Clinical and imaging characteristics of classic angiomyolipoma with venous tumor thrombosis: a comparative analysis against renal cell carcinoma.

Objective: To retrospectively analyze the clinical and imaging characteristics of classic angiomyolipoma (CAML) with venous tumor thrombus (VTT) and compare them with those of clear cell renal cell carcinoma (ccRCC).

Methods: Clinical data from six patients with renal CAML complicated by VTT and 18 with ccRCC complicated by VTT, treated at Peking University Third Hospital from April 2018 and June 2022, were retrospectively analyzed. All patients underwent preoperative ultrasound and contrast-enhanced CT. Clinical manifestations, imaging characteristics, surgical findings, and pathological data were collected, and patients were followed up.

Results: Enhanced CT showed renal sinus involvement in all CAML cases versus four ccRCC cases (p = 0.002). All primary CAML tumors had fatty components, compared to one ccRCC case (p < 0.001). Enhanced CT also revealed 7 VTTs with fatty components (6 in the CAML group) (p < 0.001). Thrombus lengths in the inferior vena cava (IVC) were 8.05 ± 2.22 cm for CAML and 5.29 ± 2.38 cm for ccRCC, with no significant difference (p = 0.610). The maximum/minimum anteroposterior VTT diameter ratios were 3.98 and 1.09, respectively (p < 0.001); coronal diameter ratios were 4.00 and 1.12, respectively (p < 0.001). Ultrasound revealed that, except for one Mayo Level 0 case, the involved IVC in the CAML group had continuous, intact walls with blood flow signals in the residual lumen, while in the ccRCC group, most VTTs had unclear boundaries and only one case showed blood flow signals in the residual lumen (p = 0.001). Intraoperative blood loss was significantly lower in CAML cases (p = 0.017). No CAML patient had VTT invading the venous wall, unlike 8 ccRCC patients (p = 0.016). All patients were followed for 21-74 months (median: 34.5 months, mean: 36.6 months). All were alive with normal renal function, and no tumor recurrence or metastasis was observed.

Conclusion: Renal CAML with VTT is characterized by three imaging features: the presence of fatty components, a unique geometric growth pattern, and the absence of venous wall invasion, potentially serving as valuable indicators for differentiating CAML from ccRCC lesions.