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 Month: Massive Right Atrial Dilation After Mitral Valve Replacement

Figure 1. Chest radiograph demonstrating massive cardiomegaly with pulmonary congestion and markedly dilated right atrium.

Figure 2. Transthoracic echocardiogram demonstrating marked dilation of the right atrium to 9.6 cm in its greatest dimension.

A 92-year-old woman with a history of mechanical mitral valve replacement (+25 years prior to presentation), coronary artery bypass grafting, pacemaker placement and heart failure (EF 25%) presented from a nursing facility for dyspnea of 1 day’s duration. Recently, the patient had experienced a bowel perforation s/p surgical repair 3 weeks prior.

Admission chest radiograph was significant for massive cardiomegaly with pulmonary congestion and markedly dilated right atrium (Figure 1). Formal echocardiography was ordered, which re-demonstrated the patient’s known heart failure with reduced ejection fraction. Additionally, all 4 chambers of the heart were noted to be dilated, but the right atrium was revealed to be severely enlarged to >9 cm (Figure 2). On review of outside records, the patient’s cardiac history was notable for chronic dilation of the RA, RV and LA for several years with low, but stable, LV ejection fraction. Ultimately, the patient was noted to have worsening abdominal distension concerning for acute abdomen. However rather than pursue additional aggressive work up after her recent surgery, comfort measures were preferred.

This case illustrates some of the possible long-term effects of mitral valve replacement. In recent years mitral valve repair has become the preferred method over replacement for degenerative valve disease in western countries (1). While there are documented short term benefits to both mitral valve replacement and mitral valve repair long term data is less available (2). Long-term survival in most studies is reported in 5,10, and 15-year intervals. As was the case with our patient, patients with mitral valve replacement greater than 20 years in age have significantly less information associated with them. Although at this time longitudinal studies suggest benefits for both mitral valve replacement and repair, further investigation into long term complications is warranted (3). As our society continues to age, understanding the risks and complications associated with previous valve repair will help guide therapeutic interventions in the geriatric patient.

Richard Young, MD* and Alexander Ravajy, BS**

*University of Arizona Department of Internal Medicine

**University of Oklahoma Department of Microbiology

Banner University Medical Center

Tucson, AZ USA

References

1. Gammie JS, Sheng S, Griffith BP, Peterson ED, Rankin JS, O'Brien SM, Brown JM. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2009 May;87(5):1431-7. [CrossRef] [PubMed]
2. McNeely CA, Vassileva CM. Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review. Curr Cardiol Rev. 2015;11(2):157-62. [CrossRef] [PubMed]
3. Christina MV, Gregory M, Christian M, Theresa B, Stephen M, Steven S, Stephen H. Long term survival of patients undergoing mitral valve repair and replacement a longitudinal analysis of Medicare fee-for-service beneficiaries. Circulation. 2013;127(18):1870–6. [CrossRef] [PubMed]

Cite as: Young R, Ravajy A. Medical image of the month: Massive right atrial dilation after mitral valve replacement. Southwest J Pulm Crit Care. 2018;18(1):8-9. doi: https://doi.org/10.13175/swjpcc111-18 PDF 

Medical Image of the Week: VA Shunt Remnant Fibrosing into Right Atrium

Figure 1. Transthoracic echocardiography demonstrating tubular echo density in the right atrium (arrow).

Figure 2: Transesophageal echocardiography demonstrating the VA shunt remnant fibrosed (vs. calcified) in SVC (arrow) extending into right atrium (RA).

A 71-year-old man with a history of ventriculo-atrial (VA) shunt, removed in 2004 due to infection, was admitted to the hospital complaining of syncopal symptoms for one day’s duration. On presentation he denied any symptoms of syncope or focal weakness. The patient was placed on telemetry monitoring, and overnight observation demonstrated multiple sinus pauses with frequent episodes of premature atrial contractions. Stat transthoracic echocardiography (TTE) on the night of admission demonstrated a right tubular echodensity in the right atrium crossing the tricuspid valve (Figure 1). Follow up transesophageal echocardiography (TEE) redemonstrated evidence of a tubular structure in the SVC extending into the right atrium with evidence of fibrosis (?calcification)(Figure 2). These studies demonstrate the importance of echocardiographical work up in any patient with risk of retained foreign body even after reported removal (1).

Richard Young, MD; Joshua Sifuentes, MD; Joao Paulo Ferreira, MD

Department of Internal Medicine

Banner University Medical Center

University of Arizona

Tucson, Arizona USA

Reference

1. Choi CH, Elahi MM, Konda S. Iatrogenic retained foreign body in the right atrium. Lessons to Learn. Int J Surg Case Rep. 2013;4(11):985-7. [CrossRef] [PubMed]

Cite as: Young R, Sifuentes J, Ferreira JP. Medical image of the week: VA shunt remnant fibrosing into right atrium. Southwest J Pulm Crit Care. 2017;14(3): 117-8. doi: https://doi.org/10.13175/swjpcc023-17 PDF

Medical Image of the Week: Catheter-Induced Right Atrial Thrombus

  

Figure 1. Panel A: Apical 4 chamber view showing intra cardiac mass (arrow) in the right atrium located above the closed tricuspid valve in systole (left). Panel B: The mass moves into the right ventricle through the open tricuspid valve in diastole.

Figure 2. Axial TRUFISP MRI images through the mediastinum demonstrate a central venous catheter (yellow arrow) within the distal superior vena cava (a-b) and proximal right atrium (c).  A hypointense lesion (red arrow) is seen extending from and in close approximation of the catheter tip (d-e).  Axial T1 post-contrast MRI image through the heart demonstrates no associated enhancement (f) in this lesion. These findings are most consistent with a catheter-related thrombus. 

A 71-year-old woman with a history of renal amyloidosis complicated by end stage renal disease on long term hemodialysis through a permacath presented with complaints of recurrent syncope during hemodialysis. When propped up at 45 degrees, her examination showed an early systolic murmur located over her right upper sternal border and a crescendo systolic murmur located over left axillary region. The murmurs were grade 2/6 in intensity but increased to 4/6 when propped up at 90 degrees. A transthoracic echocardiogram revealed a 2.5 x 2.7 cm echogenic mass arising from the right atrial side of AV groove and prolapsing through the open tricuspic valve into the right ventricle during diastole (Figure 1). On contrast enhanced cardiac magnetic resonance imaging, the mass was identified as a thrombus measuring 2.9 x 2.7 x 2.2 cm and connected to the distal tip of the dialysis catheter (Figure 2).

It is difficult to confidently determine the best catheter tip position to avoid thrombosis.  Although placement of the catheter tip in the right atrium may decrease thrombosis, this location is debatable and subject to controversy (1). The optimal treatment for catheter-induced right atrial thrombus is also an area of controversy (2).  

Anticoagulation therapy is preferred over surgery by most physicians. For our patient, we treated her with warfarin to a target INR (International Normalized Ratio) of 2 to 3.  We were concerned about the possibility of thrombus detachment and catastrophic embolism. We retained the internal jugular catheter in place and obtained a new femoral access site for future hemodialysis.

Manjinder Kaur DO, Hem Desai MBBS, Emily S Nia MD, and Imo Ebong MD

Department of Medicine

University of Arizona

Tucson, AZ USA

References

1. Vesely TM. Central venous catheter tip position: a continuing controversy. J Vasc Interv Radiol. 2003 May;14(5):527-34. [CrossRef] [PubMed]
2. Lalor PF, Sutter F. Surgical management of a hemodialysis catheter-induced right atrial thrombus. Curr Surg. 2006 May-Jun;63(3):186-9. [CrossRef] [PubMed] 

Cite as: Kaur M, Desai H, Nia ES, Ebong I. Medical image of the week: catheter-induced right atrial thrombus. Southwest J Pulm Crit Care. 2016;13(2):82-3. doi: http://dx.doi.org/10.13175/swjpcc062-16 PDF