case_images: PMC10898852_01
case_images: Preoperative contrast-enhanced computed tomography (CT). a Enhanced abdominal CT revealing a 15 cm enhancing left adrenal mass compressing the pancreatic body ventrally. The red arrow denotes the splenic artery, and the yellow arrows denote the pancreatic body and tail compressed by the tumor. b, c CT revealing the tumor embolism continuing to the inferior vena cava (IVC) below the liver approximately 5 cm downstream from the left renal vein and left adrenal vein. The red arrow in b denotes the thrombus in the left renal vein. The red arrow in c denotes a thrombus in the IVC, and the yellow arrow in c denotes a thrombus in the left adrenal vein. d Magnetic resonance image revealing a 15 cm mass located in the left adrenal gland. The image also presents tumor thrombus extension into both the left renal vein and IVC.
case_images: cro-2024-0017-0001-535367_F01.jpg
case_images: PMC10898852_01_cro-2024-0017-0001-535367_F01.jpg
case_images: F1
case_images: Computed tomography and magnetic resonance imaging revealed a 15 cm enhancing left adrenal mass compressing the pancreatic body ventrally (Fig. 1a). The tumor embolism continued to the IVC below the liver approximately 4-5 cm downstream from the left renal vein (Fig. 1b-d).
case_images: Intraoperative observation. The tumor was located in the posterior wall of the pancreatic tail extending from the gastric cardia, and its diameter was approximately 15 cm. The yellow arrows in a are the pancreas. b The pancreatic parenchyma was divided at the level of the root of the splenic artery. c After distal pancreatic resection, splenectomy, and left nephrectomy, the left renal vein and inferior vena cava (IVC) were exposed and taped with the left renal vein with the intravascular tumor embolism. d Blood circulation was blocked after taping the IVC in the lower part of the liver, the right renal vein, and the IVC downstream from the right renal vein. e The IVC was incised on the side at the base of the left renal vein, and the tumor thrombus was removed. f Photograph after tumor removal.
case_images: cro-2024-0017-0001-535367_F02.jpg
case_images: PMC10898852_01_cro-2024-0017-0001-535367_F02.jpg
case_images: F2
case_images: The tumor was located on the posterior wall of the body of the stomach and the body of the pancreas (Fig. 2a), extending above the body of the stomach, on the right side of the aorta, and below the left renal vein. Because the tumor had adhered to the pancreatic body and left kidney, the pancreatic parenchyma was divided at the level of the root of the splenic artery (Fig. 2b). We then taped the left renal vein, which was dilated by a tumor thrombus (Fig. 2c). Subsequently, the confluence of the left renal vein and IVC was opened, the tumor thrombus was successfully removed from the IVC with no adhesion observed in the IVC, and we divided the left renal vein and removed the specimen en bloc (Fig. 2d-f).
case_images: a Macroscopic findings of the resected specimens revealing a relatively soft yellow tumor. The yellow arrow denotes the pancreatic dissection stump, and the red arrow denotes the left renal vein tumor thrombus. b Pathological findings of the tumor cells with a high nucleus-to-cytoplasmic ratio, acidophilic to clear polygonal cytoplasm, and irregular nuclei of various sizes, which are proliferating solidly (original magnification, x100; hematoxylin and eosin stain). Tumor cells stained positively for steroidogenic factor-1 antibody (c), calretinin (d), and inhibin alpha (e). f The Ki-67 labeling index was 38% (c-f, original magnification, x100).
case_images: cro-2024-0017-0001-535367_F03.jpg
case_images: PMC10898852_01_cro-2024-0017-0001-535367_F03.jpg
case_images: F3
case_images: III (International Union Against Cancer, eighth edition). Immunohistochemically, the tumor was positive for anti-steroidogenic factor-1 antibody, its cells were positive for calretinin and inhibin alpha were positive, and approximately 38% of the cells were positive for Ki-67 (Fig. 3b-f).
case_images: Postoperative contrast-enhanced computed tomography. a Two liver metastases were observed 6 months after the operation (red arrows). b Photograph after liver removal. c Macroscopic findings of the resected specimens.
case_images: cro-2024-0017-0001-535367_F04.jpg
case_images: PMC10898852_01_cro-2024-0017-0001-535367_F04.jpg
case_images: F4
case_images: Unfortunately, two liver metastases developed recurred 6 months after the operation (Fig. 4a). Posterior segmentectomy was performed for the liver metastases 16 months after the first operation (Fig. 4b, c).