Abstract Number: PB2122
Meeting: ISTH 2020 Congress
Background: Intravascular tumor thrombus (ITT) is a common complication in patients with renal cell carcinoma (RCC), with optimal management remaining uncertain.
Aims: To report the challenge and initial approach in a case of massive life-threatening ITT in the vena cava, right atrium and bilateral pulmonary embolism (PE) as the first manifestation of RCC.
Methods: We report a case study.
Results: A 33-year-old woman was admitted to hospital for acute shortness of breath. Physical examination showed arterial hypotension (70/50 mmHg), tachycardia (150 bpm) and tachypnea (35 bpm) requiring high concentration oxygen (FiO2 40%). Electrocardography showed complete right blockade. Bedside ultrasound showed severe right ventricular dysfunction and dilation. Computed tomography angiography confirmed the presence of a massive bilateral PE (Figure 1A) and a right renal mass associated with a large ITT in the inferior vena cava (IVC) extending up to the right atrium (Figure 1B). Fibrinolytic therapy was performed with no hemodynamic improvement and vasoactive support and anticoagulation with unfractioned heparin (UFH) was continued. Endovascular or surgical thrombectomy was ruled out by a multidisciplinary team based on the large extension and tumoral thrombus nature. The main outcome features are shown in table 1. Grade 4 thrombocytopenia due to heparin-induced thrombocytopenia (HIT) was diagnosed on day +9 and confirmed by detection of anti-heparin platelet factor 4 antibodies that normalized after switching low molecular weight heparin (LMWH) to fondaparinux. Renal biopsy confirmed the diagnosis of RCC and first-line anticancer therapy with nivolumab + ipilimumab was started as outpatient treatment on day +40.
Conclusions: This case illustrates the challenges associated with the management of a massive ITT and the subsequent development of HIT. Optimal management of ITT deserves further research.
|Date||Clinical findings||Radiological findings|
|November 9th 2019. Day +1||Acute dyspnea and tachypnea. Hypotension and tachycardia. Admission to ICU for vasoactive support, high flow oxygen and UFH.||Bedside ultrasound: right ventricular dysfunction and dilation; thrombus in the IVC and right atrium. Angio-CT: massive bilateral PE, right renal mass and ITT from the IVC to the right atrium.|
|Day +3||Vasoactive support withdrawn.|
|Day +6||Transfer to the oncology ward. Switch to LMWH.|
|Day +7||ECOG-PS 3. Tachypnea requiring high concentration oxygen (40%).||Angio-CT: thrombus persistence in bilateral pulmonary arteries with mild retraction.|
|Day +9||ECOG-PS 3. Grade 4 thrombocytopenia (26.000). Detection of anti-heparin platelet factor 4 antibodies. Switch to fondaparinux (7.5 mg/24h).|
|Day +20||ECOG-PS 2. Oxygen withdrawal. Ambulation around the unit.||Thoracoabdominal CT: bilateral PE without changes; thrombus shrinkage in the hepatic IVC; thrombus progression in the infrarenal IVC with caudal extension to the left femoral vein. Echocardiography: thrombus persistence in the right atrium (18x14mm); no dilation nor dysfunction of the right ventricle; no signs of pulmonary hypertension.|
|Day +24||ECOG-PS 1. Renal biopsy performed. Hospital discharge.|
|Day +40||ECOG-PS1. Outpatient treatment with nivolumab + ipilimumab initiated.|
|Day +70||ECOG-PS0. Excellent tolerance. Third cycle of nivolumab + ipilimumab.||Echocardiography: thrombus persistence in the IVC but with shrinkage in the right atrium; no dilation nor dysfunction of the right ventricle; no signs of pulmonary hypertension.|
[Table 1. Clinical and radiological findings over time]
To cite this abstract in AMA style:Seguí E, García de Herreros M, Laguna JC, Orrillo M, Mellado B, Font C. Massive Life-Threatening Intravascular Tumor Thrombus (ITT) as the Initial Manifestation of Renal Cell Carcinoma Complicated with Heparin-Induced Thrombocytopenia: A Case Study [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/massive-life-threatening-intravascular-tumor-thrombus-itt-as-the-initial-manifestation-of-renal-cell-carcinoma-complicated-with-heparin-induced-thrombocytopenia-a-case-study/. Accessed November 30, 2021.
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