Clinical History
A 33-year-old female patient with known history of carcinoma of distal oesophagus treated three years ago and under remission presently, presented to casualty with vague abdominal pain and reduced cognition. Emergency ultrasound showed a heterogeneous mass in the left kidney for which the patient was forwarded to CT scan evaluation.
Imaging Findings
Ultrasound revealed a heterogeneous left renal parenchyma with prominent echogenic hilar pedicle. So the patient was referred for CT abdomen to rule out renal mass with vascular thrombus.
Early arterial phase imaging showed an ill-defined, mildly enhancing left renal mass lesion predominantly located in mid and inferior poles replacing the renal parenchyma. Minimal opacification of the left ureter was seen in delayed images.
An enhancing filling defect with gross luminal expansion of the left renal vein was extending up to the inferior vena cava with infiltration of the left gonadal vein.
Feeding jejunostomy defect was noted in the anterior abdominal wall with enhancement of the tract.
Short segment circumferential thickening of the oesophagus was noted at the level of carina along with enhancing necrotic mediastinal, bronchopulmonary and para-aortic lymph nodes.
Other findings included cholecystolithiasis, splenic calcifications, minimal ascites, minimal left pleural effusion and umbilical hernia.
Follow-up brain MRI revealed extensive cerebral metastases.
Discussion
Oesophageal cancer is making strides as one of the leading causes of cancers in the world. Oesophageal cancer has multifactorial causes. Consuming alcoholic drinks, red meat, salt and energy-dense diet along with a large amount of body fat are well-established causes known to increase the risk of oesophageal cancer. Metastatic oesophageal carcinoma is not an infrequent finding in autopsy workup [1]. However, this is seldom diagnosed before as most of the lesions will be silent and may not manifest as haematuria or proteinuria and generally present late with a poor prognosis [2]. Surgical resection has been advised in solitary metastatic lesions [3], but the guidelines are not clear. Survival rates of metastatic oesophageal cancer are low with mean survival times being less than one year [4]. Our patient in question had undergone surgical removal of the primary oesophageal tumour followed by multiple cycles of chemoradiotherapy three years ago and was on routine follow-up. On extensive recent evaluation other than the suspicious renal mass lesion we found extensive lymph nodal and cerebral metastases which correlated to reduced mental function. The diagnosis was confirmed by biopsy. The patient had multiple associated co-morbidities and being unfit for surgery was put on palliative therapy.
Teaching points:
Renal metastases with tumour thrombus has to be kept in mind in evaluating a patient with this imaging morphology which is otherwise a hallmark of primary renal cell carcinoma.
Differential Diagnosis List
Metastatic oesophageal carcinoma
Primary renal cell carcinoma
Renal lymphoma
Final Diagnosis
Metastatic oesophageal carcinoma
