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: 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: 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