From Kidney to Heart: A Rare Journey of a Mass Causing Hemodynamic Collapse

Introduction: Renal cell carcinoma (RCC) accounts for 2–3% of adult cancers. In 4–10% of cases, tumor thrombus extends into the inferior vena cava (IVC), and in rare instances, into the right atrium, leading to obstructive shock and high mortality. Surgical resection offers the best survival chance, but extensive hepatic or vascular involvement can make surgery nonviable. We present a rare case of RCC with IVC and atrial extension in a patient with cirrhosis and hemodynamic instability. Case Description: A 71-year-old woman with hypertension and newly identified cirrhosis presented with three months of worsening bilateral lower extremity edema, abdominal discomfort, nausea, and early satiety. On admission, she was hypotensive (BP 85/60 mmHg), tachycardic, and had tense ascites and peripheral edema. Labs showed hyperbilirubinemia, elevated INR, and metabolic acidosis. CT and MRI revealed a right renal mass with tumor thrombus extending into the IVC and right atrium, obstructing the tricuspid valve and causing shock. The mass also invaded the liver. A multidisciplinary team (nephrology, oncology, surgery, hepatology) determined the tumor was unresectable due to hepatic infiltration and portal hypertension. A palliative right renal artery embolization was performed. Despite this, the patient remained hypotensive and developed multiorgan failure. She was transitioned to comfort care and passed away. Discussion: This case illustrates the clinical severity of RCC with cardiac extension, particularly in the setting of cirrhosis and portal hypertension. Although surgery is standard, advanced disease can preclude it. Multidisciplinary collaboration was essential in evaluating options and prioritizing patient-centered care. Early recognition and novel treatment strategies are urgently needed for nonsurgical candidates.