CASE 13678 Published on 22.06.2016

Isolated intracaval recurrence of resected renal carcinoma

Section

Uroradiology & genital male imaging

Case Type

Clinical Cases

Authors

Tonolini Massimo, M.D.; Vella Adriana, M.D.

"Luigi Sacco" University Hospital,
Radiology Department;
Via G.B. Grassi 74
20157 Milan, Italy;
Email:mtonolini@sirm.org

Patient

58 years, female

Categories

Area of Interest Veins / Vena cava, Kidney, Vascular ; Imaging Technique CT, MR

Procedure Diagnostic procedure ; Special Focus Neoplasia ;

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Clinical History

Asymptomatic woman on regular clinical and imaging follow-up after previous (6 years earlier) radical surgery for 8-cm T3b renal cell carcinoma with venous invasion, including right nephrectomy vena cavotomy and thrombectomy.
No significant abnormalities of laboratory studies, including stable renal function.

Imaging Findings

Routine follow-up CT (Fig. 1) showed a sizeable, faint filling defect in the intrahepatic inferior vena cava (IVC), consistent with partial luminal thrombosis. The left renal vein and infrahepatic IVC appeared patent; the left kidney showed normal findings. Distant metastases, adenopathies and local recurrence in the surgical bed were excluded.
Further investigation with MRI (Figs. 2, 3) confirmed partial thrombosis of the intrahepatic IVC, characterised by solid-type, moderately high T2- and hypointense T1 signal consistent with neoplastic tissue, and by arterial hypervascularity during the dynamic post-contrast study with subsequent washout of enhancement. The intraluminal mass measured 2.5x2 cm in axial diameters and nearly 6 cm in its longitudinal extent.
The diagnosis of tumour thrombus from recurrent renal carcinoma was confirmed by effective response after sunitinib therapy (Fig. 4a, b). Further follow-up (Fig. 4c, d) confirmed markedly reduced intracaval thrombus with loss on contrast enhancement. The patient was alive without further signs of recurrence ten years after nephrectomy.

Discussion

Locally advanced renal cell carcinoma (RCC) characteristically tends to invade the ipsilateral renal vein (stage T3a, in almost 35% of patients), subsequently the inferior vena cava (IVC) below the diaphragm (T3b, 4 10%) and occasionally extends to the right atrium (T3c). Aggressive surgical resection is warranted for RCC with neoplastic venous thrombosis (NVT). Free-floating intravascular tumours which do not invade the IVC wall can be successfully removed with 50–69% five-year survival in absence of metastases. Compared to T3b and T3c tumours, patients with NVT limited to the renal vein have significantly better prognosis (53% versus 16% at 5 years) and relapse-free survival (26 versus 12 months) [1-4].
After radical nephrectomy, current guidelines suggest intensive surveillance protocols including serial CT, based on risk factors including primary tumour size, stage and nuclear grade [1-3]. Although RCC may recur over an unpredictable time frame, the vast majority of cases develop within the first three years after radical surgery. RCC may reappear in almost every body tissue, with the lungs, skeleton, liver and brain as the commonest sites in descending order of frequency. Furthermore, local regrowth in the surgical bed may occur in 1.6-5% of patients [3, 5-9].
As shown in this case, the isolated post-surgical recurrence into the IVC is exceptional, almost invariably (90%) associated with right-sided RCCs, and possibly secondary to initial undetected infiltration of the IVC wall. Slow-growing NVTs causing incomplete obstruction are generally asymptomatic, and associated with limited or no laboratory changes: as a result, the recurrent NVT is generally first detected at imaging. Dilated superficial abdominal wall veins, pulmonary embolism and proteinuria may occur [5, 10].
Albeit differentiation from bland thrombus may be challenging, NVT generally appears as an intravascular filling defect with solid-type CT attenuation or MRI signal intensity, positive contrast enhancement or frank arterial-phase neovascularisation. Malignancy is further suggested by IVC dilatation, and by absence of deep venous thrombosis at the extremities and related risk factor [6, 7, 11, 12].
The prognosis of locally recurrent RCC is generally poor, with a five year survival rate less than 30%. Systemic chemotherapy with novel agents targeting angiogenesis such as sorafenib, sunitinib and bevacizumab is increasingly offered and may effectively improve survival and quality of life [4]. Alternatively, surgical resection of the recurrent NVT with reconstruction of the IVC has been reported as feasible [10].

Differential Diagnosis List

Recurrent renal cella carcinoma in the inferior vena cava.

Pseudothrombus artefact due to dense return from the renal veins

Bland inferior vena cava thrombosis

Primary leiomyosarcoma of the inferior vena cava

Final Diagnosis

Recurrent renal cella carcinoma in the inferior vena cava.

References

[1] Casalino DD, Remer E, Bishoff JT, et al. (2014) ACR appropriateness criteria post-treatment follow-up of renal cell carcinoma. J Am Coll Radiol 11:443-449 (PMID: 24793039)

[2] Chin AI, Lam JS, Figlin RA, et al. (2006) Surveillance strategies for renal cell carcinoma patients following nephrectomy. Reviews in urology 8:1-7 (PMID: 16985554)

[3] Stephenson AJ, Chetner MP, Rourke K, et al. (2004) Guidelines for the surveillance of localized renal cell carcinoma based on the patterns of relapse after nephrectomy. J Urol 172:58-62 (PMID: 15201737)

[4] Ljungberg B, Bensalah K, Bex A, et al. (2014) Guidelines on Renal Cell Carcinoma. European Association of Urology (EAU). Available at: http://www.uroweb.org/gls/pdf/10%20Renal%20Cell%20Carcinoma_LR.pdf Accessed March 17, 2016

[5] Sameh WM, Hashad MM, Eid AA, et al. (2012) Recurrence pattern in patients with locally advanced renal cell carcinoma: The implications of clinicopathological variables. Arab J Urol 10:131-137 (PMID: 26558015)

[6] Scatarige JC, Sheth S, Corl FM, et al. (2001) Patterns of recurrence in renal cell carcinoma: manifestations on helical CT. AJR Am J Roentgenol 177:653-658 (PMID: 11517065)

[7] Cocquia SF, Johnson PT, Ahmed S, et al. (2013) MDCT imaging following nephrectomy for renal cell carcinoma: protocol optimization and patterms of tumour recurrence. World J Radiol 5:436-445. (PMID: 24349648)

[8] Abel EJ, Margulis V, Bauman TM, et al. (2016) Risk factors for recurrence after surgery in non-metastatic RCC with thrombus: a contemporary multicentre analysis. BJU Int 17(6B):E87-94 (PMID: 26305276)

[9] Chae EJ, Kim JK, S.H. K, et al. (2004) Renal Cell Carcinoma: Analysis of Postoperative Recurrence Patterns. Radiology 234:189-196 (PMID: 15537838)

[10] Li G, Zhang Z, Xie D, et al. (2015) Surgical resection of recurrent inferior vena cava tumor following radical nephrectomy for renal cell carcinoma: A case report. Oncol Lett 10:111-114. (PMID: 26170985)

[11] Ng CS, Wood CG, Silverman PM, et al. (2008) Renal cell carcinoma: diagnosis, staging, and surveillance. AJR Am J Roentgenol 191:1220-1232 (PMID: 18806169)

[12] Sheth S, Fishman EK (2007) Imaging of the Inferior Vena Cava with MDCT. AJR Am J Roentgenol 189:1243-1251 (PMID: 17954667)

Case information

URL:	https://www.eurorad.org/case/13678
DOI:	10.1594/EURORAD/CASE.13678
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Contrast-enhanced multidetector CT for follow-up of resected renal carcinoma

Portal venous phase images (a, b): sizeable, faint filling defect (arrows) in the intrahepatic inferior vena cava.

Portal venous phase images (a, b): sizeable, faint filling defect (arrows) in the intrahepatic inferior vena cava. Note metallic clips from previous radical nephrectomy without local recurrence in the surgical bed or adenopathies.

Delayed images (c...e): the sizeable, faint filling defect (arrows) in the intrahepatic inferior vena cava persisted in the delayed acquisition. Note metallic clips from previous radical nephrectomy without local recurrence or adenopathies.

The left renal vein (thin arrows) and infrahepatic vena cava (thick arrows) were homogeneously opacified, without signs of thrombosis. The left kidney showed normal size, parenchymal opacification and contrast excretion, without hydronephrosis.

Figure 2

Unenhanced MRI

Unenhanced T2- (a-d) and T1-weighted (e) images showed tumour thrombosis in the intrahepatic vena cava (arrows) and normal flow-void signal at the hepatic vein confluence (arrowheads).

Figure 3

Follow-up contrast-enhanced CT studies after sunitinib therapy

Follow-up contrast-enhanced CT after sunitinib therapy showed dramatic size decrease of tumor thrombosis (a, b) at six months (arrows) and only a small filling defect (c, d) at three years (arrows).

Follow-up contrast-enhanced CT after sunitinib therapy showed dramatic size decrease of tumor thrombosis (a,b ) at six months (arrows) and only a small filling defect (c, d) at three years (arrows).

Follow-up contrast-enhanced CT after sunitinib therapy showed dramatic size decrease of tumor thrombosis (a, b) at six months (arrows) and only a small filling defect (c, d) at three years (arrows).

Figure 4

Dynamic contrast-enhanced MRI

Dynamic contrast-enhanced MRI acquisition showed strong enhancement in the tumour thrombus (arrows) in the arterial phase (f), portal phase (g) and delayed phase (h).