case_images: PMC6046184_01
case_images: Computed tomography (CT) finding of primary site (A, C), lung metastasis (B, D, E), and intramuscular metastasis (F-H). Hypervascular renal tumor with liver invasion, IVC extension (arrowhead, left), and lung metastasis (arrowhead, right) were observed. After a month of presurgical treatment, tumor thrombus and lung metastasis had decreased (A-B, F: before treatment, C-D, G: after treatment). CT appearance of lung metastasis and that of intramuscular metastasis at 18 months after surgery are shown (E, H).
case_images: CRIU2018-5139034.001.jpg
case_images: PMC6046184_01_CRIU2018-5139034.001.jpg
case_images: fig1
case_images: The tumor measured 10 cm in diameter with tumor thrombus toward the inferior vena cava (IVC) (Figure 1(A)). One-month treatment achieved shortened tumor thrombus and shrinkage of the primary site (Figure 1(C)); however, liver invasion had progressed (Figure 2(b)). Lung and intramuscular metastases were controllable (Figures 1(D) and 1(G)). The patient recovered without postoperative hepatic or urinary complications and has remained free of local recurrence and any de novo metastasis for 18 months (Figures 1(E) and 1(H)).
case_images: CT and magnetic resonance imaging (MRI) findings at the site of liver invasion. Appearance of invasion front (arrows) is shown before axitinib treatment (a), 2 months after treatment (b), and 3 months after treatment (c). Focal invasion is suspected at pretreatment period (a); however, invasion was progressed at 2 months after treatment (b), and apparent nodular formation was observed at 3 months (c).
case_images: CRIU2018-5139034.002.jpg
case_images: PMC6046184_01_CRIU2018-5139034.002.jpg
case_images: fig2
case_images: In addition, direct infiltration to the liver was observed (Figure 2(a)). One-month treatment achieved shortened tumor thrombus and shrinkage of the primary site (Figure 1(C)); however, liver invasion had progressed (Figure 2(b)). In spite of an increase in the dose of axitinib, liver infiltration was revealed to be worsening at 2 months from initial treatment (Figure 2(c)).
case_images: Result of volumetric analysis by the Synapse Vincent Work Station ((a) before portal vein embolization (PVE), (b) after PVE, D: estimated liver volume) and intraoperative finding of the liver (c). In 3-dimensional graphics of (a) and (b), estimated resected liver is shown in green, estimated remnant liver is light brown, IVC and major veins are blue, portal vein is pink, and kidney is purple. The estimated resected tumor liver volume was 921 ml (71% of whole liver) at pre-PVE status (a). After PVE, estimated resected liver volume reduced to 599 ml (53.4% of whole liver) (b). Intraoperative findings showed morphologically shrunken right liver parenchyma (arrows show the midline) due to portal ischemia (c). Hanging tube is shown by dotted arrows. Total and estimated liver volume are shown (d).
case_images: CRIU2018-5139034.003.jpg
case_images: PMC6046184_01_CRIU2018-5139034.003.jpg
case_images: fig3
case_images: The estimated resected liver volume was 921 cm3 (71% of the whole liver) (Figure 3(a)). PVE (Figures 3(b) and 3(d)). Preoperative ICGR15 was mildly worsened at 18%; however, the permitted resected volume by Placement of nasogastric tube in the retrohepatic space for LHM was performed according to the original Belghiti's maneuver (Figure 3(c)).
case_images: Macroscopic appearance (a) and pathological findings (b-e) of resected specimen. Renal tumor directly invading the right lobe of the liver (arrows, (a)). Tumor cells showing clear cytoplasm with atypical nuclei infiltrated into the liver parenchyma ((b) invasion front is shown by arrows). Pathological appearance of tumor cells at invasion front is compatible with conventionally clear cell-type renal cell carcinoma (inset, high magnification). The primary tumor also shows similar pathological findings ((c) arrows show renal pelvis, inset: high magnification). Infiltration to large vessel ((d) arrows) and large amount of necrotic area (e) are observed.
case_images: CRIU2018-5139034.004.jpg
case_images: PMC6046184_01_CRIU2018-5139034.004.jpg
case_images: fig4
case_images: The tumor was composed of atypical polygonal cells (Fuhrman grade 2) with clear cytoplasm proliferating mainly in solid or nested fashion (Figure 4(c)), and papillary architecture was also observed in part of the tumor. The tumor cells infiltrated directly to the renal vein, renal pelvis, right adrenal gland, and the liver (Figures 4(a)-4(b)). Apparent pathological difference between primary site and invasion front was not confirmed (Figure 4). Necrosis was observed in approximately 50% of the tumor with organization of obstructed medium-sized vessels, suggesting the effect of presurgical treatment (Figure 4).