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 Table of Contents  
Year : 2021  |  Volume : 16  |  Issue : 1  |  Page : 189-191

Ultrasonography and doppler diagnosis in a rare asymptomatic case of renal cell carcinoma associated with renal vein thrombosis

Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India

Date of Submission17-Jul-2020
Date of Decision18-Nov-2020
Date of Acceptance10-Jan-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, Jawahralal Nehru Medical College, Dmims.Du, Sawangi, Wardha, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_270_20

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Renal cell carcinoma (RCC) is the primary malignant adenocarcinoma that is derived from the renal tubular epithelium and is the most common malignant renal tumor. The peak age of occurrence is 50–70 year. Cigarette smoking and dialysis-related cystic disease are the most common risk factors. Almost half of all identified RCCs are found incidentally on imaging performed for other purposes. On grayscale ultrasound (US), they appear solid or partially cystic and may be hyper, iso, or hypoechogenic to the surrounding renal parenchyma. The tumor pseudocapsule can sometimes be visualized with US as a hypoechoic halo. Sometimes, the tumor may produce thrombosis of ipsilateral renal vein which on grayscale US show renal enlargement with hypoechoic cortex from edema (early phase) and decreasing size and increased echogenicity (late phase). On Doppler visualization of thrombus within the lumen is possible. Early diagnosis of this tumor with precise localization of thrombus extent is important for planning the further course of management. We present a rare case of RCC, without any symptom of hematuria.

Keywords: Color Doppler, renal cell carcinoma, renal vein, thrombosis, ultrasound

How to cite this article:
Gupta R, Phatak S, Varma A, Badurwar K. Ultrasonography and doppler diagnosis in a rare asymptomatic case of renal cell carcinoma associated with renal vein thrombosis. J Datta Meghe Inst Med Sci Univ 2021;16:189-91

How to cite this URL:
Gupta R, Phatak S, Varma A, Badurwar K. Ultrasonography and doppler diagnosis in a rare asymptomatic case of renal cell carcinoma associated with renal vein thrombosis. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Sep 23];16:189-91. Available from: http://www.journaldmims.com/text.asp?2021/16/1/189/322622

  Introduction Top

Asymptomatic renal cell carcinoma (RCC) without any hematuria is extremely rare and has incidence of 0.86%.[1] RCC represents approximately 3% of all neoplastic processes, usually seen in patients older than 50 years. About 60–75% are resectable at diagnosis representing only a local disease. Metastatic advanced disease is unresectable. This tumor tends to spread intravascularly, leading to tumoral thrombosis within the inferior vena cava (4%–10% of cases) and renal vein (21%–35% of cases).[2] Cigarette smoking and dialysis-related cystic disease are the most common risk factors. Hematuria, flank pain, and weight loss are the most common symptoms that patients have. However, few cases might be asymptomatic and RCC is detected incidentally while scanning for other complaints.

  Case Report Top

A 55-year-old male patient presented with complaints of breathlessness, fever, and diffuse abdominal pain. No complaints of hematuria, flank pain, or weight loss were present. On grayscale ultrasound (US), an iso to hyperechoic mass was seen arising from middle and lower pole of the left kidney. The mass contained few hypoechoic cystic necrotic areas and few calcifications. The left renal vein was found to be enlarged and on tracing it along the course, a hyperechoic tumor thrombus was found on grayscale US, reaching up to inferior vena cava. Color Doppler showed absent flow in the left renal vein. Contrast-enhanced computed tomography (CT) of the abdomen study confirmed our ultrasonography (USG) and Doppler findings.

  Discussion Top

Early detection of renal tumors may improve the prognosis and the overall survival of patients with RCC and allow one to plan radical or partial nephrectomy since local extension has a considerable impact on the operative strategy.[3] The results indicate that USG is a useful tool to detect low-stage asymptomatic RCC at low cost.[1]

The increased use of abdominal imaging techniques for a variety of indications has contributed to more-frequent detection of RCC. USG has been used to characterize the solid versus cystic nature of renal masses.[4] Combined grayscale and color Doppler US findings strongly suggest the histopathologic nature of a renal tumor with respect to the size, the US attenuation characteristics, and the vascular distribution of the lesion.

Grayscale US shows isoechoic, homogeneous, solid renal mass responsible for capsular bulging. Tumor vascularity on color Doppler exhibits a penetrating vascular distribution.[5] Accurate detection and assessment of tumor thrombus extension into the renal veins and the inferior vena cava are crucial to the choice of an operative approach. The diagnostic criteria for tumor thrombus included the presence of echogenic material within the lumen of an enlarged vein by grayscale imaging and the complete or partial absence of flow by color or spectral Doppler sonography, which is the modality of choice for tumor thrombosis diagnosis.[6] Color Doppler sonography seems to be fairly accurate in assessing tumor thrombous extension into renal veins and inferior vena cava in patients with RCC. If tumor thrombus involves the medial segment of the left renal vein or inferior vena cava below the hepatic venous confluence, a chevron or rooftop incision is given.[7] The accuracy of color Doppler US was the same as magnetic resonance imaging in the evaluation of the extent of the thrombus.[8]

Intraoperative US remains the only available tool that enables to ensure renal-parenchymal-sparing surgery.[9]

CT is frequently used to both diagnose and stage RCCs. On noncontrast CT, the lesions are soft-tissue attenuation between 20 and 70 HU. Larger lesions frequently have areas of necrosis. Approximately 30% demonstrate some calcification. Small lesions enhance homogeneously, whereas larger lesions have irregular enhancement due to areas of necrosis. The clear cell subtype may show much stronger enhancement. The corticomedullary phase is also best for assessing vascular anatomy, both for renal vein involvement and for arterial variation if partial nephrectomy is being contemplated. Intraluminal growth into the venous circulation, in particular, the renal vein, occurs in 4%–15%. When computerized tomography is not available, USG provides a useful alternative to angiography in preoperative tumor assessment in many cases.[10]

Management can be planned according to the level of the tumor thrombus. Invasion of the venous wall was found to be a bad prognostic factor affecting survival [Figure 1], [Figure 2], [Figure 3], [Figure 4].[8],[11],[12],[13],[14],[15]
Figure 1: Grayscale ultrasound of the left kidney showing a solid mass arising from the mid and lower pole of the left kidney

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Figure 2: Colour Doppler showing internal vascularity in renal mass

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Figure 3: Grayscale ultrasound showing tumor-filled left renal vein

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Figure 4: Transverse section at renal hilum showing enlarged (2.1cm) left renal vein containing tumor thrombus

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  Conclusion Top

RCC can be readily diagnosed on grayscale US and color Doppler. The local extent of disease in the form of renal vein thrombosis is very well demonstrated by color Doppler and this helps in guiding the surgeon with the most favorable approach for treatment.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Tosaka A, Ohya K, Yamada K, Ohashi H, Kitahara S, Sekine H, et al. Incidence and properties of renal masses and asymptomatic renal cell carcinoma detected by abdominal ultrasonography. J Urol 1990;144:1097-9.  Back to cited text no. 1
Fernández López-Peláez MS, García Gómez JM, Ortíz Vico F, Roldán Ramos J. Tumor thrombosis of the left renal vein and inferior vena cava secondary to renal cell carcinoma. Findings with ultrasonography, Echo-Doppler, and computerized tomography. Actas Urol Esp 2000;24:664-8.  Back to cited text no. 2
Porena M, Vespasiani G, Rosi P, Costantini E, Virgili G, Mearini E, et al. Incidentally detected renal cell carcinoma: Role of ultrasonography. J Clin Ultrasound 1992;20:395-400.  Back to cited text no. 3
Leveridge MJ, Bostrom PJ, Koulouris G, Finelli A, Lawrentschuk N. Imaging renal cell carcinoma with ultrasonography, CT and MRI. Nat Rev Urol 2010;7:311-25.  Back to cited text no. 4
Hélénon O, Correas JM. Ultrasound and Doppler in kidney cancer. InImaging of Kidney Cancer. Berlin, Heidelberg: Springer; 2006. p. 15-28.  Back to cited text no. 5
Habboub HK, Abu-Yousef MM, Williams RD, See WA, Schweiger GD. Accuracy of color Doppler sonography in assessing venous thrombus extension in renal cell carcinoma. AJR Am J Roentgenol 1997;168:267-71.  Back to cited text no. 6
Khan AR, Anwar K, Fatima N, Khan SF. Comparison of CT scan and colour flow Doppler ultrasound in detecting venous tumour thrombous in renal cell carcinoma. J Ayub Med Coll Abbottabad 2008;20:47-50.  Back to cited text no. 7
Gupta NP, Ansari MS, Khaitan A, Sivaramakrishna MS, Hemal AK, Dogra PN, et al. Impact of imaging and thrombus level in management of renal cell carcinoma extending to veins. Urol Int 2004;72:129-34.  Back to cited text no. 8
Hélénon O, Correas JM, Balleyguier C, Ghouadni M, Cornud F. Ultrasound of renal tumors. Eur Radiol 2001;11:1890-901.  Back to cited text no. 9
Cronan JJ, Zeman RK, Rosenfield AT. Comparison of computerized tomography, ultrasound and angiography in staging renal cell carcinoma. J Urol 1982;127:712-4.  Back to cited text no. 10
Agrawal A, Keche HA, Adakane R. A Study of Accessory Renal Arteries and Its Clinical Implications. Int J Pharm Pract Res 2019;11:1141-4. Available from: https://doi.org/10.31838/ijpr/2019.11.01.200. [Last accessed on 2019 Dec 22].  Back to cited text no. 11
Balwani MR, Bawankule C, Khetan P, Ramteke, P. Tolani, and V. Kute. An Uncommon Cause of Rapidly Progressive Renal Failure in a Lupus Patient: Pauci-Immune Crescentic Glomerulonephritis. Saudi Journal of Kidney Diseases and Transplantation: An Official Publication of the Saudi Center for Organ Transplantation, Saudi Arabia 2018;29:989-92. Available from: https://doi.org/10.4103/1319-2442.239632. [Last accessed on 2019 Dec 22].  Back to cited text no. 12
Balwani MR, Pasari A, Meshram A, Jawahirani A, Tolani P, H. Laharwani, et al. An Initial Evaluation of Hypokalemia Turned out Distal Renal Tubular Acidosis Secondary to Parathyroid Adenoma. Saudi Journal of Kidney Diseases and Transplantation : An Official Publication of the Saudi Center for Organ Transplantation, Saudi Arabia 2018;29:1216-9. Available from: https://doi.org/10.4103/1319-2442.243965. [Last accessed on 2019 Dec 22].  Back to cited text no. 13
Balwani MR, Pasari A, Tolani P. Widening Spectrum of Renal Involvement in Psoriasis: First Reported Case of C3 Glomerulonephritis in a Psoriatic Patient. Saudi Journal of Kidney Diseases and Transplantation 2019;30:258-60. Available from: https://doi.org/10.4103/1319-2442.252922. [Last accessed on 2019 Dec 22].  Back to cited text no. 14
Pattabiraman S, Phatak SV, Patwa PA, Marfani G. Bilateral Sporadic Renal Angiomyolipoma .Ultrasonography and Computed Tomography Imaging. J Datta Meghe Inst Med Sci Univ 2020;15:134-5. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_199_19. [Last accessed on 2019 Dec 22].  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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