Metastatic Prostate Cancer Causing Complete Obstruction of the IVC

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1 Department of Radiology Henry Ford Health System Detroit, Michigan Metastatic Prostate Cancer Causing Complete Obstruction of the IVC Jennifer Johnston MSIII, Wayne State Medical School

2 Stage 4 Metastatic Prostate Cancer Severe Trunk and Lower Extremity Swelling. PSA 957 History

3 Findings CT: Demonstrated diffuse, scattered metastatic foci

4 Findings

5 Findings Extensive venous collaterals

6 Findings Pelvic Lymphadenopathy

7 Findings Severe peri-aortic lymphadenopathy with a normal caliber IVC at the level of the porta hepatis, which becomes completely occluded by the external compression of the peri-aortic/peri aortic/peri- caval lymphadenopathy

8 Findings

9 Findings

10 Interventional The left common and external iliac veins and the right common iliac vein were found to be patent. There was complete occlusion of the infrarenal inferior vena cava. Enlarged cross pelvic collaterals and enlarged paravertebral veins. There were several small nonocclusive filling defects identified within the iliac veins which is consistent with thrombus.

11 Interventional A stiff angled Glidewire was advanced through the caval occlusion to the level the right atrium. Imaging demonstrated a small channel with some associated thrombus. The suprarenal cava is widely patent. The renal veins are identified at the L1-L2 L2 intervertebral level.

12 Interventional

13 Interventional A 14 mm x 4 cm Atlas balloon was advanced over the wire. The caval occlusion was dilated in its entirety.

14 Interventional Contrast injection demonstrated no improvement in flow and a 20 mm x 80 mm Wallstent was advanced over the wire. It was deployed so that the proximal extent of the stent was at the level of the renal veins and the lower portion at the level of the common iliac vein confluence. The inferior portion of the stent could not be fully expanded secondary to elastic recoil.

15 Interventional Inflow from both renal veins was seen. The stent was at the level of the renal vein inflow. The inferior aspect of the stent was not fully expanded and there appeared to be compression secondary to adjacent thrombus at the level of confluence and left common iliac vein.

16 Interventional Additional dilatation of this region failed to produce any improvement which necessitated placement of an additional stent down into the left common iliac vein.

17 Interventional Follow-up venography demonstrated brisk flow from the left iliac system through the stents into the suprarenal cava. The stents appeared well positioned and expanded.

18 DDx: : Extrinsic Compression (Neoplastic) Lymphoma Non-Hodgkin > Hodgkin Nodes surrounding the IVC and aorta appear symmetrical Metastatic retroperitoneal lymph nodes especially ovaries, cervix, and PROSTATE > melanoma > breast > lung Nodes surrounding the IVC and aorta appear asymmetrical Sarcoma Eccentric mass that displaces the abdominal viscera. Contains areas of varying densities; liposarcoma > leiomyosarcoma

19 DDx: : Extrinsic Compression (Non- neoplastic) Infectious/Inflammatory Nodes Hepatitis, mononucleosis, TB, sarcoid Correlating clinical and radiographic data Retroperitoneal Hemorrhage Coagulopathic or ruptured aneurysm High density fluid dissecting along fascial planes

20 Differential Dx No matter what the cause, most cases (60-70%) with chronic obstruction are asymptomatic with significant collaterals. Those with more acute obstruction and in 20-30% with chronic obstruction will present with bilateral lower extremity edema.

21 Discussion Prostate ca. is the most common cancer in men in the United States and the second leading cause of cancer death. In the past it was detected by DRE or urinary symptoms. Today it is typically detected by elevated serum PSA levels while clinical presentation is asymptomatic. The tumor-node-metastasis (TNM) system is the most popular method of staging prostate cancer. Together with analysis of tumor histology (Gleason grade) provides some index of prognosis and may also guide local therapy. The primary variables predicting the likelihood of nodal disease include the stage of the primary tumor (T), tumor grade (Gleason score), and the serum PSA level. The prostate lymph node drainage is to the external and internal iliac lymph nodes, common iliac lymph nodes and lumbar lymph nodes.

22 Discussion Surgical staging of lymph nodes is the gold standard, but imaging studies can be used to identify positive pelvic lymph nodes Superparamagnetic iron oxide-enhanced MRI can give sensitive results. However, it is not widely available, and is time consuming/expensive due to the need to perform two MRI scans within a 24-hour period. Immunoscintigraphy using Prostascint which is directed against the prostate-specific membrane antigen. Sensitivity, however does not justify routine use. Using criteria based on lymph node size CT and MRI have NOT been reliable in identifying PLN. PET scan using fluorodeoxyglucose has been found insensitive Radionuclide bone scan, axial skeleton MRI, and PET have all been used to detect evidence of distant metastases.

23 Discussion This is a ProstaScint CT fusion study performed on a patient with a rising PSA level following radiotherapy. Abnormal ProstaScint accumulation is demonstrated in the seminal vesicles (red arrows on image A) and right pelvic lymph nodes (yellow arrow on image B). This patient s prostate cancer most likely has spread beyond the prostate gland into the seminal vesicles and pelvic lymph nodes. (prostate-cancer.org)

24 References 1. Carcinoma of the prostate presenting as IVC obstruction Maneesh Sinha, Nitin S Kekre, Ganesh Gopalakrishnan Department of Urology, Christian Medical College and Hospital, Vellore, India Year : 2004 Volume : 20 Issue : 2 Page : Evaluation of regional lymph nodes in men with prostate cancer: Carvell Nguyen and Eric Klein. UpToDate,, Updated IVC Obstruction: Stat DX Simon, SM Ho Updated Overview of the clinical presentation, diagnosis, and staging of prostate cancer: Philip Kantoff and Mary- Ellen Taplin. UpToDate, Updated Retroperitoneal Mass, Soft Tissue Density: Stat DX Simon, SM Ho Updated

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