Downloaded from www.ajronline.org by 119.1.227.11 on 11/02/15 from IP address 119.1.227.11. Copyright ARRS. For personal use only; all rights reserved

Renal

Extension

of

as the

renal

second

syndrome mon.

frequent

failed

has

been

cause

of being

manifestation

to

initially

A.

vera

a common

of

finding

reveal

any

presenting

Presenting

THOMAS

carcinoma

this

is not

carcinoma

Carcinoma

polycythemia

However,

literature

cell

most

[1],

cinoma

Cell

the

OKULSKI1’2

most

renal

com-

cell

reference

to

carof

the

renal

cell

Budd-Chiani

syn-

drome. Case

Report

A 60-year-old white male was admitted with a 2 month history of progressive weakness and abdominal fullness. Several days earlier he noticed slight painless swelling in his left leg. He had no other symptoms. Physical examination revealed no evidence of jaundice, petechia, or dilated abdominal venous collaterals. Hepatosplenomegaly, ascites, and bilateral ankle edema, more prominent on the left, were all present. The patient had a low grade fever but no cvi-

Fig.

1.

Received

3361 Am

-

Early

April

1

Department

2

Present

23,

J Roentg.nol

1976;

accepted

of Radiology,

address:

2. Address

(A) and late phase

aortograms

Department

reprint

after

revision

Temple University

requests

128:140-142,

of Radiology,

(B) demonstrating

August

24.

Health Sciences University

neovasculatune

1977

Syndrome

L. SOULEN1

extending

along

course

of left

renal

vein and suprarenal

vena

cava.

1976.

Center,

of South

Philadelphia.

Florida

to T. A. Okulski.

January

RENATE

Budd-Chiari

dence of peripheral adenopathy. Diagnostic possibilities included lymphoma, Budd-Chiari syndrome, and diffuse malignancy. Urinalysis, blood urea nitrogen, creatinine, total serum protein, albumin, a2 globulins, and cholesterol were all normal. Total bilirubin, LDH, APT, SGOT, and SGPT were mildly to moderately elevated. The erythrocyte sedimentation rate and complete blood count were normal. A liver-spleen scan showed two-fold splenic enlargement plus an enlarged nonhomogeneous liver compatible with the diagnosis of parenchymal liven disease. Liver biopsy revealed dilated central sinusoids with atrophy of the central lobular liver cells, suggesting hepatic venous occlusion. Intravenous unography and nephrotomography demonstrated a large left lower pole mass which produced a complex ultrasound pattern. Subsequent angiography showed this to be a renal malignancy with tumor extension through the left renal vein and inferior vena cava into the right atrium (fig. 1 ). No hepatic

Budd-Chiani

the

A review

the

AND

described

[2-4]. as

as the

I 40

Medical

Pennsylvania School,

Tampa

19140. Veterans

Administration

Hospital.

Tampa.

Florida

Downloaded from www.ajronline.org by 119.1.227.11 on 11/02/15 from IP address 119.1.227.11. Copyright ARRS. For personal use only; all rights reserved

CASE

metastases were seen. An inferior vena cavognam demonstrated a filling defect entering the cava at the level of the left renal vein with total obstruction and diversion of contrast into the lumbar-azygos system. Contrast medium failed to reflux into the inferior vena cava or hepatic veins on superior vena caval injection, supporting the diagnosis of hepatic venous obstruction secondary to tumor extension (fig. 2). Surgery confirmed the angiographic observations. The tumor was not adherent to the vena cava or endocardium and was removed at nephnectomy. After brief improvement, the patient died of distant metastases.

141

REPORTS

and

a palpable

was

a left

believed

include

gross

presentations hematunia,

abdominal

renal pain,

cell

carcinoma weight

loss,

an

mass

[5].

mass

which

enlarged

In our

spleen.

scan. This peripheral

finding, edema,

This plus supported

extension thnombus

into the hepatic in the inferior

in

itself

sufficient

veins.

Vena

more

common [6,

with

of the

obstruct

the

was

confirmed

hepatomegaly, a diagnosis syndrome). of tumor

veins, the extent of the tumor vena cava and right atrium was

extension on

there

examiners

the of

ostia

renal

right

due

the

need

of

the

carcinoma

to

the

to

consider

hepatic also

shorter

is

renal

7]. case

sibility

to

caval

patient,

several

venous occlusion (Budd-Chiani there was no direct visualization

This of

be

quadrant

of hepatic Although

vein common

to

by isotopic ascites, and

Discussion The

abdominal

upper

emphasizes renal

Budd-Chiani

cell

carcinoma syndrome.

in

a patient

the

pos-

presenting

CASE

142

Downloaded from www.ajronline.org by 119.1.227.11 on 11/02/15 from IP address 119.1.227.11. Copyright ARRS. For personal use only; all rights reserved

REFERENCES

1 . Parker RGF: Occlusion of the hepatic veins in man. Medicine 38:369-402, 1959 2. McCullough DL, Gettes RF: Vena cava resection for renal cell carcinoma. J Urol 112:162-167, 1974 3. Leiter E: Inferior vena caval thrombosis in malignant renal lesions. JAMA 1 98: 1 ,1 67-1 ,1 70, 1966 4. Svane 5: Tumor thrombosis of the inferior vena cava re-

REPORTS

suIting from renal carcinoma-a report on 12 autopsied cases. Scand J Urol Nephrol 3:245-256, 1969 5. Ochsner MG, Brannan W, Pond HS, Goodier EH: Renal cell carcinoma: review of 26 years of experience at the Ochsner Clinic. J Urol 110:643-646, 1973 6. McCullough DL, Talnen LB: Inferior vena caval extension of renal carcinoma, a lost cause? Am J Roentgenol 121: 819-826, 7.

Ney

C:

malignant

1974 Thrombosis

renal

of

tumors.

inferior

J Urol

vena

cava

55:583-590,

associated

1946

with