1
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Pio L, Abib S, Guerin F, Chardot C, Blanc T, Sarrai N, Martelli H, De Souza FKM, Fanelli MCA, Tamisier D, Guilhen JCS, Le Bret E, Belli E, Fadel E, Cypriano MDS, Minard V, Pasqualini C, Schleiermacher G, Lemelle L, Rod J, Irtan S, Pistorio A, Gauthier F, Branchereau S, Sarnacki S. Surgical Management of Wilms Tumors with Intravenous Extension: A Multicenter Analysis of Clinical Management with Technical Insights. Ann Surg Oncol 2024; 31:4713-4723. [PMID: 38578552 DOI: 10.1245/s10434-024-15232-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/12/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND About 5% of Wilms tumors present with vascular extension, which sometimes extends to the right atrium. Vascular extension does not affect the prognosis, but impacts the surgical strategy, which is complex and not fully standardized. Our goal is to identify elements of successful surgical management of Wilms tumors with vascular extensions. PATIENTS AND METHODS A retrospective study of pediatric Wilms tumors treated at three sites (January 1999-June 2019) was conducted. The inclusion criterion was the presence of a renal vein and vena cava thrombus at diagnosis. Tumor stage, pre and postoperative treatment, preoperative imaging, operative report, pathology, operative complications, and follow-up data were reviewed. RESULTS Of the 696 pediatric patients with Wilms tumors, 69 (9.9%) met the inclusion criterion. In total, 24 patients (37.5%) had a right atrial extension and two presented with Budd-Chiari syndrome at diagnosis. Two died at diagnosis owing to pulmonary embolism. All patients received neoadjuvant chemotherapy and thrombus regressed in 35.6% of cases. Overall, 14 patients had persistent intra-atrial thrombus extension (58%) and underwent cardiopulmonary bypass. Most thrombi (72%) were removed intact with nephrectomy. Massive intraoperative bleeding occurred during three procedures. Postoperative renal insufficiency was identified as a risk factor for patient survival (p = 0.01). With a median follow-up of 9 years (range: 0.5-20 years), overall survival was 89% and event-free survival was 78%. CONCLUSIONS Neoadjuvant chemotherapy with proper surgical strategy resulted in a survival rate comparable to that of children with Wilms tumors without intravascular extension. Clinicians should be aware that postoperative renal insufficiency is associated with worse survival outcomes.
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Affiliation(s)
- Luca Pio
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France.
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN, USA.
- Paris Kids Cancer, Paris, France.
| | - Simone Abib
- Department of Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
- Pediatric Oncology Institute-GRAACC-Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Florent Guerin
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
- Paris Kids Cancer, Paris, France
| | - Christophe Chardot
- Department of Pediatric Surgery, Hôpital Necker Enfants Malades-Université de Paris Cité, Paris, France
- Paris Kids Cancer, Paris, France
| | - Thomas Blanc
- Department of Pediatric Surgery, Hôpital Necker Enfants Malades-Université de Paris Cité, Paris, France
- Paris Kids Cancer, Paris, France
| | - Nadia Sarrai
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Helene Martelli
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Fernanda K M De Souza
- Department of Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
- Pediatric Oncology Institute-GRAACC-Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Mayara C A Fanelli
- Department of Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
- Pediatric Oncology Institute-GRAACC-Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Daniel Tamisier
- Department of Cardiovascular Surgery, Hôpital Universitaire Necker Enfants Malades-Université de Paris Cité, Paris, France
| | - José Cícero S Guilhen
- Department of Cardiovascular Surgery, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Emmanuel Le Bret
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue-Groupe Hospitalier Paris-Saclay, Université Paris-Saclay, Le Plessis-Robinson, France
| | - Emré Belli
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue-Groupe Hospitalier Paris-Saclay, Université Paris-Saclay, Le Plessis-Robinson, France
| | - Elie Fadel
- Department of Pediatric Cardiology and Congenital Heart Disease, Hôpital Marie Lannelongue-Groupe Hospitalier Paris-Saclay, Université Paris-Saclay, Le Plessis-Robinson, France
| | - Monica D S Cypriano
- Pediatric Oncology, Pediatric Oncology Institute-GRAACC-Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Véronique Minard
- Pediatric Oncology Unit, Institut Gustave Roussy, Paris, France
- Paris Kids Cancer, Paris, France
| | - Claudia Pasqualini
- Pediatric Oncology Unit, Institut Gustave Roussy, Paris, France
- Paris Kids Cancer, Paris, France
| | - Gudrun Schleiermacher
- Pediatric Oncology Unit, Institut Curie, Paris, France
- Paris Kids Cancer, Paris, France
| | - Lauriane Lemelle
- Pediatric Oncology Unit, Institut Curie, Paris, France
- Paris Kids Cancer, Paris, France
| | - Julien Rod
- Department of Pediatric Surgery, Hôpital Necker Enfants Malades-Université de Paris Cité, Paris, France
| | - Sabine Irtan
- Department of Pediatric Surgery, Hôpital Necker Enfants Malades-Université de Paris Cité, Paris, France
- Paris Kids Cancer, Paris, France
| | - Angela Pistorio
- Epidemiology, and Biostatistics Unit, Instituto Giannina Gaslini, Genoa, Italy
| | - Frederic Gauthier
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
| | - Sophie Branchereau
- Bicêtre Hospital, Paris-Saclay University, GHU Paris Saclay Assistance Publique Hôpitaux de Paris (AP-HP), Le Kremlin Bicêtre, France
- Paris Kids Cancer, Paris, France
| | - Sabine Sarnacki
- Department of Pediatric Surgery, Hôpital Necker Enfants Malades-Université de Paris Cité, Paris, France
- Paris Kids Cancer, Paris, France
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Kanneganti P, Verma A, Kumar B, Nigam N. Retroperitoneal yolk sac tumour encroaching the liver and adrenal gland with tumour thrombus in cavo-atrial region and hepatic veins. BMJ Case Rep 2023; 16:e255968. [PMID: 37923340 PMCID: PMC10626902 DOI: 10.1136/bcr-2023-255968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Paediatric germ cell tumours (GCT) are rare tumours and are unique because of varied clinical presentation and locations. Yolk sac tumour is the predominant malignant histology and a serum marker; alpha fetoprotein is used to see treatment response and recurrent disease. It is extremely rare to find a retroperitoneal GCT with tumour thrombus extending up to the cavo-atrial region with involvement of the hepatic veins. We report a case of retroperitoneal yolk sac tumour (RPYST) with extension to the liver and right adrenal gland along with tumour thrombus in the inferior vena cava and in the right and middle hepatic veins. The child was operated after satisfactory response to chemotherapy. Excision of the tumour along with the right adrenal gland and around 5 cm of retro-hepatic caval resection was done. Inferior vena cava resection was tolerated without reconstruction. Currently child is disease-free and symptom-free at 22 months of follow-up with normal serum marker.
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Affiliation(s)
- Pujana Kanneganti
- Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India
| | - Anju Verma
- Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India
| | - Basant Kumar
- Pediatric Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India
| | - Neha Nigam
- Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, UP, India
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3
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Yi H, Li X, Wang H. Surgical treatment of cardiac tumour thrombus in children. Cardiol Young 2023; 33:2443-2445. [PMID: 37489509 DOI: 10.1017/s1047951123002652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Cardiac mass in children is rare and insidious onset, and primary cardiac mass is less than secondary mass. Among the malignant tumours in children with tumour thrombus in the venous system, about 98% of the cases are nephroblastoma. But it is still rare for the tumour thrombus to reach the level of the atrium or even enter the right ventricle. In this case, the child complained of chest tightness and palpitation and went to the doctor and found Wilms tumour complicated with intracardiac tumour thrombus.
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Affiliation(s)
- Hanlu Yi
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Xiaofeng Li
- Department of Cardiac Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
| | - Huanmin Wang
- Department of Oncology Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
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4
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Cairo SB, Urias AR, Murphy JT. Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience. J Surg Res 2022; 280:396-403. [PMID: 36037617 DOI: 10.1016/j.jss.2022.06.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/19/2022] [Accepted: 06/09/2022] [Indexed: 10/15/2022]
Abstract
INTRODUCTION Inferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. METHODS In this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. RESULTS Fourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. CONCLUSIONS IVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.
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Affiliation(s)
- Sarah B Cairo
- University of Texas Southwestern, Department of Pediatric Surgery, Dallas, Texas.
| | | | - Joseph T Murphy
- University of Texas Southwestern, Department of Pediatric Surgery, Dallas, Texas
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5
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Boam TD, Gabriel M, Shukla R, Losty PD. Impact of neoadjuvant chemotherapy on thrombus viability in patients with Wilms tumour and caval extension: systematic review with meta-analysis. BJS Open 2021; 5:6289805. [PMID: 34052849 PMCID: PMC8164777 DOI: 10.1093/bjsopen/zrab020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/19/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inferior vena cava (IVC) tumour thrombus in children with Wilms tumour is typically managed with neoadjuvant chemotherapy with the intention of achieving thrombus regression in order to minimize the risks associated with complex vascular surgery. METHODS A systematic review of Medline and Embase databases was undertaken to identify all eligible studies with reference to thrombus viability in Wilms tumour index cases with caval/cardiac extension. A meta-analysis of proportions was utilized for pooled thrombus viability data across studies. Logistic regression was used to analyse the relationship between thrombus viability and duration of chemotherapy. RESULTS Thirty-five eligible observational studies and case reports met inclusion criteria describing a total of 236 patients with thrombus viability data. The pooled proportion of patients with viable tumour thrombus after neoadjuvant chemotherapy was 0.53 (0.43-0.63). Logistic regression analysis of 54 patients receiving either a standard (4-6 weeks) or extended (more than 6 weeks) course of neoadjuvant chemotherapy resulted in an odds ratio of 3.14 (95 per cent c.i. 0.97 to 10.16), P = 0.056, with extended course therapy trending towards viable tumour thrombus. CONCLUSION Preoperative chemotherapy is successful in achieving non-viability of caval and cardiac thrombi in around 50 per cent of children, without added benefit from extended cycles of neoadjuvant chemotherapy. Risks versus benefits of extirpative vascular surgery must be considered, therefore, for these high-risk patients.
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Affiliation(s)
- T D Boam
- Department of Paediatric Surgery, Chelsea and Westminster Hospital, London, UK
| | - M Gabriel
- Department of Paediatric Surgery, Norfolk and Norwich Hospital, Norwich, UK
| | - R Shukla
- Department of Pathology, Alder Hey Children's Hospital, Liverpool, UK
| | - P D Losty
- Alder Hey Children's Hospital NHS Foundation Trust, School of Health and Life Science, University of Liverpool, UK
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6
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Fanelli MCA, Guilhen JCS, Duarte AAB, de Souza FKM, Cypriano MDS, Caran EMM, Lederman HM, de Seixas Alves MT, Abib SDCV. Management of Pediatric Tumors With Vascular Extension. Front Pediatr 2021; 9:753232. [PMID: 35059362 PMCID: PMC8764352 DOI: 10.3389/fped.2021.753232] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Pediatric tumors can present with vascular extension to the inferior vena cava and right atrium, which impacts the surgical strategy and can be challenging during surgical treatment. Wilms tumor (WT) is the most common retroperitoneal tumor that can present with vascular extension, but also adrenal tumors, clear cell tumors from the kidney, and hepatoblastomas can present with this situation. Surgical aims include obtaining complete tumor resection without risk for patients, to avoid severe bleeding, cardiac arrest, and embolization, and to avoid cardiac bypass if possible. Objective: To describe and discuss the surgical strategies to deal with pediatric tumors with vascular extension and propose a protocol. Method: Retrospectivly review the experience of treating patients with vascular extension in a single institution, describing different scenarios and a decision making fluxogram based on the preoperative evaluation regarding the surgical techniques and the need for cardiac bypass that are adequate for each situation. Image studies are important to guide the surgical strategy. Depending on the quality of image available, computerized tomography (CT) or magnetic resonance imaging (MRI) can be enough to give the information needed for surgical decisions. Ultrasonography (US) with Doppler is helpful to confirm diagnosis and describes factors to guide the adequate surgical strategy, like the upper level extension and presence or absence of blood flow around the thrombus. Neoadjuvant chemotherapy is indicated in most cases, in order to reduce the upper level of extension (and avoid the need for cardiac bypass) and to lower the risk of embolization. The approach is based on the upper level of the thrombus and can include cavotomy or cavectomy, sometimes with cardiac bypass and cardiac arrest with hypothermia, when the thrombus reaches the diaphragmatic level or above. Pathology analysis of the thrombus can guide staging and the need for radiotherapy postoperatively. Results: A decision making fluxogram protocol is presented focusing on the surgical treatment of such condition. Conclusion: Surgery strategy is highly impacted by the presence of vascular extension in pediatric tumors. Surgeons should be aware of potential complications and how to prevent them. Such cases should be treated in reference centers.
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Affiliation(s)
- Mayara Caroline Amorim Fanelli
- Department of Pediatric Surgery, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | | | - Alexandre Alberto Barros Duarte
- Department of Pediatric Surgery, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | | | - Monica Dos Santos Cypriano
- Department of Pediatric Oncology, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | - Eliana Maria Monteiro Caran
- Department of Pediatric Oncology, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | - Henrique Manoel Lederman
- Department of Pediatric Radiology, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil
| | - Maria Teresa de Seixas Alves
- Department of Pediatric Surgery, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil.,Department of Pediatric Pathology, Federal University of São Paulo, São Paulo, Brazil
| | - Simone de Campos Vieira Abib
- Department of Pediatric Surgery, Pediatric Oncology Institute, Grupo de Apoio ao Adolescente e à Criança com Câncer (GRAACC), São Paulo, Brazil.,Department of Pediatric Surgery, Federal University of São Paulo, São Paulo, Brazil
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Altwaeel H, Kabbani MS, Shammari AA, Al-Namshan M, Alghamdi AA. Perioperative management of Wilms' tumor with intracardiac extension: Report of two cases with review of literature. J Saudi Heart Assoc 2020; 32:106-109. [PMID: 33154901 PMCID: PMC7640600 DOI: 10.37616/2212-5043.1018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/21/2019] [Accepted: 10/23/2019] [Indexed: 11/23/2022] Open
Abstract
Wilms' tumor (WT) is one of the solid tumor that affects children. It involves the kidney and may extend to the lungs and liver. WT conquers the adjacent blood vessels such as renal veins and inferior vena cava (IVC); its extension to IVC and right-sided heart chambers is unusual. Furthermore, when the tumor extends to heart chambers, its surgical management becomes challenging and demands multidisciplinary medical and surgical specialties including pediatric cardiac surgery. In this report, we discuss the surgical management and perioperative treatment of two unusual cases of WT with IVC and intracardiac extension.
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Affiliation(s)
- Hayan Altwaeel
- Section of Pediatric Cardiac Intensive Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Mohamed S Kabbani
- Section of Pediatric Cardiac Intensive Care, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Saud Bin AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Ahmad Al Shammari
- Section of Urology Surgery, Department of Surgery, King Abdulaziz Medical City. Riyadh, Saudi Arabia.,King Saud Bin AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Al-Namshan
- Department of Pediatric Surgery, King Abdullah Specialist Children Hospital, Riyadh, Saudi Arabia.,King Saud Bin AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abdullah A Alghamdi
- Section of Cardiac Surgery, Department of Cardiac Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia.,King Saud Bin AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia
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8
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Elayadi M, Hammad M, Sallam K, Ahmed G, Ahmed S, Ibrahim A, Refaat A, Elkinaai N, Younes A, Graf N, Zekri W. Management and outcome of pediatric Wilms tumor with malignant inferior Vena cava thrombus: largest cohort of single-center experience. Int J Clin Oncol 2020; 25:1425-1431. [PMID: 32249334 DOI: 10.1007/s10147-020-01667-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/23/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Wilms tumor (WT) with an inferior Vena cava (IVC) malignant thrombus comprises 4-10% of all WT cases. METHODS This retrospective analysis included 51 pediatric patients presenting at Children Cancer Hospital Egypt-57357 from July 2007 to December 2016 with the diagnosis of WT with malignant IVC thrombus. RESULTS Median age at presentation = 4.4 years and 28 cases (55%) were females. Twenty-five patients (49%) were metastatic and 4 patients (7.8%) had bilateral disease. Forty-seven cases (92.2%) had favorable histology with no evidence of anaplasia. Level of thrombus extension at presentation was classified as infra-hepatic, retro-hepatic, supra-hepatic and intra-cardiac in 33, 9, 6 and 3 patients, respectively. Fifty patients started neoadjuvant chemotherapy (CTH) with 16 patients showing complete resolution of thrombus after 6 weeks of CTH. None of the patients developed thrombus progression after neoadjuvant CTH; one patient had stationary intra-cardiac thrombus, while remaining patients showed partial regression of their thrombus and had nephrectomy with en-bloc thrombectomy. The mean cranio-caudal dimension of IVC thrombi at initial presentation was 6.5 cm, and 3.6 cm post 6th week of CTH. The 5-year OS and EFS were 75.9% and 71.1%, respectively. There was no significant correlation of initial levels of thrombus extension with survival. CONCLUSION Neoadjuvant chemotherapy followed by radical nephrectomy with en-bloc thrombectomy and radiotherapy seems a successful approach for management of patients with WT and IVC tumor thrombus. Measurement of the cranio-caudal dimension of thrombus and its response to treatment should be considered in the surgical planning.
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Affiliation(s)
- Moatasem Elayadi
- Department of Pediatric Oncology, National Cancer Institute, Cairo University, Fom El-khalig, Square Kasr El-Aini St., Cairo, 11796, Egypt. .,Department of Pediatric Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt.
| | - Mahmoud Hammad
- Department of Pediatric Oncology, National Cancer Institute, Cairo University, Fom El-khalig, Square Kasr El-Aini St., Cairo, 11796, Egypt.,Department of Pediatric Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt
| | - Kareem Sallam
- Department of Surgery, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Gehad Ahmed
- Department of Surgery, Faculty of Medicine, Helwan University, Cairo, Egypt.,Department of Surgical Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt
| | - Soha Ahmed
- Department of Radiation Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt.,Department of Clinical Oncology, Aswan University, Aswan, Egypt
| | - Ahmed Ibrahim
- Department of Clinical Research, Children Cancer Hospital Egypt-57357, Cairo, Egypt
| | - Amal Refaat
- Department of Radio-Diagnosis, National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Radio-Diagnosis, Children Cancer Hospital Egypt-57357, Cairo, Egypt
| | - Naglaa Elkinaai
- Department of Pathology, National Cancer Institute, Cairo University, Cairo, Egypt.,Department of Pathology, Children Cancer Hospital Egypt-57357, Cairo, Egypt
| | - Alaa Younes
- Department of Surgical Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt.,Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Norbert Graf
- Department of Pediatric, Saarland University, Campus Homburg, Homburg, Germany
| | - Wael Zekri
- Department of Pediatric Oncology, National Cancer Institute, Cairo University, Fom El-khalig, Square Kasr El-Aini St., Cairo, 11796, Egypt.,Department of Pediatric Oncology, Children Cancer Hospital Egypt-57357, Cairo, Egypt
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9
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Abstract
The prognosis of children with Wilms tumour has greatly improved since the introduction of adjuvant radiotherapy and chemotherapy more than 70 years ago with a current overall long-term survival approaching 90%. Before this, surgery was the only option with around 20% survival, even in low-risk categories. The focus is now on management options for those patients in specific subgroups, who continue to have lower event-free survival and who suffer from the long-term effects of treatment. These include those with anaplastic histology, bilateral Wilms, biologically high-risk tumours and those that relapse (Aldrink et al. in J Pediatr Surg 54(3):390-397, 2019). The major advances that have already been made in risk assessment and tailoring the chemotherapy/radiotherapy to achieve maximum advantage with minimum toxicity and long-term morbidity have been predicated on safe and complete resection and staging of the tumour. There are, however, still surgical challenges faced with respect to resection of 'complex' tumours; thus, surgeons need to understand their role and advance their expertise in the overall treatment of children with Wilms tumour. These include very large tumours not responding to chemotherapy, ruptured tumours, tumours with intravascular invasion into the inferior vena cava (± 10%), heart and hepatic veins (± 4%) and Wilms tumours in horseshoe kidneys (< 1%) (Kieran and Ehrlich in Urol Oncol https://doi.org/10.1016/j.urolonc.2015.05.029, 2015). This review describes surgical strategies and techniques used in these situations, gleaned from the authors' experience in the surgical management of over 300 children with Wilms tumours in our centres over the last 30 years.
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Affiliation(s)
- Sharon Cox
- Division of Paediatric Surgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa.
| | - Cenk Büyükünal
- Division of Paediatric Urology, Department of Paediatric Surgery, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Alastair J W Millar
- Division of Paediatric Surgery, University of Cape Town and Red Cross War Memorial Children's Hospital, Klipfontein Road, Rondebosch, Cape Town, 7700, South Africa
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10
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Morris L, Squire R, Sznajder B, van Tinteren H, Godzinski J, Powis M. Optimal neoadjuvant chemotherapy duration in Wilms tumour with intravascular thrombus: A literature review and evidence from SIOP WT 2001 trial. Pediatr Blood Cancer 2019; 66:e27930. [PMID: 31339231 DOI: 10.1002/pbc.27930] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/16/2019] [Accepted: 06/28/2019] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Preoperative chemotherapy is recommended for children with Wilms tumour with intravascular extension. Extended chemotherapy may improve resectability, but increase tumour adherence to vascular endothelium, precluding complete resection. To evaluate the optimal length of preoperative treatment, we report a two-part review comprising systematic review of the literature and investigation of patients treated in the International Society of Paediatric Oncology (SIOP) WT 2001 trial. METHODS Studies were identified using Medline and Embase databases from 1996 to present. English language titles reporting management of intravascular Wilms tumour were analysed. Patients with Wilms tumour and thrombus were identified from the SIOP WT 2001 trial. Overall survival (OS) and event-free survival (EFS), tumour regression, completeness of resection and cavectomy were investigated. RESULTS The search retrieved 43 articles documenting 498 children. Note that 72% of the patients received neoadjuvant chemotherapy: 101 received standard course (4-6 weeks, standard course neoadjuvant chemotherapy [StC]) and 62 extended course (> 6 weeks, extended course neoadjuvant chemotherapy [EC]). There was no significant difference between the groups in terms of thrombus regression or completeness of resection. EFS was greater in the StC group (78 vs 54%; P = .04). Of 4511 patients registered in the SIOP WT 2001 trial, 166 had thrombus. Note that 97% of the patients received neoadjuvant chemotherapy: 63 StC and 67 EC. There was no significant difference between the groups with regard to tumour regression, complete resection, or cavectomy. Survival was significantly higher in those receiving StC than EC (OS: 95% vs 82%, P = .025; EFS: 88% vs 72%, P = .047). CONCLUSION There is no evidence that prolonged courses of neoadjuvant chemotherapy beyond the recommended protocols confer any additional benefit in treating intravascular extension of Wilms tumour.
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Affiliation(s)
- Louise Morris
- Department of Paediatric Surgery, Nottingham University Hospitals, Nottingham, UK
| | - Roly Squire
- Department of Paediatric Surgery, Leeds Teaching Hospitals, Leeds, UK
| | - Beata Sznajder
- School of Agriculture, Food and Wine, University of Adelaide, Adelaide, Australia
| | - Harm van Tinteren
- Biostatistics Department, Netherlands Cancer Institute-Antonie van Leeuwenhoekhuis Plesmanlaan, Amsterdam, The Netherlands
| | - Jan Godzinski
- Department of Paediatric Surgery, Marciniak Hospital, and Chair of Emergency Medicine, Medical University, Wroclaw, Poland
| | - Mark Powis
- Department of Paediatric Surgery, Leeds Teaching Hospitals, Leeds, UK
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11
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Grimaldi C, Bertocchini A, Crocoli A, de Ville de Goyet J, Castellano A, Serra A, Spada M, Inserra A. Caval replacement strategy in pediatric retroperitoneal tumors encasing the vena cava: a single-center experience and review of literature. J Pediatr Surg 2019; 54:557-561. [PMID: 29980348 DOI: 10.1016/j.jpedsurg.2018.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 06/03/2018] [Accepted: 06/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Complete encasement of the inferior vena cava by retroperitoneal tumors is rare. Although replacement of the vena cava has been considered for various conditions in adults, it is rarely used in children except for challenging resections and as a last chance approach - often aiming more at debulking than cure. MATERIALS AND METHODS From January 2009 to February 2017, 4 patients (2 adrenal neuroblastomas, 1 renal cell carcinoma, 1 infantile fibrosarcoma) underwent elective en-bloc resection of tumor and of the infrahepatic portion of the inferior vena cava (IVC), with planned IVC prosthetic replacement. In three cases a portion of the left renal vein had to be resected as well, with the vein reanastomosed onto the prosthesis, and a concomitant auto-transplantation of the right kidney was associated in one neuroblastoma patient. RESULTS All patients had an uncomplicated postoperative course. In one patient, the prosthetic conduit is patent at long-term (43 months), while the middle portion of the prosthesis did eventually thrombose at mid-term after surgery in the three others - with no related symptoms. Interestingly, all renal venous reconstructions remain patent. Three patients (2 neuroblastomas and 1 infantile fibrosarcoma) are alive and disease-free at 43, 74 and 108 months after surgery, respectively. One patient with renal cell carcinoma died of recurrence of the disease 21 months after surgery. CONCLUSION Resection and reconstruction of the vena cava, including the renal vein portion, can be considered and planned electively in case of tumoral encasement. This strategy is associated with good tolerance of the operation, low morbidity and satisfactory long-term function, even in cases with progressive and/or secondary partial thrombosis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Chiara Grimaldi
- Department of Pediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
| | - Arianna Bertocchini
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
| | - Alessandro Crocoli
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy.
| | - Jean de Ville de Goyet
- Department of Pediatrics, ISMETT IRCCS, Via Ernesto Tricomi 5, Palermo 90127, Italy; Pediatric Surgery, Tor Vergata University, Roma, Italy
| | - Aurora Castellano
- Pediatric Oncology and Hematology, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
| | - Analisa Serra
- Pediatric Oncology and Hematology, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
| | - Marco Spada
- Department of Pediatric Surgery and Transplantation, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
| | - Alessandro Inserra
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, IRCCS, Piazza San Onofrio 4, 00165, Rome, Italy
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12
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Imle R, Tosev G, Behnisch W, Schenk JP, Rauch H, Mueller A, Gorenflo M, Loukanov T, Kulozik A, Nyarangi-Dix J. Intracardiac Extension of Wilms Tumor: A Case of a 2.5-Year-Old Girl Presenting with Upper Venous Congestion Caused by Tumor Growth into the Right Cardiac Ventricle. Case Rep Oncol 2019; 12:33-38. [PMID: 30792643 PMCID: PMC6381912 DOI: 10.1159/000496020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 12/04/2018] [Indexed: 12/30/2022] Open
Abstract
While Wilms tumors (WT) typically present solely with an abdominally palpable mass, rare cases exhibiting vascular tumor growth can also present with circulatory problems. Here, we report the case of a 2.5-year-old girl presenting with upper venous congestion and arterial hypertension as the primary symptoms of intraventricular tumor growth exhibiting remarkable tubular and perfused morphology. Clinical situation stabilized after initiation of neoadjuvant chemotherapy (NAC) with actinomycin D and vincristine, followed by surgical resection via laparotomy and sternotomy supported by cardiopulmonary bypass and deep hypothermia. Our results highlight the previously reported feasibility of this approach, even in primarily unstable patients.
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Affiliation(s)
- Roland Imle
- Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Heidelberg, Germany
| | - Georgi Tosev
- Department of Urology, University of Heidelberg, Heidelberg, Germany
| | - Wolfgang Behnisch
- Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Heidelberg, Germany
| | - Jens-Peter Schenk
- Division of Pediatric Radiology, Clinic of Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany
| | - Helmut Rauch
- Department of Anesthesiology, University of Heidelberg, Heidelberg, Germany
| | - Andreas Mueller
- Department of Pediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Matthias Gorenflo
- Department of Pediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Tsvetomir Loukanov
- Department of Cardiac Surgery, Division of Pediatric Cardiac Surgery, Heidelberg, Germany
| | - Andreas Kulozik
- Department of Pediatric Oncology, Hematology and Immunology, University of Heidelberg, Heidelberg, Germany
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13
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Szymanska A, Augustyn C, Stankowski T, Walek E, Kowalski JP, Koltowski P, Cichon R. Wilms' Tumor With Intra-Atrial Extension: Treatment and Management. World J Pediatr Congenit Heart Surg 2016; 7:116-9. [PMID: 26715006 DOI: 10.1177/2150135115583728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Wilms' tumor is the most common renal cancer in children. It can grow for a long time without any characteristic symptoms, causing only fever, abdominal pain, nausea, or vomiting, which is the reason why it is often discovered accidentally. In 1% to 4% of the cases, nephroblastoma leads to complications in the form of intravascular and intra-atrial extension. We present a case of a five-year-old boy with Wilms' tumor extending into the inferior vena cava, right atrium, and then prolapsing through the tricuspid valve into the right ventricle.
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Affiliation(s)
- Anna Szymanska
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland
| | - Cyprian Augustyn
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland
| | - Tomasz Stankowski
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland
| | - Ewa Walek
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland
| | - Jan P Kowalski
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland Cardiac Surgery Department, Medical University of Wroclaw, Wroclaw, Poland
| | - Piotr Koltowski
- Department of Cardiac Surgery, MEDINET Heart Center Ltd, Wroclaw, Poland
| | - Romuald Cichon
- Cardiac Surgery Department, Medical University of Warsaw, Warsaw, Poland
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14
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Abstract
Wilms tumor (WT) is one of the most common solid tumors in children. It is the second most common extracranial solid tumor after neuroblastoma. WT has a strong tendency to invade blood vessels in the form of tumor thrombus, into the renal veins, and inferior vena cava and even into the right atrium. Extension of tumor thrombus along to the renal vein into the inferior vena cava occurs in 4-10% of all patients. Tumor thrombus extending to the right atrium is less reported as 0.7-1%. WT with renal vein thrombus has been reported to be more common in the right kidney because of the shorter right renal vein. Most patients with tumor thrombus are asymptomatic and diagnosis is only made on imaging investigations. Several imaging modalities including computed tomography (CT), magnetic resonance imaging (MRI) and Doppler ultrasonography (USG) can demonstrate intravascular tumor thrombus before surgery. In addition to CT and MRI, Doppler USG is reliable in demonstrating the presence and extent of inferior vena cava tumor thrombus. The management of WT with tumor thrombus is determined by multiple factors such as extent of tumor thrombus, chemotherapy response of the tumor. Now, it is generally recommended to use preoperative chemotherapy to a patient presenting with intravascular tumor thrombus. This approach is helpful to decrease the extent of the vascular thrombus which facilitates surgical excision. Most intracaval and intraatrial thrombi in WT show a response to chemotherapy. Neoadjuvant chemotherapy causes tumor regression in nearly half of the patients. Most of them can be managed without the need for cardiac bypass surgery. The decision of initial surgery or preoperative chemotherapy should be carefully determined on every case. Primary surgery would only be indicated in a patient who is unstable because of thrombus that might dislodge and cause acute symptoms. Presence of tumor thrombus in WT needs for multidisciplinary care including pediatric oncologists, pediatric surgeons, and pediatric cardiac surgeons.
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Affiliation(s)
- Suna Emir
- Department of Pediatric Hematology Oncology, Ankara Children's Hematology Oncology Training and Research Hospital, Altındağ, Ankara, Turkey
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15
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Parelkar SV, Mundada D, Oak SN, Sanghvi BV, Joshi PB, Kapadnis SP, Kulkarni DK. Nonresponsiveness to chemotherapy: a formidable surgical challenge in wilms' tumor with intracardiac extension. Indian J Surg Oncol 2013; 4:362-5. [PMID: 24426758 DOI: 10.1007/s13193-013-0255-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 06/25/2013] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sandesh V Parelkar
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - Dinesh Mundada
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - Sanjay N Oak
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - Beejal V Sanghvi
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - Prashant B Joshi
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - Satish P Kapadnis
- Department of Pediatric Surgery, King Edward Memorial Hospital, E. Borges road, Pin: 400012 Parel, Mumbai India
| | - D K Kulkarni
- Department of CVTS, King Edward Memorial Hospital, Parel, Mumbai India
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16
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Uehara S, Takama Y, Yoshida H, Hashii Y, Oue T, Usui N. Abdominal neuroblastoma with inferior vena cava and right atrial extension. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2013. [DOI: 10.1016/j.epsc.2013.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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17
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Bader MI, Abdelaal K, Rogers T, Arul SG. A surgical approach to Wilms' tumour with retrohepatic vena caval extension. Pediatr Surg Int 2013; 29:229-32. [PMID: 23344152 DOI: 10.1007/s00383-013-3263-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Wilms' tumours (WT) with retrohepatic vascular extension traditionally requires cardiac bypass for complete excision. We share our experience of these complex cases. METHODS A retrospective review was performed of children with WT with retrohepatic vascular extension presenting to two UK children's hospitals. Tumour stage, chemotherapy, level of vascular extension, operative details and complication data were analysed. RESULTS Ten children were identified. Mean age 6.6 years (range 3.3-8.2 years); tumour side 6 right, 2 left, 2 bilateral. Level of tumour extension was to the right atrium in two, diaphragm in two, hepatic vein (HV) level in four and retrohepatic inferior vena cava (IVC) in one patient. Following chemotherapy it reduced to hepatic veins (5) or below (4). Surgery involved radical nephrectomy and complete mobilisation of the liver off the IVC, which was then clamped, opened and the thrombus excised. There were no intraoperative complications. Mean hospital stay was 9.77 days (7-20 days). Histology showed viable tumour thrombus in six patients. One patient died after 1 year from metastatic disease. CONCLUSION Retrohepatic extension of WT can be managed without bypass using pre-operative chemotherapy and by complete liver mobilisation. The tumour was always adherent to IVC and required sharp dissection.
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Affiliation(s)
- Mohammad I Bader
- Department of Surgery, Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, UK.
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18
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Abstract
Clear cell sarcoma of the kidney (CCSK) is an uncommon neoplasm that accounts for almost 3 % of pediatric renal tumors. Cavoatrial tumor thrombosis is very rare and because of poor response to chemotherapy, invasive surgical interventions such as open heart surgery may be indicated. A 6-year-old girl with CCSK of right kidney was treated with neoadjuvant chemotherapy. According to poor chemosensitivity, surgical intervention was planned. Right atriotomy was done, but intra-atrial part of tumor was very firm and unsuctionable; so the procedure was completed by laparotomy and en bloc resection of tumoral kidney and its cavoatrial extension through a limited venotomy on inferior vena cava. Although radical resection of CCSK with intracaval involvement should be considered as a multidisciplinary approach and intensive care and supports should be provided, atriocaval tumor in growth in CCSK is firm, non friable and non-adherent, and tumor en bloc resection may be possible through a limited venotomy via primary abdominal approach.
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19
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Gooskens SLM, Furtwängler R, Vujanic GM, Dome JS, Graf N, van den Heuvel-Eibrink MM. Clear cell sarcoma of the kidney: a review. Eur J Cancer 2012; 48:2219-26. [PMID: 22579455 DOI: 10.1016/j.ejca.2012.04.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Revised: 03/29/2012] [Accepted: 04/16/2012] [Indexed: 02/07/2023]
Abstract
Clear cell sarcoma of the kidney (CCSK) is a rare renal tumour that is observed most often in children under 3years of age. Only a few large series of CCSK have been reported and patients with CCSK are often included among patients with other types of childhood renal tumours. The purpose of this paper is to review the published series and case reports of CCSK and to create an up-to-date overview of clinical and histological features, genetics, treatment, and outcome.
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Affiliation(s)
- S L M Gooskens
- Department of Pediatric Hematology and Oncology, Erasmus MC-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands
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