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Transitional cell carcinoma of renal pelvis with invasion of renal vein and thrombosis of subhepatic inferior vena cava
TRANSITIONAL
CELL CARCINOMA
OF RENAL PELVIS
WITH INVASION OF RENAL VEIN AND THROMBOSIS OF SUBHEPATIC INFERIOR VENA CAVA JAMES GEIGER, QUOCK
FONG,
M.D. M.D.
RAYMOND FAY, M.D. From the Department of Urology, University of California, School of Medicine, and French Hospital, San Francisco, California
ABSTRACT-A case of transitional cell carcinoma of the renal pelvis with invasion of the renal veins and inferior vena cava is reported. Radical surgical excision of the kidney and inferior vena cava was performed. The patient is alive one year post surgery.
Thrombosis of the subhepatic inferior vena cava due to invasive transitional cell carcinoma of the renal pelvis is a most unusual clinical presentation. No such instance has been reported in the literature in the past twenty years. Herein we describe a case of transitional cell carcinoma of the renal pelvis with invasion of the renal vein and the inferior vena cava. Case Report A seventy-three-year-old Chinese woman presented with bilateral flank pain, greater on the right side. She had lost twenty-eight pounds in the last three months. She denied gross hematuria and irritative or obstructive voiding symptoms, and had no previous history of urinary tract infection. No significant abnormalities were found on physical examination. Urinalysis showed specific gravity of 1.016, pH 6, and was negative for protein, glucose, ketones, and occult blood. Microscopic examination showed 26 white blood cells and 5-8 red blood cells per high-powered field. Serum creatinine and blood urea nitrogen values were normal. Hemoglobin level was 10.4 Gm/lOO ml, hematocrit 31.3 per cent, and white blood cells 11,200 with normal differential. Electrolytes and se-
52
quential multiple analysis panel (SMA-12) were within normal limits. On excretory urography (IVP) the right kidney was not visualized, and there was compensatory enlargement of a normal left kidney and collecting system. Right retrograde pyelogram showed a normal distal 2 cm of the ureter, with extravasation of contrast material in the periureteral area up to the ureteropelvic junction, without distinct visualization of the caliber and nature of the proximal right ureter. Ultrasonic examination of the right kidney revealed a complex lesion with sonolucent areas posteriorly and superiorly suggesting cystic changes, and a large echogenic zone suggestive of a parenchymal mass lesion inferiorly and an enlarged collecting system (Fig. 1). The left kidney and ureter were essentially normal. Computerized tomography (CT) of the abdomen with dye injection revealed a slightly enlarged multicystic nonfunctioning right kidney suggestive of tumor with multiple abscess sites and/or necrosis. There was loss of normal fascial planes in the hilar region but the perirenal fat appeared intact. The right renal vein and inferior vena cava (spinal level Li to Lz) were invaded with tumor.
UROLOGY
I
JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
Selective right renal arteriogram revealed a right renal artery smaller than the left, although both renal artery ostia were of the same caliber. In the upper pole of the right kidney was a distinctly lucent lesion with neovascularity, compatible with a renal cyst. The mid and lower kidney showed fine neovascularity. There was no tumor blush. There was fine neovascularity from the right renal pelvis down to the midureteral level, which suggests tumor extension down the right proximal ureter. The inferior vena cavagram revealed complete obstruction of the inferior vena cava below Lz (Fig. 2A). There was notable collateral circulation via the paravertebral and lumbar veins (Fig. 2B). FIGURE 1. Ultrasonic examination of abdomen. Multiple parenchymal abscesses. Invasion of renal vein and inferior vena cava by tumor.
Treatment A thoracoabdominal approach was used to do a right radical nephrectomy and en bloc lymphadenectomy with excision of the inferior vena cava from the level of the left renal vein to the bifurcation of the common iliac veins. The tumor arising from the right kidney extended from the base of the diaphragm to the level of the ilium. The colon was deviated medially, and the tumor was contiguous with the duodenum and the hepatic flexure of the colon. The inferior vena cava and aorta were encased
Lung CT showed a 1.5 cm irregular nodule in the left midlung field, without central calcification. Tissue sampled via thin needle biopsy revealed a dysplastic lesion, which will be reassessed with possible open biopsy in six months. Bone and liver scans were negative for metastatic disease.
FIGURE 2. (A) inferior venacavagram. Subdiaphragmatic portion is patent and free of tumor to level of left renal vein ostium. (B) Inferior venacavagram demonstrates complete obstruction of inferior vena cava below left renal vein. Collateral circulation by paravertebral and lumbar veins.
UROLOGY
i
JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
53
FIGURE 4. carcinoma.
FIGURE 3. Tumor invasion of right renal vein and inferior vena cava with bland thrombus extension to external iliac veins.
in dense fibrotic tissue, which proved nonneoplastic on multiple biopsies. Blood thrombus was identified in the vena cava from below the right renal vein to the common iliac vein (Fig. 3). A psoas abscess of approximately 50 cc was also encountered and evacuated. Pathologic examination revealed poorly differentiated carcinoma of uroepithelial origin, acute and chronic pyelonephritis with abscess formation and hydronephrosis (Fig. 4). The tumor obliterated the renal pelvis, compressed the vessels and ureter in the hilum, and penetrated the capsule fat pad in the lower pole. The entire lumen of the right renal vein was filled with tumor. Sections of the vena cava near the origin of the right renal vein showed tumor growth through the wall. The renal artery, ureter, a hilar lymph node, and all surgical margins are free of tumor. To date, one year after the operation, the patient is alive and well.
54
Poorly differentiated
transitional
cell
Tumors of uroepithelial origin are generally less invasive than renal cell carcinoma, but it has been reported with large, invasive, urothelial tumors.3 The spread of tumors of the renal pelvis may be to urothelium, perirenal lymphatics, or distant organs. A review of 28 cases of transitional cell carcinoma shows local spread to the urothelium in 21 cases, and spread to the kidney in 13 cases; distant spread was observed to the lymphatics in 4 cases, to the bone in 4 cases, to the lungs in 2 cases, and to splanchnic organs in 2 cases.4 Invasion of the inferior vena cava due to local extension of metastatic urothelial carcinoma resulting in thrombosis as in the case described here is most unusual. Urology M-553
University of California San Francisco, California 94143 (DR. FAY) References 1. Rubenstein MA, Welz BJ, and Bucy JC: Transitional cell carcinoma of the kidney-25 years experience, J Urol 119: 594 (1978). 2. Murphy DM, Zincke H, and Furlou WL: Management of high grade transitional cell cancer of the upper urinary tract, ibid 125: 25 (1981). 3. Scully RE, Galdabini JI, and McNeely BU: Weekly clinicopathological exercises. Case 11-1981, N Engl J Med 304: 657 (1981). 4. Rafla S: ‘Ihmors of the upper urothelium, Am J Roentgen01 Radium Ther Nucl Med 123: 540 (1975).
UROLOGY
/
JULY 1986
/
VOLUME XXVIII,
NUMBER 1
CELL CARCINOMA
OF RENAL PELVIS
WITH INVASION OF RENAL VEIN AND THROMBOSIS OF SUBHEPATIC INFERIOR VENA CAVA JAMES GEIGER, QUOCK
FONG,
M.D. M.D.
RAYMOND FAY, M.D. From the Department of Urology, University of California, School of Medicine, and French Hospital, San Francisco, California
ABSTRACT-A case of transitional cell carcinoma of the renal pelvis with invasion of the renal veins and inferior vena cava is reported. Radical surgical excision of the kidney and inferior vena cava was performed. The patient is alive one year post surgery.
Thrombosis of the subhepatic inferior vena cava due to invasive transitional cell carcinoma of the renal pelvis is a most unusual clinical presentation. No such instance has been reported in the literature in the past twenty years. Herein we describe a case of transitional cell carcinoma of the renal pelvis with invasion of the renal vein and the inferior vena cava. Case Report A seventy-three-year-old Chinese woman presented with bilateral flank pain, greater on the right side. She had lost twenty-eight pounds in the last three months. She denied gross hematuria and irritative or obstructive voiding symptoms, and had no previous history of urinary tract infection. No significant abnormalities were found on physical examination. Urinalysis showed specific gravity of 1.016, pH 6, and was negative for protein, glucose, ketones, and occult blood. Microscopic examination showed 26 white blood cells and 5-8 red blood cells per high-powered field. Serum creatinine and blood urea nitrogen values were normal. Hemoglobin level was 10.4 Gm/lOO ml, hematocrit 31.3 per cent, and white blood cells 11,200 with normal differential. Electrolytes and se-
52
quential multiple analysis panel (SMA-12) were within normal limits. On excretory urography (IVP) the right kidney was not visualized, and there was compensatory enlargement of a normal left kidney and collecting system. Right retrograde pyelogram showed a normal distal 2 cm of the ureter, with extravasation of contrast material in the periureteral area up to the ureteropelvic junction, without distinct visualization of the caliber and nature of the proximal right ureter. Ultrasonic examination of the right kidney revealed a complex lesion with sonolucent areas posteriorly and superiorly suggesting cystic changes, and a large echogenic zone suggestive of a parenchymal mass lesion inferiorly and an enlarged collecting system (Fig. 1). The left kidney and ureter were essentially normal. Computerized tomography (CT) of the abdomen with dye injection revealed a slightly enlarged multicystic nonfunctioning right kidney suggestive of tumor with multiple abscess sites and/or necrosis. There was loss of normal fascial planes in the hilar region but the perirenal fat appeared intact. The right renal vein and inferior vena cava (spinal level Li to Lz) were invaded with tumor.
UROLOGY
I
JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
Selective right renal arteriogram revealed a right renal artery smaller than the left, although both renal artery ostia were of the same caliber. In the upper pole of the right kidney was a distinctly lucent lesion with neovascularity, compatible with a renal cyst. The mid and lower kidney showed fine neovascularity. There was no tumor blush. There was fine neovascularity from the right renal pelvis down to the midureteral level, which suggests tumor extension down the right proximal ureter. The inferior vena cavagram revealed complete obstruction of the inferior vena cava below Lz (Fig. 2A). There was notable collateral circulation via the paravertebral and lumbar veins (Fig. 2B). FIGURE 1. Ultrasonic examination of abdomen. Multiple parenchymal abscesses. Invasion of renal vein and inferior vena cava by tumor.
Treatment A thoracoabdominal approach was used to do a right radical nephrectomy and en bloc lymphadenectomy with excision of the inferior vena cava from the level of the left renal vein to the bifurcation of the common iliac veins. The tumor arising from the right kidney extended from the base of the diaphragm to the level of the ilium. The colon was deviated medially, and the tumor was contiguous with the duodenum and the hepatic flexure of the colon. The inferior vena cava and aorta were encased
Lung CT showed a 1.5 cm irregular nodule in the left midlung field, without central calcification. Tissue sampled via thin needle biopsy revealed a dysplastic lesion, which will be reassessed with possible open biopsy in six months. Bone and liver scans were negative for metastatic disease.
FIGURE 2. (A) inferior venacavagram. Subdiaphragmatic portion is patent and free of tumor to level of left renal vein ostium. (B) Inferior venacavagram demonstrates complete obstruction of inferior vena cava below left renal vein. Collateral circulation by paravertebral and lumbar veins.
UROLOGY
i
JULY 1986
/ VOLUME
XXVIII,
NUMBER
1
53
FIGURE 4. carcinoma.
FIGURE 3. Tumor invasion of right renal vein and inferior vena cava with bland thrombus extension to external iliac veins.
in dense fibrotic tissue, which proved nonneoplastic on multiple biopsies. Blood thrombus was identified in the vena cava from below the right renal vein to the common iliac vein (Fig. 3). A psoas abscess of approximately 50 cc was also encountered and evacuated. Pathologic examination revealed poorly differentiated carcinoma of uroepithelial origin, acute and chronic pyelonephritis with abscess formation and hydronephrosis (Fig. 4). The tumor obliterated the renal pelvis, compressed the vessels and ureter in the hilum, and penetrated the capsule fat pad in the lower pole. The entire lumen of the right renal vein was filled with tumor. Sections of the vena cava near the origin of the right renal vein showed tumor growth through the wall. The renal artery, ureter, a hilar lymph node, and all surgical margins are free of tumor. To date, one year after the operation, the patient is alive and well.
54
Poorly differentiated
transitional
cell
Tumors of uroepithelial origin are generally less invasive than renal cell carcinoma, but it has been reported with large, invasive, urothelial tumors.3 The spread of tumors of the renal pelvis may be to urothelium, perirenal lymphatics, or distant organs. A review of 28 cases of transitional cell carcinoma shows local spread to the urothelium in 21 cases, and spread to the kidney in 13 cases; distant spread was observed to the lymphatics in 4 cases, to the bone in 4 cases, to the lungs in 2 cases, and to splanchnic organs in 2 cases.4 Invasion of the inferior vena cava due to local extension of metastatic urothelial carcinoma resulting in thrombosis as in the case described here is most unusual. Urology M-553
University of California San Francisco, California 94143 (DR. FAY) References 1. Rubenstein MA, Welz BJ, and Bucy JC: Transitional cell carcinoma of the kidney-25 years experience, J Urol 119: 594 (1978). 2. Murphy DM, Zincke H, and Furlou WL: Management of high grade transitional cell cancer of the upper urinary tract, ibid 125: 25 (1981). 3. Scully RE, Galdabini JI, and McNeely BU: Weekly clinicopathological exercises. Case 11-1981, N Engl J Med 304: 657 (1981). 4. Rafla S: ‘Ihmors of the upper urothelium, Am J Roentgen01 Radium Ther Nucl Med 123: 540 (1975).
UROLOGY
/
JULY 1986
/
VOLUME XXVIII,
NUMBER 1