Dian Komala Dewi1, Freedy Tambunan1, M Rezza1, Ristaniah Soetikno1, Farhan anwary1, Undang Ruhimat1, Leni Santiana1

Radiology Department, Faculty of Medicine Padjadjaran University- Hasan Sadikin General Hospital, Pasteur 38, West Java, Bandung 40161 – Indonesia, email:freedyradiologyrshs@gmail.com

Introduction: Tumor thrombus migration are unique aspects of renal cell carcinoma that associated with venous tumor thrombus, which invades along the renal vein to the inferior vena cava (IVC) and ultimately ascends to the right atrium and invaded into brain1,2. Therefore it is necessary to establish various types of examinations to make a diagnosis.

Report: We report a 50-years-old male patient presented with a few days history of headache, confussion, difficulty of walking, numbness in the palms to the feet, difficulty lifting the limbs and hypertension, previously the patient was diagnosed with renal cell carcinoma and complained of pain in the lump on his left waist and red urination. The ECG showed sinus tachycardia with Poor R-wave progression (PRWP). At the time of ultrasound examination is obtained the enlarged left kidney with an abnormal shape. Abdominal and pelvic CT scan confirms that left kidney mass extends to the left kidney vein, inferior vena cava, accessory liver vein accompanied by thrombus, enlarged liver, ascites and left pleural effusion. Two months later, CT angiography was examined and obtained inhomogeneous solid mass which includes the inferior vena cava and the suprahepatic segment to the kidney segment accompanied by thrombus then extends to the right atrium. Head CT scan shows several lacunar infarcts. Two months later a radical nephrectomy operation was performed and anatomical pathology results were clear cell kidney carcinoma (Class III Fuhrman) who had invaded the lymph vessels.

Conclusion: A higher level of the thrombus in the IVC did not affect the long-term survival; nevertheless, it was associated with a higher rate of surgical complications and hospital stay especially with Level III and IV thrombus3.

(A.B) Ultrasound description of the thrombus in the paraaorta area and doppler examination.

C. Ultrasound examination is obtained the enlarged left kidney with an abnormal shape.

A B

C D

D. Ultrasound examination in the presence of a thrombus inferior vena cava.

(E,F,G) Abdominal and pelvic CT scan confirms that left kidney mass extends to the left kidney vein, inferior vena cava, accessory liver vein accompanied by thrombus, enlarged liver, ascites and left pleural effusion.

E F

G H

H. CT angiography was examined thrombus then extends to the right atrium.

G. Inhomogeneous solid mass which includes the inferior vena cava and the suprahepatic segment to the kidney.

I

I. Head CT scan shows several lacunar infarcts at ganglia basalis and subtansia alba periventrikularis bilateral.

Refference 1. Noguchi, K., Hori, D., Nomura, Y., & Tanaka, H. (2012). Renal cell carcinoma with tumor–thrombus extension into the right

ventricle. Annals of vascular diseases, 5(3), 376-380. 2. Quencer, K. B., Friedman, T., Sheth, R., & Oklu, R. (2017). Tumor thrombus: incidence, imaging, prognosis and

treatment. Cardiovascular diagnosis and therapy, 7(Suppl 3), S165. 3. Alfreijat, M. (2016). A case of renal cell carcinoma with an extensive inferior vena cava thrombosis. Journal of community hospital

internal medicine perspectives, 6(5), 32101.