma.

Andrew I. Kovoor MD and Sudhir Kumar Tutiki MD

Department of Medicine

University of Arizona

Tucson, Arizona

Reference as: Kovoor AI, Tutiki SK. Medical image of the week: parietal mass. Southwest J Pulm Crit Care. 2014;8(5):290. doi: http://dx.doi.org/10.13175/swjpcc045-14 PDF

Medical Image of the Week: Leptomeningeal Carcinomatosis

Figure 1. PET/CT scan showing metabolic activity in the mid 3^rd of the left breast without significant adenopathy (arrows).

Figure 2. Panel A: Brain MRI T1 pre contrast image shows normal signal intensity in cerebrum, brain stem and cerebellum with no evidence of acute infarction. Panels B and C: Post contrast images show diffuse leptomeningeal enhancement involving bilateral cerebellar folia and around the surface of brainstem (arrows).

A 65 year old woman with a history of breast cancer presented to the emergency department (ED) with dizziness and disequilibrium, which started a week prior to admission. A year ago, she was diagnosed with locally advanced lobular carcinoma confined to the left breast (Figure 1). She underwent mastectomy followed by chemoradiation including taxol, sunitinib, cyclophosphamide and doxorubicin with remarkable response, and achieved complete remission. In the ED, her neurologic status deteriorated rapidly, she developed tonic-clonic seizures and became unresponsive to verbal and painful stimuli. CT of the head showed no evidence of acute intracranial abnormality or metastatic lesion, however, a brain MRI brain showed contrast enhancement and increased fluid attenuated inversion recovery (FLAIR) signal of the leptomeninges in cranial nerves III, V, VII and VIII as well as cerebellar surface, suggesting meningeal carcinomatosis (Figure 2B and 2C). A lumbar puncture demonstrated malignant cells in the cerebospinal fluid confirming the diagnosis of leptomeningeal carcinomatosis. Palliative radiation therapy with thiotepa was planned, however, her family opted for comfort care only and the patient passed away 6^th day of hospital stay.

Leptomeningeal carcinomatosis (LC) is a devastating complication of systemic cancer that can occur in patients with solid or hematologic malignancies. LC has been described in 5% to 10% of patients with solid tumors, more frequently breast adenocarcinoma, lung adenocarcinoma and melanoma (1,2). LC may be the first manifestation of cancer in 5% to 11% of patients and maybe the sole site of relapse in patients successfully treated for cancer (2). Treatment of LC is currently palliative for most patients, with an expected median survival of less than 6 months (1,2)

Roberto Bernardo MD, Seongseok Yun MD PhD, Ateefa Chaudhury MD, Keri Maher DO, and Tauseef Siddiqi MD

Department of Medicine, University of Arizona, Tucson, AZ

References

1. Bruna J, González L, Miró J, Velasco R, Gil M, Tortosa A. Leptomeningeal carcinomatosis: prognostic implications of clinical and cerebrospinal fluid features. Cancer. 2009;115(2):381–9. [CrossRef] [PubMed] 
2. Kesari S, Batchelor TT. Leptomeningeal metastases. Neurol Clin. 2003:21(1): 25-66. [CrossRef] [PubMed]

Referece as: Bernardo R, Yun S, Chaudhury A, Maher K, Siddiqi T. Medical image of the week: leptomeningeal carcinomatosis. Southwest J Pulm Crit Care. 2014;8(3):190-1. doi: http://dx.doi.org/10.13175/swjpcc028-14 PDF