Renal Cell Carcinoma With Extensive Tumor Thrombus Into the Inferior Vena Cava and Right Atrium in a 70-Year-Old Man

Migration of an Inferior Vena Cava Tumor Thrombus during Renal Cell Carcinoma Resection

Approximately 4%-10% of patients with renal cell carcinoma (RCC) have tumoral vascular invasion with resultant thrombi in the renal vein and in the inferior vena cava (IVC). The authors describe an interesting case of IVC tumor thrombus that migrated to the right cardiac chambers during RCC resection. The diagnosis was made by intraoperative transesophageal echocardiography (TEE), which revealed the presence of a free-floating thrombus between the right atrium (RA) and right ventricle (RV). The patient required an urgent sternotomy with cardiopulmonary bypass (CPB) for atrial thrombus removal prior to the completion of the nephrectomy. The patient made a full recovery and was discharged to a rehabilitation facility. These findings illustrate the importance of intraoperative TEE monitoring during nephrectomy and IVC thrombectomy. In this case, TEE allowed for the diagnosis of an unexpected complication necessitating prompt cardiac surgical management.

The Role of Anticoagulation in Tumor Thrombus Associated with Renal Cell Carcinoma: A Literature Review

Tumor thrombus (TT) is a complication of renal cell carcinoma (RCC) for which favorable medical management remains undefined. While radical nephrectomy has been shown to increase overall survival in RCC patients, surgical interventions such as cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) utilized to perform TT resection carry high mortality rates. While it has been documented that RCC with TT is associated with venous thromboembolism (VTE) development, anticoagulation use in these patients remains controversial in clinical practice. Whether anticoagulation is associated with improved survival outcomes remains unclear. Furthermore, if anticoagulation is initiated, there is limited evidence for whether direct oral anticoagulants (DOACs), heparin, or warfarin serve as the most advantageous choice. While the combination of immunotherapy and tyrosine kinase inhibitors (TKIs) has been shown to improve the outcomes of RCC, the clinical benefits of this combination are not well studied prospectively in cases with TT. In this literature review, we explore the challenges of treating RCC-associated TT with special attention to anticoagulation. We provide a comprehensive overview of current surgical and medical approaches and summarize recent studies investigating anticoagulation in RCC patients undergoing surgery, targeted therapy, and/or immunotherapy. Our goal is to provide clinicians with updated clinical insight into anticoagulation for RCC-associated TT patients.

Cancer-Associated Abdominal Vein Thrombosis

Cancer is associated with an increased risk of developing venous thromboembolism, due to its direct influence on the three pillars of Virchow's triad (e.g., compression on the blood vessels by the tumour, blood vessels invasion, and cytokine release), together with the effect of exogenous factors (such as chemotherapy, radiotherapy, surgery). In cancer patients, the risk of thrombosis at unusual sites, such as splanchnic, ovarian and renal vein thrombosis, is also increased. Abdominal vein thromboses are frequently incidental findings on abdominal imaging performed as part of the diagnostic/staging workup or the follow-up care of malignancies. There is little evidence on the management of unusual site venous thromboembolism in cancer patients since there are only a few specific recommendations; thus, the management follows the general principles of the treatment of cancer-associated deep vein thrombosis and pulmonary embolism. This narrative review summarises the latest evidence on cancer-associated abdominal vein thrombosis, i.e., thrombosis of the splanchnic, ovarian and renal veins.

Inferior Vena Cava Thrombus Associated With Renal Cell Carcinoma With an Atypical Radiological Presentation: A Case Report

Renal cell carcinoma (RCC) is characterized by the development of kidney masses, which can lead to various long-term complications. Among the extrarenal manifestations associated with RCC, the formation of a thrombus within the inferior vena cava (IVC) is particularly prevalent due to the substantial tumor burden imposed by the kidneys. In this report, we present an exceptional case involving an 80-year-old male patient who presented with an intravascular thrombus within the inferior vena cava (IVC), which originated from RCC. The diagnosis of RCC was conclusively established through core needle biopsy and subsequent tumor marker staining. Remarkably, despite the confirmation of RCC within the IVC thrombus through biopsy and tumor marker analysis, radiological assessments failed to reveal any discernible renal cell masses within the kidneys. The patient subsequently received treatment for RCC with a combination regimen of cabozantinib and nivolumab, which resulted in a noteworthy improvement in his clinical condition. The presentation of RCC in this report is notably atypical, given that the biopsy of the thrombus yielded definitive evidence of RCC while radiological investigations did not yield any indications of renal masses or a tumor burden within the kidneys that would typically be associated with RCC.

Evaluation and Application of Drug Resistance by Biomarkers in the Clinical Treatment of Liver Cancer

Liver cancer is one of the most lethal cancers in the world, mainly owing to the lack of effective means for early monitoring and treatment. Accordingly, there is considerable research interest in various clinically applicable methods for addressing these unmet needs. At present, the most commonly used biomarker for the early diagnosis of liver cancer is alpha-fetoprotein (AFP), but AFP is sensitive to interference from other factors and cannot really be used as the basis for determining liver cancer. Treatment options in addition to liver surgery (resection, transplantation) include radiation therapy, chemotherapy, and targeted therapy. However, even more expensive targeted drug therapies have a limited impact on the clinical outcome of liver cancer. One of the big reasons is the rapid emergence of drug resistance. Therefore, in addition to finding effective biomarkers for early diagnosis, an important focus of current discussions is on how to effectively adjust and select drug strategies and guidelines for the treatment of liver cancer patients. In this review, we bring this thought process to the drug resistance problem faced by different treatment strategies, approaching it from the perspective of gene expression and molecular biology and the possibility of finding effective solutions.

Renal cell carcinoma with inferior vena cava tumor thrombus initially misdiagnosed as bland thrombus due to hypercoagulable state

Renal cell carcinoma with inferior vena cava tumor thrombus can be misdiagnosed as an inferior vena cava thrombosis if not evaluated carefully with imaging. We describe a case of renal cell carcinoma with inferior vena cava tumor thrombus that was initially misdiagnosed as an inferior vena cava thrombosis due to a possible hypercoagulable state. After 7 months of anticoagulation therapy with no improvement, a right radical nephrectomy and thrombectomy was performed without cardiopulmonary bypass, and a diagnosis of papillary renal cell carcinoma with a level-IIId tumor thrombus was confirmed with no presence of a bland thrombus. We demonstrate the complexity of identifying and treating renal cell carcinoma with venous tumor thrombus and the importance of differentiating between a malignant thrombus and a bland thrombus.

Surgical management of ovarian carcinosarcoma with inferior vena cava extension into the right atrium

Gynecological carcinosarcomas are aggressive tumors with rare occurrence and high rates of metastases. We present the case of a 49-year-old woman with vaginal bleeding and abdominal distension who was found to have a large ovarian carcinosarcoma invading the gonadal vein and inferior vena cava (IVC) and extending into right atrium (RA). She underwent gynecologic tumor resection, IVC cavotomy and en bloc resection of tumor/thrombus through the RA. Use of intraoperative transesophageal echocardiography helped assess extent and mobility of mass in the RA to guide surgical approach. This case posed unique challenges with regard to management of induction, hemodynamics and coagulopathy.

Collision tumors of the lung: A case report of urothelial carcinoma metastasizing to renal cell carcinoma with heterotopic ossification

Collision tumors are rare entities that consist of at least two or more histologically and ontologically distinct tumor types within the same organ. It is still not well understood how collision tumors form; yet, three main theories have been proposed to explain the pathogenesis, including the “random collision effect,” “field cancerization,” and “tumor-to-tumor carcinogenesis.” Collision tumors have been encountered in various body organs, including the lung. They either consist of a metastasizing tumor colliding with primary cancer or distinct primary or metastatic cancers colliding together. Here, we describe a rare case of collision tumors of the lung that consists of two metastatic carcinomas, namely renal cell carcinoma and urothelial carcinoma of the bladder. We propose that the urothelial carcinoma disseminated into several pre-existing pulmonary metastases of renal cell carcinoma with heterotopic bone formation. The possible mechanisms underlying the development of this peculiar tumor are discussed.

Renal Cell Carcinoma with Right Ventricular Metastatic Spread: An Unusual Finding with Poor Prognosis

•RCC is the most common type of renal cancer. •RCC is capable of passing through the renal vein into the IVC. •Surgical resection requiring cardiopulmonary bypass is currently the only curative treatment. •Metastatic RCC tumor spread into the heart is a poor long-term prognostic factor.

Role of microRNA-33a in malignant cells

Cancer causes most of the mortality and morbidity worldwide, with a significant increase in incidence during recent years. MicroRNAs (miRNAs/miRs) are non-coding small RNAs capable of regulating gene expression. They regulate crucial cellular processes, including proliferation, differentiation, metastasis and apoptosis. Therefore, abnormal miRNA expression is associated with multiple diseases, including cancer. There are two types of cancer-associated miRNAs, oncogenic and tumor suppressor miRNAs, depending on their roles and expression patterns in cancer. Accordingly, miRNAs are considered to be targets for cancer prevention and treatment. miR-33a controls cellular cholesterol uptake and synthesis, which are both closely associated with carcinogenesis. The present review thoroughly describes the roles of miR-33a in more than a dozen types of cancer and the underlying mechanisms. Accordingly, the present review may serve as a guide for researchers studying the involvement of miR-33a in diverse cancer settings.

Adrenocortical carcinoma and pulmonary embolism from tumoral extension

SUMMARY

Adrenococortical carcinoma (ACC) is a rare cancer, occurring at the rate of one case in two million person years. Cushing syndrome or a mixed picture of excess androgen and glucocorticoid production are the most common presentations of ACC. Other uncommon presentations include abdominal pain and adrenal incidentalomas. In the present report, a 71-year-old male presented with abdominal pain and was eventually diagnosed with ACC. He was found to have pulmonary thromboembolism following an investigation for hypoxemia, with the tumor thrombus extending upto the right atrium. This interesting case represents the unique presentation of a rare tumor, which if detected late or left untreated is associated with poor outcomes, highlighting the need for a low index of suspicion for ACC when similar presentations are encountered in clinical practice.

LEARNING POINTS

ACC is a rare but aggressive tumor. ACC commonly presents with rapid onset of hypercortisolism, combined hyperandrogenism and hypercortisolism, or uncommonly with compressive symptoms. Clinicians should have a low index of suspicion for ACC in patients presenting with rapid onset of symptoms related to hypercortisolism and/or hyperandrogenism. Venous thromboembolism and extension of the tumor thrombus to the right side of the heart is a very rare but serious complication of ACC that clinicans should be wary of. The increased risk of venous thromboembolism in ACC could be explained by direct tumor invasion, tumor thrombi or hypercoagulability secondary to hypercortisolism. Early diagnosis and prompt treatment can improve the long-term survival of patients with ACC.