Retroaortic left renal vein in testicular cancer patient: potential staging and treatment pitfall

Unusual Drainage of the Bifurcated Left Renal Vein Into a Dilated Lumbar Azygos Vein and Inferior Vena Cava

We report a unique case of unusual drainage of the bifurcated retroaortic left renal vein, with the cranial wider branch draining into a dilated lumbar azygos vein and caudal thinner branch connecting with the inferior vena cava. The right renal vein was duplicated. The anomaly was discovered on multimodal ¹⁸F-labeled fluorodeoxyglucose positron emission tomography/computed tomography performed for oncological purposes. The basis enabling occurrence of such variation was probably persistent developmental extra left-right venous connections, intercardinal, or intersupracardinal, depending on the theory. The embryology of the chest and abdominal veins is a complicated process and there is no unanimity concerning its concepts. The old models are currently being questioned and reevaluated. Knowledge of possible variants of renal and azygos veins course is important from clinical, imaging, and surgical points of view. The retroaortic left renal veins course may sometimes cause pain, hematuria, proteinuria, and pelvic congestion syndromes. Dilated parts of uncommonly located veins, because of assuming a nodular shape on transverse images, may be mistaken for abnormal lymph nodes, other tumors or aneurysms on imaging. During a variety of surgical procedures, including venous sampling, renal transplantation, or any retroperitoneal surgery, knowledge of an aberrant venous course may be important for the success of the procedure and may be crucial even earlier during the qualification process.

Problem in diagnostic imaging

The staging of malignant disease for metastatic spread requires a sound understanding of the normal anatomy and possible anatomical variants as well as the expected pathology. This article illustrates this in the case of a young man with seminoma of the testis undergoing CT imaging to assess for para-aortic metastatic spread. A potential pitfall that may mislead the unwary is demonstrated.

A rational approach to managing stage I nonseminomatous germ cell cancer

Regardless of the treatment option selected for management of low-stage germ cell cancer, ultimate survival is nearly identical. Treatment-related morbidity is very low regardless of management modality and the individual patient can expect similar physical limitations owing to therapy. The overall difference in loss of productivity between treatment programs varies by little more than 1 week. The cost of treatment is similar for all methods, although there is a definite financial advantage to surveillance, less so for selective surveillance, when compared with other forms of management. Socioeconomic factors are of importance when managing limited resources for a large population, but are of less concern to an individual, especially when the mean differences in per patient costs vary by only $5000. Because of these close similarities in efficacy, morbidity, and costs treatment decisions should be individualized. A responsible and reliable patient can be managed safely by selective surveillance. Those individuals considered to be less self-motivated to pursue intensive care should be managed by primary therapy. Without more information regarding the long-term outcomes associated with primary adjuvant chemotherapy, primary adjuvant RPLND, where experienced surgical support is available, is the preferred management for low-stage germ cell cancer in patients selected for, or electing, active treatment rather than surveillance. Active investigations examining the role of medical management in this population should be continued. Our preferred choice of initial management is to offer selective surveillance to appropriate patients and modified RPLND to the remainder.

MR venography of left renal vein anomalies

The examinations of 71 patients having comprehensive 2D time of flight (TOF) abdominal magnetic resonance venography (MRV) in three planes (axial, sagittal and 10 degrees offset coronal) were evaluated to assess the appearances of anomalous left renal veins as shown by MRV. Six cases of circumaortic left renal vein (CLRV) (8.5%) and one example of retro-aortic left renal vein only (1.4%) were identified, an incidence higher than that in previous computed tomography (CT) studies but comparable to venographic and post-mortem investigations. All retro-aortic components passed in a caudal direction to join the inferior vena cava (IVC) inferior to the anterior limb. MRV acquired in the sagittal plane was found to be most useful for identifying these variants and provided highest signal by avoidance of in-plane flow saturation effects.

Magnetic resonance angiography of the left renal vein

The authors evaluated magnetic resonance angiography (MRA) as a possible diagnostic method to image the left renal vein. Twenty-five patients with abdominal aortic aneurysm underwent both plain and contrast-enhanced CT, as well as two-dimensional (2D) sequential time of flight (TOF) MRA. MRA images were evaluated on the basis of the results of CT, taken as the "gold standard" for vessel demonstration. MRA was performed with a 1.5 T superconductive magnet (Magnetom), fast imaging with steady-state free precession (FISP) 2D sequence (TR 40 ms, TE 10 ms, FA 18 degrees). Images were acquired in breath-hold on the coronal and sagittal plane and reconstructed according to maximum intensity projection (MIP) and targeted-MIP techniques. MRA images acquired on the sagittal plane correctly showed the retroaortic course on the left renal v. in six cases. On the coronal plane, targeted-MIP reconstructions for the course of the left renal v. correctly detected its outlet at the level of the inferior vena cava in five cases and of the left iliac v. in one case. MRA appears to be a promising noninvasive vascular imaging technique capable of correctly detecting the course and the outlet of the left renal v. We particularly noticed that the left renal v. can be imaged in a few seconds by using only one scout view with 2D sequential TOF technique on the sagittal plane at the level of the abdominal aorta.

Retroaortic left renal vein: a report of six cases

Six cases of retroaortic left renal vein have been studied, two in corpses and four by means of Computed Tomography. Any previous pathology has been rejected. The total number of dissected specimens was 116, whereas the patients with non-pathological retroperitoneum studied by CT numbered 170. In our six cases, the left renal vein formed a single trunk of considerable size, retroaortic position and directed obliquely towards the inferior vena cava.