A rare case of renal cell carcinoma with venous tumor thrombus involving lumbar vein

Abhay Dinkar Mahajan; Bhushan V Dodia; Prashant P Darakh

doi:10.4103/oji.oji_19_20

CASE REPORT

Year : 2020 | Volume : 4 | Issue : 3 | Page : 138-141

A rare case of renal cell carcinoma with venous tumor thrombus involving lumbar vein

Abhay Dinkar Mahajan, Bhushan V Dodia, Prashant P Darakh
Department of Urology, MGM Medical College and Hospital, Aurangabad, Maharashtra, India

Date of Submission	13-Apr-2020
Date of Decision	19-Aug-2020
Date of Acceptance	15-Sep-2020
Date of Web Publication	26-Nov-2020

Correspondence Address:
Abhay Dinkar Mahajan
MGM Medical College and Hospital, Aurangabad, Maharashtra
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/oji.oji_19_20

Abstract

The incidence of renal cell carcinoma (RCC) is around 3% of all cancers. Venous tumor thrombus (VTT) formation and migration are unique aspects of RCC with an incidence of 4%–10%. Venous extension into the renal vein, inferior vena cava, and cardiac extension have been well documented in RCC. Various surgical approaches, including a cardiopulmonary bypass for tumor embolus extraction, may be needed. However, VTT extending into the lumbar vein at the initial presentation is very rare. We hereby report such rarity of RCC presentation of VTT involving renal vein and lumbar vein in a 50-year-old male.

Keywords: Lumbar vein, renal cell carcinoma, venous tumor thrombus

How to cite this article:
Mahajan AD, Dodia BV, Darakh PP. A rare case of renal cell carcinoma with venous tumor thrombus involving lumbar vein. Oncol J India 2020;4:138-41

How to cite this URL:
Mahajan AD, Dodia BV, Darakh PP. A rare case of renal cell carcinoma with venous tumor thrombus involving lumbar vein. Oncol J India [serial online] 2020 [cited 2021 Apr 10];4:138-41. Available from: https://www.ojionline.org/text.asp?2020/4/3/138/301577

Introduction

Renal cell carcinoma (RCC) represents around 3% of all cancers. Venous migration and tumor thrombus formation are unique aspects of RCC with significant therapeutic and prognostic implications.^[1] Incidence of venous extension to the inferior vena cava (IVC) in RCC is increasingly diagnosed recently due to advances in diagnostic modalities. It has been reported to occur in 4%–10% of patients with renal neoplasms.^[1] Complete surgical resection with thrombus extraction forms the mainstay of the treatment for RCC with venous tumor thrombus (VTT) and it implies heightened surgical challenges.^[2] However, VTT involving the lumbar vein at the initial presentation is extremely rare. Only one case report has been reported of delayed lumbar vein thrombus after 4 months of radical nephrectomy.^[3] We hereby present an interesting case of RCC with VTT involving the renal vein and lumbar vein simultaneously at the initial presentation.

Case Report

A 50-year-old male patient, a known diabetic and hypertensive, got admitted to the department of urology due to the chief complaints of backache and left flank pain for 1 month, and hematuria for the past 10 days. The patient had a history of passing clots in urine and repeated episodes of urinary retention. On physical examination, the patient was found to have pallor with right-sided hydrocele and left Grade 3 varicocele. Investigations showed his hemoglobin of 8.9 mg/dl and serum creatinine of 3.0 mg/dl with plenty of red blood cells in urine routine microscopy. Ultrasonography of the patient showed left renal exophytic lesion measuring 11 cm × 9 cm with peripheral heterogenicity and increased vascularity and central necrosis within and left renal vein extension. Abdominal noncontrast magnetic resonance imaging (MRI) scan showed a 9.6 cm × 9.7 cm heterogeneous mass involving the left kidney with extension to perirenal space, renal vein involvement and extension to IVC and lumbar vein (confirmed retrospectively after the surgery), with multiple enlarged lymph nodes in perirenal, hilar, and paraaortic region [Figure 1]a and [Figure 1]b. High-resolution computed tomography (CT) scan of the thorax ruled out the presence of any pulmonary or other distant metastasis. With these findings, the patient was planned for left radical nephrectomy with lymph node dissection. An 11^th ribbed incision with retroperitoneal, extragerotal approach was chosen. The renal mass was mobile suggesting an operable renal mass. There were plenty of perirenal large venous collaterals, which were ligated and cut. The renal artery was dissected on the posterior-superior aspect, doubly ligated, and cut. Intraoperatively patient was found to have a dilated renal vein with palpable venous thrombus in it and with the extension of the thrombus into IVC. While we tried to dissect the renal vein on the posterior aspect, we encountered a large dilated lumbar vein inserting on the posterior aspect. On palpation, a large thrombus was palpable in the lumbar vein [Figure 2]a and b]. IVC was clamped partially with satinsky clamp and renal vein thrombus was completely extracted by milking. The lumbar vein was ligated below the thrombus, doubly ligated and cut. Venotomy closure was done using 6–0 Prolene.

Figure 1: (a) Transverse sections of magnetic resonance imaging film showing left renal mass with involvement of renal vein and lumbar vein involvement. (Blue arrow indicates renal vein and red arrow indicates lumbar vein) (b) Coronal sections of magnetic resonance imaging showing renal vein and lumbar vein involvement: (Blue arrow indicates renal vein and red arrow indicates lumbar vein)

Click here to view

Figure 2: (a) Intraoperative picture of renal mass and involvement of renal vein and lumbar vein. (b) Picture of specimen delivered out showing renal vein and lumbar vein involvement with renal mass. (Blue arrow indicates renal vein and red arrow indicates lumbar vein)

Click here to view

Lymph node dissection was done and postoperatively patient had an uneventful course. We did not use any anticoagulants pre- or post-operatively. Histopathological examination of the operated specimen showed features of clear cell type RCC with Grade 2 differentiation invading capsule and perinephric fat. The renal vein, IVC, and lumbar vein showed features of tumor thrombus in it. The wall of the IVC was free from the tumor thrombus. A single paraaortic lymph node was positive. The final postoperative tumor, node, and metastasis staging were PT3bPN1CM0. The patient was advised for postoperative follow-up every 3 monthly with X-ray chest, ultrasonography, and serum creatinine level.

Discussion

Conventionally, RCC caval thrombus is classified into four groups or levels such as:^[4]

Group 1: VTT in the renal vein not reaching IVC
Group 2: Infrahepatic IVC thrombus
Group 3: Retrohepatic/Suprahepatic IVC thrombus not reaching into the right atrium
Group 4: Cardiac extension of thrombus (right atrium).

IVC thrombus extension has great implications related to prognosis and considerations from surgical removal, including IVC exposure and degree of vascular control.^[3] The majority of cases with VTT in RCC are symptomatic due to venous occlusion and can be presented with lower extremity edema, right-sided varicocele, ascites, caput medusa, BuddChiari syndrome, or pulmonary embolism.^[2]

There is a progressively rising incidence of RCC due to early detection of the tumor by the wide-spread use of abdominal imagining modalities as ultrasonography, CT scan, and MRI. These preoperative imagining aims to determine tumor size, location and determine capsule invasion/perinephric invasion, regional lymph node metastasis in addition to the renal vein and IVC involvement, and characterization of the tumor thrombus extent.^[1],[2],[4]

Ultrasonography is the primary imaging investigation to evaluate patients with renal mass. However, the overall sensitivity in detecting tumor thrombus is low, especially for detecting infrahepatic thrombus.^[4] CT scan is beneficial in demonstrating the extension of thrombus in the majority of cases. Venous thrombus is visualized as a low-density filling defect within the vein. Multiplanar reconstructed CT improved CT sensitivity in RCC up to 95% by accurately demonstrating renal mass and facilitating the detection of tumor thrombi and distant metastasis.^[4] MRI scan is the gold standard for delineating the level and extent of thrombus in IVC and for the staging of RCC with a sensitivity of 96%–100%.^[5] It is superior to CT scan for venous thrombus detection, delineating its extent and staging of RCC.^[4] The intrinsic contrast superiority of MRI over CT scan does not require further contrast medium to differentiate tumor thrombus making it useful in renal insufficiency patients.^[5]

The involvement of renal vein or IVC with tumor thrombus should be treated aggressively with surgical management. The surgical approach is the most preferred modality of treatment for these patients which results in satisfactory long-term survival rates.^[6]

Level 1 venous thrombi can be safely managed by nephrectomy with minimal dissection of IVC. Thrombus can be safely removed with milking maneuver along with sequential clamping with cavotomy and thrombectomy as required. Whereas level 2 venous thrombus requires a more extensive vascular dissection to expose infrahepatic and retrohepatic IVC.^[1]

Level 3 and 4 VTT extension requires more vigorous surgical manipulation with complete mobilization of the liver and IVC. Extensive dissection with venovenous bypass/cardiopulmonary bypass and hypothermic circulatory arrest may at times be needed.^[2] The risk of morbidity can be substantial for thrombi extending above the diaphragm and its 30-days mortality rate of 9.2%.^[2]

We herein report a rarity of presentation of RCC. RCC presenting with venous thrombosis is a well-known phenomenon and generally renal vein, and IVC above and below are found to be involved. However, simultaneous lumbar vein involvement in RCC with VTT is a rare initial presentation with no case of such type reported till date. One case reported by Tomic et al. showed recidive intraluminal IVC thrombus, arising from the lumbar vein on the IVC posterior wall, presenting after 4 months of a radical nephrectomy, and thrombectomy of the IVC (level II). They concluded that RCC tumor thrombus can spread from the kidney to IVC through the lumbar vein.^[3]

In our case, the lumbar vein was found to be involved along with the renal vein and IVC at the initial presentation. Preoperatively, MRI studies showed RCC mass with thrombus involving renal vein, lumbar vein, and extending to IVC. We were successful in mobilizing IVC and lumbar vein. Sequential clamping above and below along with partial clamping of IVC, helped us to milk out the thrombus from IVC using venotomy. The lumbar vein was ligated proximal to the thrombus and completely excised.

Conclusion

A rare entity of the lumbar vein thrombus should be kept in mind in cases of RCC with venous involvement of IVC and renal vein.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Hevia V, Ciancio G, Gómez V, Álvarez S, Díez-Nicolás V, Burgos FJ. Surgical technique for the treatment of renal cell carcinoma with inferior vena cava tumor thrombus: Tips, tricks and oncological results. Springerplus 2016;5:132.
2.	Psutka SP, Leibovich BC. Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015;7:216-29.
3.	Tomić A, Milović N. Recidive of renal cell carcinoma tumour thrombus in inferior vena cava via lumbar vein. Int Surg 2010;95:366-70.
4.	Nouh MA, Inui M, Kakehi Y. Renal cell carcinoma with IVC thrombi; current concepts and future perspectives. Clin Med Oncol 2008;2:247-56.
5.	Lawrentschuk N, Gani J, Riordan R, Esler S, Bolton DM. Multidetector computed tomography vs magnetic resonance imaging for defining the upper limit of tumour thrombus in renal cell carcinoma: A study and review. BJU Int 2005;96:291-5.
6.	Kaplan S, Ekici S, Doǧan R, Demircin M, Ozen H, Paşaoǧlu I. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Am J Surg 2002;183:292-9.