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Renal cell carcinoma with extensive tumor thrombus

      A 60-year-old man presented to the emergency department with a 8 h history of swelling of right lower limb. Duplex ultrasonography showed extensive deep venous thrombosis in both legs. Laboratory evaluation revealed the following: D2 polymer level, 10.59 mg/L (reference range, 0–0.55 mg/L); prothrombin activity, 66.10% (reference range, 75 to 130%); plasma fibrinogen 4.14 g/L (reference range, 2–4 g/L); and the level of neuron-specific enolase was elevated (32.34 ng/mL; reference range, 15.7–17.0 ng/mL). Abdominal enhanced computed tomography (CT) (Fig. 1) demonstrated an irregular left renal mass (red arrow) with enhancing tumor thrombus into the left renal vein (yellow arrow) and into the inferior vena cava to more than 2 cm above the renal vein but below the hepatic veins (green arrow). Extensive venous thromboses were revealed in the distal part of the inferior vena cava (blue arrow) and the bilateral iliac veins (purple arrows). 18-fluorine-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) displayed slightly increased FDG metabolisms in the left kidney, left renal vein and inferior vena cava. Left renal cell carcinoma with level-II tumor thrombi was diagnosed according to the Mayo Clinic grading system of inferior vena cava tumor thrombus.
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