An uncommon and insidious presentation of renal cell carcinoma with tumor extending into the inferior vena cava and right atrium: a case report
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Renal cell carcinoma is a potentially lethal cancer with aggressive behavior and it tends to metastasize. Renal cell carcinoma involves the inferior vena cava in approximately 15 % of cases and it rarely extends into the right atrium. A majority of renal cell carcinoma are detected as incidental findings on imaging studies obtained for unrelated reasons. At presentation, nearly 25 % of patients either have distant metastases or significant local-regional disease with no symptoms that can be attributed to renal cell carcinoma.
A 64-year-old Indian male with a past history of coronary artery bypass graft surgery, congestive heart failure, and diabetes mellitus complained of worsening shortness of breath for 2 weeks. Incidentally, a transthoracic echocardiography showed a “thumb-like” mass in his right atrium extending into his right ventricle through the tricuspid valve with each systole. Abdomen magnetic resonance imaging revealed a heterogenous lobulated mass in the upper and mid-pole of his right kidney with a tumor extending into his inferior vena cava and right atrium, consistent with our diagnosis of advanced renal cell carcinoma which was later confirmed by surgical excision and histology. Radical right nephrectomy, lymph nodes clearance, inferior vena cava cavatomy, and complete tumor thrombectomy were performed successfully. Perioperatively, he did not require cardiopulmonary bypass or deep hypothermic circulatory arrest. He had no recurrence during the follow-up period for more than 2 years after surgery.
Advanced extension of renal cell carcinoma can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of renal cell carcinoma should be considered in a patient presenting with right atrial mass detected by echocardiography. Renal cell carcinoma with inferior vena cava and right atrium extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques, and close perioperative patient care.
KeywordsRight atrial mass Renal cell carcinoma Thrombus
coronary artery bypass graft
deep hypothermic circulatory arrest
inferior vena cava
magnetic resonance imaging
renal cell carcinoma
Renal cell carcinoma (RCC) is a potentially lethal cancer with aggressive behavior and it tends to metastasize. RCC may present atypically with rare metastatic sites [1, 2]. Intravascular tumor growth along the renal vein into the inferior vena cava (IVC) occurs in up to 15 % of all patients with RCC and further extension of the tumor reaching the right atrium (RA) will be found in approximately 1 % of all patients .
In a routine clinic follow-up, a 64-year-old Indian male with a past history of coronary artery bypass graft (CABG) surgery, congestive heart failure, and diabetes mellitus complained of worsening shortness of breath for 2 weeks. He reported normal urination and had no fever or weight loss. He had no past history or family history of cancer. On examination, he was obese (BMI 38 kg/m2), his radial pulse was regular (95/minute), afebrile, and his blood pressure was 110/70 mmHg. Cardiovascular examinations revealed a mid-line sternotomy scar, displaced apex beat, and diminution of heart sounds with no murmur. Fine crepitations were heard in his lung bases bilaterally. His liver and spleen were not enlarged. The results of the remainder of his examinations were normal. His laboratory results were as follows: hemoglobin, 13 g/dl; leukocyte count, 7.4×109/L; platelet count, 159×109/L; serum creatinine, 90 μmol/L; alanine aminotransferase (ALT), 15 IU/L; and urinalysis revealed plenty of microscopic red blood cells. His chest X-ray showed cardiomegaly and his ECG showed sinus rhythm with nonspecific T inversion at lateral leads.
Advanced extension of RCC can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of RCC should be considered in a patient presenting with right atrial mass detected by echocardiography. RCC with IVC and RA extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques and close perioperative patient care.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
Apical four chamber view by tranthoracic echocardiography. Renal cell carcinoma extending into ventricle with cardiac motion. (WMV 841 kb)
Inferior vena cava view by transthoracic echocardiography. A "thumb-like" lesion protruding into right atrium and right ventricle. (WMV 833 kb)
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