A case of left renal cell carcinoma with massive tumor thrombus extending into the inferior vena cava.

A 58-year-old male presented to our division complaining of mild lumbago and transient gross hematuria during the recent 1 month. Physical examination revealed Grade 2 hypertension and low-grade fever. Laboratory tests showed mild anemia and slightly elevated serum C-reactive protein level (6.55 mg/dl). Contrast-enhanced computed tomography depicted a heterogeneously enhanced tumor in the left kidney, 12 cm in diameter, with massive retroperitoneal invasion (Fig. 1A, axial and B, coronal images). Abdominal ultrasonography demonstrated an irregularly fluctuating tumor thrombus extending through the left renal vein into the inferior vena cava (IVC), and the apex of the tumor thrombus existed just below the confluence of the hepatic veins (Fig. 2, arrow). No distant metastasis was recognized in preoperative radiological studies. Left radical nephrectomy with tumor thrombectomy was successfully performed (Fig. 3, tumor thrombus; arrow). After adequate vascular control of the IVC, the root of the left renal vein was cut and the tumor thrombus was dissected from the IVC wall and removed through the opening. Pathologic analysis of the surgical specimen revealed a conventional renal cell carcinoma (RCC) associated with a spindle cell carcinoma component with extracapsular invasion, and no lymph node metastasis (T3bN0M0). Unfortunately, magnetic resonance imaging 1 month after the operation revealed an epidural metastasis with lumbar spine invasion, and the patient underwent a total 39 Gy of radiation therapy. In RCC, a tumor thrombus is sometimes formed in the IVC, and it arises from the left kidney in 20% of the cases.