Ultrasound
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Ultrasonic Diagnosis of Hypernephroma Extending into the Inferior Vena Cava 1 David Greene, M.D.,2 and Herbert L. Steinbach, M.D.
Extension of hypernephroma into the inferior vena cava was demonstrated by ultrasound. When a solid renal lesion is encountered, it is suggested that the inferior vena cava be scanned. The possible significance of gray scale scanning as a more precise diagnostic tool and its use in tumor staging are discussed. INDEX TERMS: Kidney Neoplasms, ultrasound diagnosis • Ultrasound, apparatus and equipment. Venae Cavae, obstruction
Radiology 115:679-680, June 1975
• is useful in delineating solid from cystic lesions in the kidney (1, 5) and is especially accurate in the diagnosis of asymptomatic renal mass lesions, particularly renal cysts (2). Solid lesions are differentiated from cystic ones by virtue of their poorer transmission of sound and by the appearance of echoes within the lesion, which reflects inhomogeneity. The incidence of renal carcinoma extending into the inferior vena cava (IVC) has been reported as 9.1 % in one large series (4) and 33% in another (3). These authors emphasize the knowledge of caval extension for tumor staging. The purpose of this report is to suggest the value of ultrasonic scanning of the IVC when a solid lesion is encountered.
U
LTRA SONOGRAPHY
CASE REPORT W. C. J., a 69-year-old white woman, was admitted to Baylor Hospital two weeks after an episode of gross, painless hematuria. Her only other medical problem was adult-onset diabetes mellitus, now under good control with insulin. There was no history of genitourinary disease. The patient looked healthy, with no palpable abdominal mass or costophrenic angle tenderness. Laboratory studies included a normal serum creatinine and blood urea nitrogen. She was not anemic. Urinalysis was positive for glucose; no red blood cells were seen microscopically. The remainder of the urinalysis was normal. Admission excretory urogram showed marked distortion of the right renal collecting system and suggested renal neoplasm. Retrograde pyelography confirmed the presence of a mass. A prone transverse and longitudinal ultrasonic scan (B-mode) of the kidney was performed using a Picker Echoview with an EDC (gray scale) module and a 19mm-diameter transducer with a frequency of 2.25 MHz. A solid mass lesion involving a large portion of the right kidney was demonstrated. Medium gain settings produced diffuse echoes throughout the kidney, indicating relative inhomogeneity. Also, the normal renal outline was distorted by a bulge anteriorly from the midportion of the kidney. A longitudinal scan in the supine position (Fig. 1, A) revealed abnormal widening of the IVC in its superior portion. Faint but definite echoes were seen within the area of widening, suggesting a solid tumor mass.
Fig. 1. A. Longitudinal ultrasonic scan of the IVC obtained 2 cm to the right of midline. Cranial is to the left and caudal to the right of the picture. Note marked widening due to tumor extension and faint echoes within this area, indicating a solid mass (solid arrows). Normal portion of cava (open arrows) is seen below. (L liver.) B. Lateral view of the biplane inferior venacavagram. Note large tumor mass in the superior portion of the IVC corresponding to the area of widening on the ultrasonic scan. NormallVC is seen inferiorly.
=
Selective right renal arteriography demonstrated a highly vascular renal mass corresponding to the solid mass seen on the ultrasonic scan. It also showed tumor vasculature extending to the region of the IVC. Biplane inferior venacavagraphy (Fig. 1, B) revealed a I~rge defect in the IVC corresponding to the ultrasonic abnormality and was interpreted as representing tumor extension. There were two renal veins draining the right kidney. One was opacified and the other was obstructed by tumor growing out of the vein into the IVC (Fig. 2). The patient was taken to surgery with a preoperative diagnosis of hypernephroma with extension into the IVC. A large necrotic tumor involving the right kidney and extending into one of the two renal veins and into the IVC was found. A right radical nephrectomy and en bloc resection of the vena cava above the unobstructed renal vein and below the central hepatic vein were performed. Pathologic confirmation of hypernephroma was obtained.
DISCUSSION Ultrasonography plays an important role in the diagnosis of renal mass lesions and is useful in the evaluation of patients with hematuria and/or other symptoms, as well as those with asymptomatic renal masses. This case illustrates the potential importance of evaluating the IVC in patients in whom a solid lesion suggesting tumor is encountered at ultrasound. While the IVC may not be as well demonstrated in some patients as in others, tumor extension into the IVC was clearly detected in this instance. Localized widening of the IVC suggested a mass involving
1 From the Departments of Radiology, Baylor University Medical Center and the University of Texas Health Science Center at Dallas, Texas. Accepted for publication in January 1975. 2 Present address: Department of Radiology, Memorial Hospital, Hollywood, Fla. 33021. shan
679
680
DAVID GREENE AND HERBERT L. STEINBACH
June 1975
sion. The echoes were relatively faint and of about the same intensity as those near the liver hilus, reflecting only moderate inhomogeneity. These echoes could not be reproduced on the bistable oscilloscope. The gray scale modality may become important in diagnosing caval mass involvement. We were unable to demonstrate the extension into the renal vein. While some authors (6) consider a readily visible IVC as representing pathologic dilatation of the vessel, we have seen the vena cava in patients with no cardiac or abdominal abnormality. In this case, the normallVC below the tumor as seen on the cavagram corresponded to the well-visualized portion below the widened area on the ultrasonic scan. A maximum amount of information should be obtained when a solid lesion is detected ultrasonically. The case presented sugdests that scanning the vena cava may be helpful in extracting more information. Further study correlating the ultrasonic and angiographic appearance of the vena cava in patients with hypernephroma is needed to determine the degree, if any, to which the tumor may be staged ultrasonically.
Department of Radiology Memorial Hospital Hollywood, Fla. 33021 REFERENCES
Fig. 2. Anteroposterior view of the biplane inferior venacavagram showing tumor mass in the widened cava. \ Superior margin of the tumor is well demonstrated (open arrows). Occlusion of the upper right renal vein by tumor growth is seen (solid arrows). The lower catheter is in the normal lower right renal vein (RV) and the upper catheter is in the aorta adjacent to the right renal artery. (HV = unobstructed hepatic vein.) the cava. Detection of echoes within the widened area at medium and high gain settings was a more specific finding and enabled us to substantiate our diagnosis of solid tumor exten-
1. Goldberg BB, Ostrum BJ, Isard HJ: Nephrosonography: ultrasound differentiation of renal masses. Radiology 90: 1113-1118. Jun 1968 2. Leopold GR, Talner LB, Asher WM, et al: Renal ultrasonography: an updated approach to the diagnosis of renal cyst. Radiology 109:671-678, Dec 1973 3. McCoy RM, Klatte EC, Rhamy RK: Use of inferior venacavography in the evaluation of renal neoplasms. J Urol 102:556-559, Nov 1969 4. Robson CJ, Churchill SM, Anderson W: The results of radical nephrectomy for renal cell carcinoma. J Urol 101:297-301, Mar 1969 5. Schreck WR, Holmes JH: Ultrasound as a diagnostic aid for renal neoplasms and cysts. J UroI103:281-285, Mar 1970 6. Weill F, Maurat P: The sign of the vena cava: echotomographic illustration of right cardiac insufficiency. J Olin Ultrasound, 2:27-32, Mar 1974
•
Ultrasonic Diagnosis of Hypernephroma Extending into the Inferior Vena Cava 1 David Greene, M.D.,2 and Herbert L. Steinbach, M.D.
Extension of hypernephroma into the inferior vena cava was demonstrated by ultrasound. When a solid renal lesion is encountered, it is suggested that the inferior vena cava be scanned. The possible significance of gray scale scanning as a more precise diagnostic tool and its use in tumor staging are discussed. INDEX TERMS: Kidney Neoplasms, ultrasound diagnosis • Ultrasound, apparatus and equipment. Venae Cavae, obstruction
Radiology 115:679-680, June 1975
• is useful in delineating solid from cystic lesions in the kidney (1, 5) and is especially accurate in the diagnosis of asymptomatic renal mass lesions, particularly renal cysts (2). Solid lesions are differentiated from cystic ones by virtue of their poorer transmission of sound and by the appearance of echoes within the lesion, which reflects inhomogeneity. The incidence of renal carcinoma extending into the inferior vena cava (IVC) has been reported as 9.1 % in one large series (4) and 33% in another (3). These authors emphasize the knowledge of caval extension for tumor staging. The purpose of this report is to suggest the value of ultrasonic scanning of the IVC when a solid lesion is encountered.
U
LTRA SONOGRAPHY
CASE REPORT W. C. J., a 69-year-old white woman, was admitted to Baylor Hospital two weeks after an episode of gross, painless hematuria. Her only other medical problem was adult-onset diabetes mellitus, now under good control with insulin. There was no history of genitourinary disease. The patient looked healthy, with no palpable abdominal mass or costophrenic angle tenderness. Laboratory studies included a normal serum creatinine and blood urea nitrogen. She was not anemic. Urinalysis was positive for glucose; no red blood cells were seen microscopically. The remainder of the urinalysis was normal. Admission excretory urogram showed marked distortion of the right renal collecting system and suggested renal neoplasm. Retrograde pyelography confirmed the presence of a mass. A prone transverse and longitudinal ultrasonic scan (B-mode) of the kidney was performed using a Picker Echoview with an EDC (gray scale) module and a 19mm-diameter transducer with a frequency of 2.25 MHz. A solid mass lesion involving a large portion of the right kidney was demonstrated. Medium gain settings produced diffuse echoes throughout the kidney, indicating relative inhomogeneity. Also, the normal renal outline was distorted by a bulge anteriorly from the midportion of the kidney. A longitudinal scan in the supine position (Fig. 1, A) revealed abnormal widening of the IVC in its superior portion. Faint but definite echoes were seen within the area of widening, suggesting a solid tumor mass.
Fig. 1. A. Longitudinal ultrasonic scan of the IVC obtained 2 cm to the right of midline. Cranial is to the left and caudal to the right of the picture. Note marked widening due to tumor extension and faint echoes within this area, indicating a solid mass (solid arrows). Normal portion of cava (open arrows) is seen below. (L liver.) B. Lateral view of the biplane inferior venacavagram. Note large tumor mass in the superior portion of the IVC corresponding to the area of widening on the ultrasonic scan. NormallVC is seen inferiorly.
=
Selective right renal arteriography demonstrated a highly vascular renal mass corresponding to the solid mass seen on the ultrasonic scan. It also showed tumor vasculature extending to the region of the IVC. Biplane inferior venacavagraphy (Fig. 1, B) revealed a I~rge defect in the IVC corresponding to the ultrasonic abnormality and was interpreted as representing tumor extension. There were two renal veins draining the right kidney. One was opacified and the other was obstructed by tumor growing out of the vein into the IVC (Fig. 2). The patient was taken to surgery with a preoperative diagnosis of hypernephroma with extension into the IVC. A large necrotic tumor involving the right kidney and extending into one of the two renal veins and into the IVC was found. A right radical nephrectomy and en bloc resection of the vena cava above the unobstructed renal vein and below the central hepatic vein were performed. Pathologic confirmation of hypernephroma was obtained.
DISCUSSION Ultrasonography plays an important role in the diagnosis of renal mass lesions and is useful in the evaluation of patients with hematuria and/or other symptoms, as well as those with asymptomatic renal masses. This case illustrates the potential importance of evaluating the IVC in patients in whom a solid lesion suggesting tumor is encountered at ultrasound. While the IVC may not be as well demonstrated in some patients as in others, tumor extension into the IVC was clearly detected in this instance. Localized widening of the IVC suggested a mass involving
1 From the Departments of Radiology, Baylor University Medical Center and the University of Texas Health Science Center at Dallas, Texas. Accepted for publication in January 1975. 2 Present address: Department of Radiology, Memorial Hospital, Hollywood, Fla. 33021. shan
679
680
DAVID GREENE AND HERBERT L. STEINBACH
June 1975
sion. The echoes were relatively faint and of about the same intensity as those near the liver hilus, reflecting only moderate inhomogeneity. These echoes could not be reproduced on the bistable oscilloscope. The gray scale modality may become important in diagnosing caval mass involvement. We were unable to demonstrate the extension into the renal vein. While some authors (6) consider a readily visible IVC as representing pathologic dilatation of the vessel, we have seen the vena cava in patients with no cardiac or abdominal abnormality. In this case, the normallVC below the tumor as seen on the cavagram corresponded to the well-visualized portion below the widened area on the ultrasonic scan. A maximum amount of information should be obtained when a solid lesion is detected ultrasonically. The case presented sugdests that scanning the vena cava may be helpful in extracting more information. Further study correlating the ultrasonic and angiographic appearance of the vena cava in patients with hypernephroma is needed to determine the degree, if any, to which the tumor may be staged ultrasonically.
Department of Radiology Memorial Hospital Hollywood, Fla. 33021 REFERENCES
Fig. 2. Anteroposterior view of the biplane inferior venacavagram showing tumor mass in the widened cava. \ Superior margin of the tumor is well demonstrated (open arrows). Occlusion of the upper right renal vein by tumor growth is seen (solid arrows). The lower catheter is in the normal lower right renal vein (RV) and the upper catheter is in the aorta adjacent to the right renal artery. (HV = unobstructed hepatic vein.) the cava. Detection of echoes within the widened area at medium and high gain settings was a more specific finding and enabled us to substantiate our diagnosis of solid tumor exten-
1. Goldberg BB, Ostrum BJ, Isard HJ: Nephrosonography: ultrasound differentiation of renal masses. Radiology 90: 1113-1118. Jun 1968 2. Leopold GR, Talner LB, Asher WM, et al: Renal ultrasonography: an updated approach to the diagnosis of renal cyst. Radiology 109:671-678, Dec 1973 3. McCoy RM, Klatte EC, Rhamy RK: Use of inferior venacavography in the evaluation of renal neoplasms. J Urol 102:556-559, Nov 1969 4. Robson CJ, Churchill SM, Anderson W: The results of radical nephrectomy for renal cell carcinoma. J Urol 101:297-301, Mar 1969 5. Schreck WR, Holmes JH: Ultrasound as a diagnostic aid for renal neoplasms and cysts. J UroI103:281-285, Mar 1970 6. Weill F, Maurat P: The sign of the vena cava: echotomographic illustration of right cardiac insufficiency. J Olin Ultrasound, 2:27-32, Mar 1974
