Clinical Imaging 31 (2007) 44 – 46
Inferior vena cava obstruction due to cecum adenocarcinoma Okkes Ibrahim Karahana,4, Guven Kahrimana, IsVn Soyuerb, Nuri Erdogana, Alper Celal Akcanc a
Department of Radiology, Erciyes University Medical Faculty, Kayseri, Turkey Department of Pathology, Erciyes University Medical Faculty, Kayseri, Turkey c Department of General Surgery, Erciyes University Medical Faculty, Kayseri, Turkey b
Received 20 August 2006; accepted 25 September 2006
Abstract In this paper, we report the radiologic findings of cecal adenocarcinoma with caval invasion in a 60-year-old man. Caval invasion was confirmed by ultrasonographically guided fine-needle aspiration biopsy and by surgery. To our knowledge, this is the first case report demonstrating malignant caval thrombus due to colon cancer. In addition, we suggest that fine-needle aspiration biopsy may be helpful for prompt diagnosis and treatment in such a case. D 2007 Elsevier Inc. All rights reserved. Keywords: Colon cancer; Associated conditions; Vena cava; Fine-needle aspiration
1. Introduction Colon cancer is one of the most common cancers in the human population, with a high metastatic potential. Thirty to forty percent of patients have metastatic disease at the initial diagnosis. The most common sites of metastasis from colon cancer are regional lymph nodes, liver, lung, and peritoneum [1]. Colon cancer metastasis to the vena cava inferior (VCI) has not been reported in the literature. In this paper, we describe a case of cecal adenocarcinoma metastatic to the VCI, which was diagnosed by ultrasonographically (US) guided fine-needle aspiration biopsy (FNAB) and confirmed by surgery.
2. Case report A 60-year-old man presented with weakness, abdominal pain and constipation of 2 months’ duration and a weight loss of 10 kg in the last year. Physical examination findings 4 Corresponding author. P K: 18 Talas 38280, Kayseri, Turkey. Tel.: +90 352 438 02 26; fax: +90 352 438 02 26. E-mail address:
[email protected] (O.I. Karahan). 0899-7071/07/$ – see front matter D 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.clinimag.2006.09.022
were abdominal distention and a palpable mass in the right lower quadrant. Routine blood laboratory test results were within normal limits except anemia. Findings from upper gastrointestinal endoscopic examination and small-bowel barium examination were normal. Colonoscopic examination was made up to the transverse colon and no abnormality was detected. Abdominal US (PoverVision 6000, Toshiba, Japan) and computerized tomography (CT) (Light Speed 16, GE Medical Systems, Milwaukee, WI) examinations revealed cecal and ileal wall thickening with intraperitoneal free fluid, VCI thrombosis and two 5-mm metastatic nodules in the liver (Fig. 1). Double-contrast barium enema showed an irregular filling defect in the cecum (Fig. 2). US guided FNAB was performed using a 20-gauge Chiba needle. Cytologic evaluation of aspirated material demonstrated them to consist of fibrin, blood elements and malignant tumor cells within the thrombus (Fig. 3). Metastasis to the VCI from cecum adenocarcinoma was diagnosed with these findings. Laparotomy was performed because of the patient’s obstructive symptoms. The primary tumor was unresectable with invasion of VCI. Ileotransversostomy was done to provide small-bowel passage. The patient was referred to the oncology department for chemotherapy.
O.I. Karahan et al. / Clinical Imaging 31 (2007) 44 – 46
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3. Discussion Colon cancer is one of the most common cancers in the human population, with a high metastatic potential. Thirty to forty percent of patients have metastatic disease at the initial diagnosis. The most common sites of metastasis from colon cancer are the regional lymph nodes, liver, lung, and peritoneum [1]. Colon cancer metastasizing to uncommon sites such as the orbita, gingiva, testicle, larynx, thyroid gland, and urinary tract has been rarely reported in the literature [1–4]. Vena cava metastasis secondary to recurrent metastatic sigmoid colon adenocarcinoma was reported in just one case by Sullivan [5]. Sullivan demonstrated a recurrent mass of 2.8 cm in diameter at the level of the left iliac vein by CT and concluded that the route of invasion to the VCI was probably through the left iliac vein. In our case, direct invasion was considered to the VCI from the cecum adenocarcinoma. Caval obstruction may be due to bland thrombus of the lower limbs, extension of a tumor such as renal cell carcinoma and germ cell tumors [6–8], extrinsic tumoral
Fig. 1. Axial contrast-enhanced CT (A) and reformatted coronal CT (B) demonstrate asymmetric tumoral thickening of the cecal wall (white arrows), pericaval invasion, and thrombosis of the VCI (black arrows).
Fig. 2. Double-contrast barium enema shows irregular filling defect in cecum.
compression such as retroperitoneal tumors, adrenal tumors, or hepatic tumors [8,9], or intrinsic caval disease such as caval interruption with azygos continuation, or membranous obstruction [9,10]. We have found no report about VCI obstruction by colon adenocarcinoma in the literature. We have diagnosed VCI metastasis by US guided FNAB in the presented case. It is important to differentiate tumor thrombus from nontumor thrombi because of different treatment protocols. Bland VCI thrombus may be treated medically, whereas radical surgery or chemotherapy may be required for tumor thrombus [7]. To our knowledge, this is the first case of malignant VCI thrombosis secondary to colon cancer. We suggest that FNAB in the presence of caval obstruction can provide preoperative tissue diagnosis as well as accurate tumor staging information in such a case.
Fig. 3. Cytologic evaluation of aspirated material from obstructed VCI shows malignant tumor cells within the thrombus (Pap, original magnification 400).
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