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A 63-year-old man with type 2 diabetes mellitus, hypertension and dyslipidaemia was referred with a right renal mass extending into the inferior vena cava. Three months earlier he had presented with epigastric pain, severe constipation, back pain and reduced appetite, without haematuria. Computed tomography of the chest, abdomen and pelvis showed a 10.3 × 8.1 × 10 cm exophytic right renal mass, consistent with clear cell renal cell carcinoma, with right renal vein extension and a CT stage of T3bN0M0 and no bone metastasis. The inferior vena cava was completely thrombosed, with tumour thrombus proximally and bland thrombus distally, and tumour thrombus extended into the right atrium. The patient was given analgesia and enoxaparin, changed to heparin when the former proved ineffective. He subsequently developed shock, severe metabolic acidosis and hepatic and renal failure, and died; the thrombus could not be removed surgically. These images document the vascular route by which renal cell carcinoma reaches the heart. Tumour thrombus involves the inferior vena cava in approximately 10% of cases and extends to the right atrium in a small proportion of these. Although most patients with cardiac involvement are asymptomatic, new arrhythmia or features of heart failure in a patient with metastatic renal cancer and no cardiac history may indicate metastatic involvement of the heart.
Keywords: oncology, cardiology, renal cell carcinoma, urology
A 63-year-old man with known type 2 diabetes mellitus, hypertension, and dyslipidemia was re- ferred to us from another hospital due to a right renal mass with inferior vena cava (IVC) extension. Three months prior, the patient had complained of epigastric abdominal pain, severe constipation and back pain, with decreased appetite. He did not, however, have haematuria. Full labs, computed tomography of the chest, abdomen, and pelvis (CT CAP), and a bone scan were performed on the patient. Imaging revealed a 10.3 x 8.1 x 10 cm exophytic right renal mass, likely clear renal cell carcinoma, with right renal vein extension (white arrow). The suggested CT staging was T3bN0M0, with no bone metastasis, but a tumour thrombus was seen in the suprahepatic IVC and right atrium. The IVC is completely thrombosed, with tumour thrombus proximally and bland thrombus distally (black arrow). The tumour thrombus extending to the right atrium of the heart in a cross-sectional CT scan (long arrow). The patient was started on pain medications and enoxaparin 80 mg twice daily, but
was later switched to heparin due to ineffectiveness of the former treatments. Later, the patient developed shock, severe metabolic acidosis, and hepatic and renal failure. He died as a result of the tumour and the severe IVC thrombosis, which could not be removed surgically.
Renal cell carcinoma has a predilection for vas- cular metastasis, resulting in tumour thrombus (TT) in the IVC in 10% of cases. In a small percentage, the TT progresses from the IVC to the right atrium (RA), causing cardiac metastasis [1]. At the time of diagnosis, around 30% of patients with renal cancer may have metastases [2], of which the lungs, bone, soft tissues, liver, and central nervous system are the most common sites [2].
Mohamad Bakir, Nariman Dyab are with College of Medicine, Alfaisal University, Riyadh, Saudi Arabia, e- mail: Mo7ammedbakir@gmail.com, e-mail: nanotdyab@hotmail.com (Corresponding author: Mohamad Bakir) Ayman Zaki Azzam is with General Surgery Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt e-mail: aazzam70@yahoo.com
Although RCC is for infiltrating the renal vein and causing thrombosis of the vena cava or even the right atrium, cardiac metastasis has only been observed infrequently. Therefore, arrhythmias or symptoms of heart failure in a patient with a metastatic who has no history of previous heart issues may reflect metastatic involvement of the heart [3]. While most patients with cardiac involvement are asymptomatic, hypertension is the most prevalent cardiac manifestation of renal cell carcinoma, affecting 20% to 37.5% of patients. Shortness of breath, cough, arrhythmia, chest discomfort, and peripheral are further cardiac manifestations [4]. Surgical resection can help relieve the symptoms of isolated cardiac metastases [4]. The five-year survival for RCC with IVC TT is between 32% and 69% [5].