Renal cell carcinoma with vena cava tumor thrombus

Case contributed by Bruno Di Muzio


Mass in the right upper quadrant of the abdomen. Loss of weight and increasing confusion, lethargic, in general malaise. Bilateral groin DVT suspected on bedside ultrasound.

Patient Data

Age: 90 years
Gender: Male

CT Abdomen and Pelvis


Right kidney is enlarged and contains a heterogeneously enhancing solid mass in its lower pole. The findings are highly suspicious for a primary renal cell carcinoma. It extends superiorly, with extensive tumor thrombus filling the right renal veins and inferior vena caval. Within the inferior vena caval, the extensive thrombus extends superiorly over a craniocaudal distance of approximately 6.4 cm. It appears to end below the level of the hepatic veins, which appear grossly patent. Below this, the inferior vena cava and pelvic veins demonstrate patchy enhancement, suspicious for bilateral proximal thrombus. There is also expansive low attenuation material within the distal left renal vein extending from the junction with the tumor thrombus within the IVC, highly suspicious for left renal vein thrombosis. Elsewhere, both kidneys contain simple cysts, the largest on the right side measuring up to 11.3 cm in the mid pole. Neither kidney is hydronephrotic. No solid masses seen within the left kidney.

A 3.1 cm fat-containing mass in the left adrenal gland is in keeping with a benign myelolipoma. The left adrenal gland, liver, spleen, and pancreas are normal. Gallbladder shows some nodularity within its posterior wall, likely stones or polyps. Apart from colonic diverticular disease, the bowel is unremarkable. Prostatomegaly. No lymphadenopathy within the abdomen or pelvis.

Coarse trabecular and expansion of the pelvic bones on the right are suggestive of Paget's disease. Bilateral pars defects at the lumbosacral junction. Diffuse idiopathic skeletal hyperostosis noted within the imaged thoracic spine. Small pericardial effusion. Lung bases are clear.

Case Discussion

The features are in keeping with a large right primary renal cell carcinoma with extensive tumor thrombus involving the right renal veins and IVC, with thrombosis of the distal left renal vein and likely downstream thrombosis within the IVC and its major feeding veins in the lower abdomen/pelvis.

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