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An overview of a patient with kidney cancer and tumour thrombus in the inferior vena cava

Introduction: kidney cancer is prone to vascular invasion, in 4-10% of cases the inferior vena cava is affected, and in 1% of cases the right atrium. Today, taking into consideration the high perioperative mortality (2, 7-13%), partial or radical nepherectomy along with thromboendarterectomy are considered to be the only surgical procedures of curative character. Case report: 63 year old patient with a history of hernioplastics of the right inguinal region, state by medial laparotomy because of the perforated duodenal ulcer, dilated cardiomyopathy with moderately reduced systolic function (EFLV 45°%) and diabetes was hospitalized in May of 2014 at the urological department of the county hospital due to gross hematuria. With the MSCT of abdomen and pelvis a doubt was raised on solid expansionary process of the upper pole of the right kidney, sized 5x4, 5 cm and tumour thrombi were verified in the right kidney vein as well as in the inferior vena cava to the mouth of the right atrium. In July of 2014, at the urological clinic, a radical right-sided nephrectomy was done, thromboendarterectomy was excluded because of hemodynamic instability. Postoperative progress went without complications. The PHD report of clear cell carcinoma of renal cell grade II, according to the AJCC system T3N1Mx, stage III. 2 lymphatic nodes, microscopically filled with tumour, were isolated. The tumour was also penetrating the kidney capsule and was located in the adipose tissue, and there was a vascular invasion as well as the invasion of the kidney vein. Postoperatively done PET CT showed a pathological glucose metabolism in the inferior vena cava- thrombotic changes. In December of 2014, he was hospitalized at the internal department of the county hospital due to pulmonary embolism. He was treated with the low molecular weight heparin with gradual introduction of warfarin to achieve the target values of the coagulation parameters. In January of 2015 he was hospitalized again because of general state and dyspnea. CT angiography verified a massive pulmonary embolism of both main branches of pulmonary arteries and all lobar or segmental branches. Echosonography showed the entire right atrium filled most probably with thrombus (differential diagnostic possibly indicates tumour formation) along with dilatation of the right ventricle. Given the initial immeasurable PV, haematologist treated the patient with fresh frozen plasma and low molecular weight heparin due to the suspicion of chronic disseminated intravascular coagulopathy. Examined by oncologist who, given the general state of the patient (ECOG 3) considered that oncological treatment was not indicated. After the stabilization, the patient was referred to a treatment in a palliative type of institution. Conclusion: patients with kidney cancer and tumour thrombus present a challenge due to the high risk of perioperative morbidity and potential mortality. It is important to agree on attitudes towards perioperative and surgical treatment which require more prospective and multi-institutional studies with a larger number of patients.

kidney cancer, patient, inferior vena cava

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