THE INITIAL MANIFESTATION OF RENAL CELL CARCINOMA IS PULMONARY EMBOLISM: A CASE REPORT

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腎細胞癌以肺動脈栓塞為初始表現

腎細胞癌以肺動脈栓塞為初始表現

腎細胞癌以肺動脈栓塞為初始表現

腎細胞癌以肺動脈栓塞為初始表現之病例報告

之病例報告

之病例報告

之病例報告

THE INITIAL MANIFESTATION OF RENAL CELL CARCINOMA IS

PULMONARY EMBOLISM: A CASE REPORT

Po-Jen Hsiao, Chi-Ping Huang, Chao-Hsiang Chang, Hsi-Chin Wu, Chi-Rei Yang Department of Urology, China Medical University Hospital, Taichung, Taiwan

Background: Pulmonary embolism is usually caused by migration of a thrombus from the deep veins in

the legs. A small proportion is due to the embolization of air, fat, talc in drugs of intravenous drug abusers or amniotic fluid. It is rare from tumor emboli. The clinical presentation of intravascular pulmonary metastatic tumor emboli and pulmonary hypertension mimics that of thrombotic pulmonary embolus. Although most cases suffered from pulmonary tumor embolism have high rate of mortality, they are diagnosed during autopsy. We report the case of a patient with massive pulmonary embolus as the initial presentation of renal cell carcinoma.

Case Report: A 67-year-old man with a history of hypertension presented to the emergency room with

dyspnea, cough, and pleuritic chest pain for several hours. No hemoptysis, no tachycardia, and no hypotension were noted. The patient committed the history of smoking three packages per day and obese for many years, but no long trips(>2 hours), no prolonged inactivity, no hip pelvic fracture or surgery, no family history of thromboembolic events. Physical examination revealed tachycardia, mild tachypnea, diminished breath sounds in the right lung base, and bilateral legs pitting edema. There was no evidence of deep venous thrombosis. Laboratory data including complete blood count, chemistry, and arterial blood gases revealed increased levels of D-dimer (3703.32). Chest radiograph showed a lung infiltrate in the right base. ECG had findings of S1Q3T3 pattern. CT angiography performed at ER showed a massive thrombus occluding the bilateral main pulmonary arteries and their branches. There were also several peripheral wedge-shaped infiltrates in bilateral lower lobes compatible with pulmonary infarcts and a small right pleural effusion. CT scan of the abdomen was also arranged and showed bilateral multiple renal cysts. Echocardiography showed slight dilatation of the left ventricle with mild tricuspid regurgitation, Mild mitral valve regurgitation and dilated left atrium. The pulmonary artery pressure was elevated. Doppler ultrasonography of the lower limbs did not reveal evidence of deep venous thrombosis. The patient was treated with heparin and shift to warfarin. His respiratory symptoms improved gradually over the following 72 h with this treatment. After 10 days treatment, he was discharged in stable status. After three months later, he came to emergency room again due to loss of consciousness because of massive recurrent pulmonary embolism with obstructive shock. The CT performed again. A large mass in the right kidney and a thrombus in the right renal vein extending into a long segment of the inferior vena cava, right common iliac vein and right external iliac vein. Fine-needle aspiration of the renal mass revealed a clear cell type renal cell carcinoma. After hemodynamic became stable with anticoagulants use, the patient underwent target therapy of Sunitinib. A follow-up CT scan 5 months after the initial one showed the thrombus still to be present in the bilateral pulmonary artery; the lung infiltrates had, however,

partially resolved. But there was no obvious change about the size of renal tumor. The patient is considering about surgical intervention now.

Conclusions: Renal cell carcinoma is usually causes no noticeable symptoms. It classically presents with

the triad of flank pain, hematuria, and abdominal mass, but this classic presentation occurs in only approximately 15% of cases. Renal cell carcinoma may manifest in an unusual way such as pulmonary embolism. The diagnosis of pulmonary tumor embolism is difficult to make due to the incidence rate is about 1% to 26%. The present case has shown that urologists should consider the rare possibility that renal cell carcinoma can cause pulmonary embolism.