An uncommon and insidious presentation of renal cell carcinoma with tumor extending into the inferior vena cava and right atrium: a case report

Abstract

BackgroundRenal cell carcinoma is a potentially lethal cancer with aggressive behavior and it tends to metastasize. Renal cell carcinoma involves the inferior vena cava in approximately 15 % of cases and it rarely extends into the right atrium. A majority of renal cell carcinoma are detected as incidental findings on imaging studies obtained for unrelated reasons. At presentation, nearly 25 % of patients either have distant metastases or significant local-regional disease with no symptoms that can be attributed to renal cell carcinoma.Case presentationA 64-year-old Indian male with a past history of coronary artery bypass graft surgery, congestive heart failure, and diabetes mellitus complained of worsening shortness of breath for 2 weeks. Incidentally, a transthoracic echocardiography showed a “thumb-like” mass in his right atrium extending into his right ventricle through the tricuspid valve with each systole. Abdomen magnetic resonance imaging revealed a heterogenous lobulated mass in the upper and mid-pole of his right kidney with a tumor extending into his inferior vena cava and right atrium, consistent with our diagnosis of advanced renal cell carcinoma which was later confirmed by surgical excision and histology. Radical right nephrectomy, lymph nodes clearance, inferior vena cava cavatomy, and complete tumor thrombectomy were performed successfully. Perioperatively, he did not require cardiopulmonary bypass or deep hypothermic circulatory arrest. He had no recurrence during the follow-up period for more than 2 years after surgery.ConclusionsAdvanced extension of renal cell carcinoma can occur with no apparent symptoms and be detected incidentally. In rare circumstances, atypical presentation of renal cell carcinoma should be considered in a patient presenting with right atrial mass detected by echocardiography. Renal cell carcinoma with inferior vena cava and right atrium extension is a complex surgical challenge, but excellent results can be obtained with proper patient selection, meticulous surgical techniques, and close perioperative patient care.Electronic supplementary materialThe online version of this article (doi:10.1186/s13256-016-0888-5) contains supplementary material, which is available to authorized users.

Atrial Metastasis of Renal Cell Carcinoma: A Rare Presentation

“…Renal cell carcinoma typically present with a triad of hematuria, flank pain, and flank mass, especially in cases of advanced disease [ 2 ]. In reality however, this classic triad is relatively uncommon, occurring in only 10% of the cases [ 3 ].…”

“…Our patient presented with symptoms of heart failure, and the diagnosis of RCC was only considered after the imaging studies. Other than primary or metastatic tumors, thrombus and tricuspid valve vegetations, rare causes of a right atrial mass include anatomic variants, coronary fistula, paced wires and indwelling catheters [ 2 ]. Renal cell carcinoma has a fascinating feature of invading local vasculature in to the renal vein and grows as a solid column of cells that can sometimes extend up to, as in our patient, the right atrium via inferior vena cava [ 2 ].…”

“…Other than primary or metastatic tumors, thrombus and tricuspid valve vegetations, rare causes of a right atrial mass include anatomic variants, coronary fistula, paced wires and indwelling catheters [ 2 ]. Renal cell carcinoma has a fascinating feature of invading local vasculature in to the renal vein and grows as a solid column of cells that can sometimes extend up to, as in our patient, the right atrium via inferior vena cava [ 2 ]. The commonest histological type of RCC is clear cell variety (70-80%), followed by the papillary type (10%) [ 1 ].…”

“…Renal cell carcinoma (RCC) is an aggressive and lethal tumor that constitutes approximately 3% of all adult malignancies [ 1 ]. Typical presentations of RCC include hematuria, flank pain and flank mass in advanced stage [ 2 ]. RCC has high frequency of metastatic spread to rare sites with atypical presentations.…”

“…RCC has high frequency of metastatic spread to rare sites with atypical presentations. Most cases of RCC are discovered as incidental findings on imaging studies for other reasons, and the tumor is aggressive enough that 25% of patients have either distant metastases or local-regional disease with atypical symptoms not related to RCC [ 2 ]. Intravascular tumor growth into the renal vein and inferior vena cava reported to be seen in about 15% of patients with extension into right atrium in approximately 1% of cases [ 2 ].…”