CASE 8938 Published on 21.10.2010

Woman with epigastric pain and abdominal distension (ECR 2010 Case of the day)

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Ros Mendoza LH1, Ibánez Muñoz D2, Riaguas Almenara A2, Sarría Octavio de Toledo L2, Alconchel Lagranja A2, Martínez Mombila E2, Ferrer Lahuerta E1.
1) Department of Radiology, General Hospital Royo Villanova; 2) University Hospital Miguel Servet, Zaragoza, Spain.

Patient

61 years, female

Categories
Area of Interest Veins / Vena cava, Abdomen ; No Imaging Technique
Clinical History
We present the case of a 61 year old woman with gastric pain, nausea, vomits, increase of abdominal perimeter and constitutional syndrome.
Imaging Findings
Figures 1 and 2: Ultrasound study, axial and sagittal sections, which show increase of the diameter
of the inferior vena cava, with the lumen occupied by a motley and heterogeneous mass.

Figure 3: CT after intravenous contrast administration, parenchymatous phase, which allows the identification of a heterogeneous and hypodense mass within the lumen of the inferior vena cava. There is also a slight quantity of intraperitoneal free fluid.

Figure 4: CT after intravenous contrast administration. There is also occupation of the right renal vein, suggestive of infiltration of this structure.

Figures 5 and 6: Coronal and sagittal CT reconstructions, which show the bulky tumor inside the inferior vena cava, protruding into the right auricle. It is not possible to identify the ending of the suprahepatic veins.

Figure 7: Ultrasound study, axial section, before and after intravenous contrast administration, at the anatomic level of the suprahepatic veins. These vascular structures are not identified.
Discussion
The primitive tumors of the inferior vena cava are exceptional, they are essentially represented by the leyomiosarcoma. This kind of tumor appears preferably in women in the fifth decade and presents a high malignant potential [1].

When the tumor is located in the suprarenal segment of the inferior vena cava, it can invade the suprahepatic veins and the right auricle. This type of lesion, usually, cannot be surgically resected, requiring a bypass. Leg edema is related to a lower location of the tumor, while pulmonary thromboembolism can be generated by any tumoral location [2].

There are described three different types of tumoral growth: extrinsic to the inferior vena cava (so this type produce symptoms in a later stage: constitutional syndrome, radiculopathy, palpable mass, digestive hemorrhage… ), purely intraluminal or mixed (these two forms produce earlier manifestations, which are mainly related to the location of the tumor).

On ultrasonography the intraluminal form appears, in the initial stage, as a homogeneous mass that, as it grows, increases the diameter of the vessel, becoming heterogeneous. Computed tomography detects the increase of the inferior vena cava diameter related to a mass of intermediate density and with an irregular and heterogeneous postcontrast enhancement, opposed to the behaviour of a benign thrombus [3].

The main cause of obstruction of the inferior vena cava is the benign thrombus, originated in the lower extremities or in the pelvis, related to inmovilization, coagulopathy, inflammatory pelvic disease, congestive heart failure, dehydration.
In some cases angiomyolipomas and pheochromocytomas can present intracaval extension.
The malignant tumors which usually produce inferior vena cava thrombus are renal cell, hepatocellular and adrenal carcinoma and Wilms tumor [4, 5].

The concept of ”pseudothrombus” depends on artefacts related to a dense drainage of the renal veins into the inferior vena cava or to a partial volume effect.
Differential Diagnosis List
Intravascular leyomiosarcoma of the inferior vena cava with associated Budd Chiari syndrome.
Idiopatic thrombosis of inferior vena cava
Interrupted inferior vena cava with azygous/hemiazygous continuation
Retroperitoneal tumor with extrinsic compression of inferior vena cava
Final Diagnosis
Intravascular leyomiosarcoma of the inferior vena cava with associated Budd Chiari syndrome.
Case information
URL: https://www.eurorad.org/case/8938
DOI: 10.1594/EURORAD/CASE.8938
ISSN: 1563-4086