CT, arterial phase
Uroradiology & genital male imaging
Case TypeClinical Cases
AuthorsA. Minervini, J. Lera, G. Salinitri, D. Caramella
Patient65 years, male
CT examinations of the abdomen at 6 and 12 months after surgery and abdominal ultrasound at 12 months after surgery were uneventful, with no evidence of recurrence. In July 2002 the patient underwent CT of the abdomen as part of the normal follow-up schedule. Routine CT identified an intraluminal mass floating in the inferior vena cava (IVC). On CT of the total body there was no evidence of distant metastases elsewhere. MRI and spiral CT with contrast medium clearly showed the extent of the thrombus. Therefore, using a thoraco-abdominal approach, cavotomy and thrombectomy by segmental clamping with no caval resection were performed. The pathology of the vena caval tumour revealed a moderately differentiated (G2) clear cell RCC neoplastic thrombus (3cm x 2cm x 1.5cm).
The most feasible explanation of these late and solitary RCC IVC recurrences is that the thrombus originated from unrecognised involvement of the IVC, and indeed three of these four cases report the solitary recurrence as a consequence of a right RCC.
This is particularly true for the 10 month recurrence [2], but RCC can also recur years after the original diagnosis, through its unpredictable tendency to remain dormant for long periods and also metastasise many years after surgery. Frequently, no clinical signs accompany this type of late and isolated recurrence. A strict follow up is therefore mandatory to achieve an early diagnosis. In our patient the CT scan of the abdomen performed 20 months after radical nephrectomy enabled early diagnosis of a small mass floating in the IVC. The abdominal ultrasound was not performed at that stage while the one performed 12 months after surgery was negative. It is difficult to assess the role of abdominal ultrasound based on this single case. There are indications that ultrasnography is highly accurate in establishing the diagnosis and in determining the extent of tumor thrombus in the IVC. However, non-diagnostic ultrasound examination can occur especially in patients with high body mass index or in case of very small recurrence. In case of radiological suspicion of caval thrombus, contrast-enhanced gadolinium MRI is of great importance in order to determine the thrombus extension and the most useful sequences to be acquired are: SE T1-weighted, GRE T1-weighted, and FSE T2-weighted. We present this rare recurrence to emphasise the importance of a strict surveillance of all patients with RCC and especially for those with pT2, pT3a and pT3b RCC, despite the complete surgical resection of all suspected tumours.
[1] 1. Kuczyk MA, Bokemeyer G, Kohn CG, Stief S, Machtens M, Truss M, Hofner K, Jonas U. Prognostic relevance of intracaval neoplastic extension for patients with renal cell carcinoma. Br J Urol. 1997;80:18-24. (PMID: 9240174)
[2] 3. Finkelstein MP, Drinis S, Tortorelis DG, Lafaro RJ, Konno S, Choudhury MS. Recurrence of renal cell carcinoma with extensive vena caval thrombus three years after radical nephrectomy. Urol Int. 2002;68:199-201. (PMID: 11919469)
[3] 2. Smith RB. Long-term survival of a vena caval recurrence of renal cell carcinoma. J Urol. 1981;125:575-8. (PMID: 7218464)
[4] 4. Uygur MC, Ozen H, Sozen S. Late recurrence of renal cell carcinoma as a solitary thrombus in the inferior vena cava. BJU Int. 2001;87(1):126. (PMID: 11318733)
URL: | https://www.eurorad.org/case/1863 |
DOI: | 10.1594/EURORAD/CASE.1863 |
ISSN: | 1563-4086 |