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Case report

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  2. Case report
  3. Comment
  4. References

A 39-year-old woman presented with a right renal mass newly detected by ultrasonography. She had undergone a left radical nephrectomy 9 years previously for localized RCC. MRI (Fig. 1a) revealed a 6.0×5.0×7.5 cm right upper pole heterogeneous mass extending into an upper pole accessory vein, with focal irregularity in the vena cava at that level, consistent with tumour thrombus. The main renal vein was patent (Fig. 1b). The patient underwent flank exploration confirming the presence of a right upper pole renal mass with extension into an accessory upper pole renal vein and a level I caval tumour thrombus. The main right renal vein was patent and uninvolved by tumour. A right upper pole partial nephrectomy (with en bloc resection of the upper pole accessory vein) with cavotomy and thrombus extraction were performed. Resection margins and biopsies of the resection bed revealed no evidence of tumour. After an uneventful postoperative course, the patient was discharged 5 days after surgery. Pathological examination revealed Grade 3 RCC with extension into the accessory vein and negative surgical margins. Over a year later the patient has no evidence of local or distant disease, with a creatinine level of 25 mg/L (preoperative creatinine 18 mg/L).

image

Figure 1. MRI of the abdomen. a, Coronal view, revealing the right upper pole renal mass with level I extension into the vena cava (arrow). b, Coronal view revealing a patent main right renal vein (arrow).

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Comment

  1. Top of page
  2. Case report
  3. Comment
  4. References

Nephron-sparing surgery is an acceptable option for patients with localized RCC, particularly those with compromised renal function [1]. However, renal vein involvement may render nephron-sparing surgery impossible without serious compromise of cancer therapy. The present case is unique, with a level I caval thrombus with an involved accessory renal vein which allowed curative resection with preservation of significant renal function. To our knowledge, this is the first such case reported in the literature.

Accessory renal veins occur in ≈21% of right renal veins and 3% of left renal veins, and their presence may allow for nephron-sparing surgery even when one of the veins is involved with tumour [2]. In the presence of a localized renal mass with extension into a duplicated renal vein with thrombus, consideration should be given to performing a partial nephrectomy with en bloc vein excision and even cavotomy to completely resect the entire tumour mass, while preserving a significant portion of functional renal parenchyma. This case shows how this surgical approach could be applied and performed safely in a patient with a solitary kidney, thus obviating radical resection which would have left her anephric and dialysis-dependent.

References

  1. Top of page
  2. Case report
  3. Comment
  4. References
  • 1
    Licht MR, Novick AC. Nephron-sparing surgery for renal cell carcinoma. J Urol 1993; 145: 16
  • 2
    Merklin RJ, Michels NA. The variant renal and suprarenal blood supply with data on the inferior phrenic, ureteral, and gonadal arteries. J Intl Col Surg 1958; 29: 4175