CTICasesRenal Cell Carcinoma with Intravascular Metastatic Spread
Imaging findings
CT demonstrates low-attenuation mediastinal and hilar adenopathy with peripheral nodal enhancement. In the left lower lobe there is a wedge resection site. Multiple pulmonary nodules are identified that are not truly random but rather clustered along vessels, with expanded vessels containing tumoral material and nodules beading along their walls. In the right lung apex there is a reverse halo or atoll sign with a wedge-shaped area of ground-glass opacity surrounded by peripheral consolidation, presumably caused by an intravascular metastasis occluding a pulmonary artery and producing an area of hemorrhagic infarction.
Key takeaways
Renal cell carcinoma is the most common cause of intravascular pulmonary metastatic spread. The CT appearance includes clustered nodules along vessels with expansion of the vascular lumen by tumoral material, and occasionally a reverse atoll sign when an intravascular metastasis occludes an artery and causes downstream pulmonary infarction. Recognizing this perivascular clustering pattern and the association with dilated vessels distinguishes intravascular metastasis from hematogenous parenchymal metastases.
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