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Tathireddy H, Rice D, Martens K, Shivakumar S, Shatzel J. Breaking down tumor thrombus: Current strategies for medical management. Thromb Res 2023; 230:144-151. [PMID: 37722206 PMCID: PMC11027429 DOI: 10.1016/j.thromres.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/13/2023] [Accepted: 09/11/2023] [Indexed: 09/20/2023]
Abstract
Tumor thrombus, the intravascular extension of tumor into adjacent blood vessels, is frequently encountered in patients with renal cell carcinoma and hepatocellular carcinoma, and often involves the abdominal vasculature including the renal vein, portal vein, and the inferior vena cava. While a bland thrombus is composed of platelets and fibrin, in contrast, a tumor thrombus refers to an organized collection of tumor cells. Though oftentimes detected incidentally on imaging, tumor thrombus may have significant clinical implications and can be challenging to differentiate from bland thrombus. Additionally, the optimal management of tumor thrombus, including the use of anticoagulation, remains poorly described. This review summarizes common causes of tumor thrombus, as well as its impact on staging, prognosis, and treatment.
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Affiliation(s)
- Harsha Tathireddy
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA.
| | - Douglas Rice
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kylee Martens
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
| | | | - Joseph Shatzel
- Division of Hematology and Medical Oncology, Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA; Department of Biomedical Engineering, Oregon Health & Science University, OR, USA
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Olivero A, Liu K, Checchucci E, Liu L, Ma L, Wang G, Mantica G, Tappero S, Amparore D, Sica M, Fiori C, Huang Q, Niu S, Wang B, Ma X, Hou X, Porpiglia F, Terrone C, Zhang X. Adrenocortical carcinoma with venous tumor invasion: is there a role for mini-invasive surgery? Langenbecks Arch Surg 2023; 408:17. [PMID: 36625975 DOI: 10.1007/s00423-023-02765-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE This study aims to investigate early oncologic outcomes in patients with adrenocortical carcinoma (ACC) with venous invasion (VI) treated using both open and mini-invasive approaches. PATIENTS AND MATERIALS We conducted a retrospective analysis of 4 international referral center databases, including all the patients undergoing adrenalectomy for ACC with VI from January 2007 to March 2020. According to CT scan or MRI, the tumor thrombus was classified into four levels: (1) adrenal vein invasion; (2) renal vein invasion; (3) infra-hepatic Inferior vena cava (IVC); and (4) retro-hepatic IVC. In addition, we divided our patients into patients who had undergone open surgery and mini-invasive surgery. RESULTS We identified 20 patients with a median follow-up of 12 months. The median tumor size was 110mm. ENSAT stage was II in 4 patients, III in 13 patients, and IV in 3 patients. Tumor thrombus extended in the adrenal vein (n=5), renal vein (n=1), infra-hepatic IVC (n=9), or into the retro-hepatic IVC (n=5). Ten patients were treated with a mini-invasive approach. The patient treated with an open approach reported a more aggressive disease. The two groups did not differ in surgical margins, surgical time, blood losses, complications, and length of stay. The prognosis resulted worse in the patient undergoing open. Kaplan-Meier analysis indicated a difference in OS for the patients stratified by ENSAT stage (Log-rank p=0.011); we also reported a difference in DFS for patients stratified for thrombus extension (p=0.004) and ENSAT stage (p<0.001). CONCLUSION The DFS of patients with VI from ACC is influenced by the staging and the extension of the venous invasion; the staging influences the OS. The mini-invasive approach seems feasible in selected patients; however, further studies investigating the oncological outcomes are needed. A mini-invasive approach for adrenal tumors with venous invasion is an explorable option in very selected patients.
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Affiliation(s)
- Alberto Olivero
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
- Department of Urology, Policlinico San Martino Hospital, University of Genoa, Genoa, Italy.
| | - Kan Liu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Enrico Checchucci
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Lei Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Guoliang Wang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Guglielmo Mantica
- Department of Urology, Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Stefano Tappero
- Department of Urology, Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Daniele Amparore
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Michele Sica
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Cristian Fiori
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Quingbo Huang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Shaoxi Niu
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Baojun Wang
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
| | - Xin Ma
- Department of Urology, Chinese PLA General Hospital, Beijing, China
| | - Xiaofei Hou
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Francesco Porpiglia
- Division of Urology, Department of Oncology, School of Medicine, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy
| | - Carlo Terrone
- Department of Urology, Policlinico San Martino Hospital, University of Genoa, Genoa, Italy
| | - Xu Zhang
- Department of Urology, Chinese PLA General Hospital, Beijing, China
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Nabeshima Y, Yamashita S, Deguchi R, Iwamoto R, Warigaya K, Koike H, Kikkawa K, Kohjimoto Y, Murata S, Hara I. Adrenocortical carcinoma with inferior vena cava tumor thrombus found during surgery. IJU Case Rep 2022; 5:362-365. [PMID: 36090946 PMCID: PMC9436663 DOI: 10.1002/iju5.12489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/15/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction The safety and efficacy of minimally invasive approaches for adrenocortical carcinoma with inferior vena cava tumor thrombus have not yet been established. We report a case of large adrenocortical carcinoma with inferior vena cava tumor thrombus found perioperatively which required conversion from a laparoscopic to an open procedure. Case presentation A 71‐year‐old woman with right‐side 10‐cm diameter adrenocortical carcinoma was scheduled for laparoscopic adrenalectomy. The operation was converted to open surgery, however, because inferior vena cava tumor thrombus, which was not detected by preoperative imaging modalities, was found during surgery. Conclusion In patients with large adrenocortical carcinoma, the possible presence of inferior vena cava thrombus should be considered when selecting surgical procedures.
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Affiliation(s)
- Yuta Nabeshima
- Department of Urology Wakayama Medical University Wakayama Japan
| | | | - Ryusuke Deguchi
- Department of Urology Wakayama Medical University Wakayama Japan
| | - Ryuta Iwamoto
- Department of Diagnostic Pathology Wakayama Medical University Wakayama Japan
| | - Kenji Warigaya
- Department of Diagnostic Pathology Wakayama Medical University Wakayama Japan
| | - Hiroyuki Koike
- Department of Urology Wakayama Medical University Wakayama Japan
| | - Kazuro Kikkawa
- Department of Urology Wakayama Medical University Wakayama Japan
| | - Yasuo Kohjimoto
- Department of Urology Wakayama Medical University Wakayama Japan
| | - Shinichi Murata
- Department of Diagnostic Pathology Wakayama Medical University Wakayama Japan
| | - Isao Hara
- Department of Urology Wakayama Medical University Wakayama Japan
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Liu Z, Ge L, Liu L, Zhao X, Chen K, Li Y, Aili A, Lu M, Pei X, Han D, Zhang S, Ma L. Clinical Experience and Management Strategy of Retroperitoneal Tumor With Venous Tumor Thrombus Involvement. Front Oncol 2022; 12:873729. [PMID: 35619905 PMCID: PMC9128060 DOI: 10.3389/fonc.2022.873729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background This study aims to report the surgical management, complications, and outcomes for patients with retroperitoneal tumor and venous thrombus. Methods We retrospectively analyzed 19 cases of retroperitoneal tumor with venous tumor thrombus from August 2015 to March 2021. A new tumor thrombus PUTH-RT grading system was proposed on the basis of the characteristics of the surgical techniques. Results Two cases of PUTH-RT-1a, two cases of PUTH-RT-1b, six cases of PUTH-RT-2, six cases of PUTH-RT-3, and three cases of PUTH-RT-4 were included. Surgeries were successfully performed in all 19 patients. Among them, five cases (26.3%) were operated via a completely laparoscopic approach and 13 cases (68.4%) via an open approach. One case (5.3%) was converted from laparoscopic to open approach. Five cases (26.3%) experienced postoperative complications. All patients were followed for a median of 14 months. Cancer-associated death occurred in three cases. Distant metastases occurred in seven cases. Conclusions We propose a new tumor thrombus grading system based on the anatomical characteristics of retroperitoneal tumors with venous tumor thrombus. Retroperitoneal tumor resection and removal of venous tumor thrombi are safe and effective for the treatment of such diseases.
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Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lei Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Kewei Chen
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Abudureyimujiang Aili
- Department of Radiation Oncology, Peking University Third Hospital, Haidian District, Beijing, China
| | - Min Lu
- Department of Pathology, School of Basic Medical Sciences, Peking University Third Hospital, Peking University Health Science Center, Beijing, China
| | - Xinlong Pei
- Department of Radiology, Peking University Third Hospital, Beijing, China
| | - Dengyang Han
- Department of Anesthesiology, Peking University Third Hospital, Haidian District, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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Wang JL, Xu CY, Geng CJ, Liu L, Zhang MZ, Wang H, Xiao RT, Liu L, Zhang G, Ni C, Guo XY. Anesthesia and perioperative management for giant adrenal Ewing’s sarcoma with inferior vena cava and right atrium tumor thrombus: A case report. World J Clin Cases 2022; 10:643-655. [PMID: 35097090 PMCID: PMC8771399 DOI: 10.12998/wjcc.v10.i2.643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/01/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ewing’s sarcoma of the adrenal gland with inferior vena cava (IVC) and right atrium thrombus is extremely rare. Here, we report a case of giant adrenal Ewing’s sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.
CASE SUMMARY A young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months. Enhanced abdominal computed tomography revealed a large retroperitoneal mass (22 cm in diameter), which may have originated from the right adrenal gland and was closely related to the liver. Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle. After preoperative preparation with cardiopulmonary bypass, sufficient blood products, transesophageal echocardiography and multiple monitoring, tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team. Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously. During transfer of the patient to the intensive care unit (ICU), cardiac arrest occurred without external stimulus. Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min. In the ICU, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were provided to maintain cardiac, liver and kidney function. Histopathologic examination confirmed the diagnosis of Ewing’s sarcoma. After postoperative treatments and rehabilitation, the patient was discharged from the urology ward.
CONCLUSION An adrenal Ewing’s sarcoma with IVC and right atrium thrombus is extremely rare, and its anesthesia and perioperative management have not been reported. Thus, this report provides significant insights in the perioperative management of patients with adrenal Ewing’s sarcoma and IVC tumor thrombus. Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery. In addition, postoperative treatments including ECMO and CRRT provide essential support in critically ill patients. Moreover, this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.
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Affiliation(s)
- Ji-Lian Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Chuan-Ya Xu
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Chun-Jing Geng
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Lei Liu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Ming-Zhu Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hua Wang
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Ruo-Tao Xiao
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Lu Liu
- Intensive Care Unit, Peking University Third Hospital, Beijing 100191, China
| | - Geng Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Cheng Ni
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiang-Yang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
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Surgical Management of Adrenocortical Carcinoma: Current Highlights. Biomedicines 2021; 9:biomedicines9080909. [PMID: 34440112 PMCID: PMC8389566 DOI: 10.3390/biomedicines9080909] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Adrenocortical carcinoma (ACC) is a rare tumor, often discovered at an advanced stage and associated with poor prognosis. Treatment is guided by staging according to the European Network for the Study of Adrenal Tumors (ENSAT) classification. Surgery is the treatment of choice for ACC. The aim of this review is to provide a complete overview on surgical approaches and management of adrenocortical carcinoma. METHODS This comprehensive review has been carried out according to the PRISMA statement. The literature sources were the databases PubMed, Scopus and Cochrane Library. The search thread was: ((surgery) OR (adrenalectomy)) AND (adrenocortical carcinoma). RESULTS Among all studies identified, 17 were selected for the review. All of them were retrospective. A total of 2498 patients were included in the studies, of whom 734 were treated by mini-invasive approaches and 1764 patients were treated by open surgery. CONCLUSIONS Surgery is the treatment of choice for ACC. Open adrenalectomy (OA) is defined as the gold standard. In recent years laparoscopic adrenalectomy (LA) has gained more popularity. No significant differences were reported for overall recurrence rate, time to recurrence, and cancer-specific mortality between LA and OA, in particular for Stage I-II. Robotic adrenalectomy (RA) has several advantages compared to LA, but there is still a lack of specific documentation on RA use in ACC.
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Shariq OA, McKenzie TJ. Adrenocortical carcinoma: current state of the art, ongoing controversies, and future directions in diagnosis and treatment. Ther Adv Chronic Dis 2021; 12:20406223211033103. [PMID: 34349894 PMCID: PMC8295938 DOI: 10.1177/20406223211033103] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.
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Affiliation(s)
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
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Adrenal tumors of different types with or without tumor thrombus invading the inferior vena cava: An evaluation of 33 cases. Surg Oncol 2021; 37:101544. [PMID: 33773281 DOI: 10.1016/j.suronc.2021.101544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/28/2021] [Accepted: 03/09/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Adrenal tumors with/out tumor thrombus (TT) in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential of massive hemorrhage and tumor thromboembolism. We report our experience in managing different types of adrenal tumors. METHODS From 11/1996-5/2015, 33 patients underwent resection of adrenal tumors with/without TT/IVC in 8 and 25 patients, respectively. Transplant-based (TB) techniques were utilized to resect the tumors. Intra-operative as estimated blood loss (EBL) and cardiopulmonary bypass (CPB) use; post-operative as length of hospital stay (LOS); and actuarial survival outcomes were recorded. RESULTS Median EBL was 200 cc (10-8,000), tumor size was 9.0 cm (4-25), and LOS was 7days (5-60). Adrenocortical carcinoma (ACC,11/33) was the commonest type. Three ACC/level IV TT/IVC underwent CPB to extract TT from the right atrium(n = 1), right atrium and right ventricle(n = 1), and right atrium and right pulmonary artery(n = 1), respectively. A complete resection of the adrenal tumors was achieved in all patients, and no deaths were observed in the immediate postoperative period. With a median follow-up of 60 (range: 18-120) months, 4/11 ACC patients have died of their disease. Actuarial survival for ACC patients at 60 months was 57.1 ± 16.4%. CONCLUSIONS An aggressive surgical approach is the only hope for curing large adrenal tumors with/without TT/IVC. TB techniques provide excellent exposure to the retroperitoneal space and safe removal of large adrenal masses.
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Hartl DM, Zafereo ME, Kowalski LP, Randolph GW, Olsen KD, Fernandez-Alvarez V, Nixon IJ, Shaha AR, Angelos P, Shah JP, Ferlito A. Occlusion of the internal jugular vein in differentiated thyroid carcinoma: Causes and diagnosis. Eur J Surg Oncol 2021; 47:1552-1557. [PMID: 33642089 DOI: 10.1016/j.ejso.2021.02.021] [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: 11/23/2020] [Revised: 02/02/2021] [Accepted: 02/17/2021] [Indexed: 01/27/2023] Open
Abstract
Occlusion of the internal jugular vein (IJV) can be observed in thyroid cancer either on preoperative imaging with ultrasound or cross-sectional imaging, particularly contrast-enhanced CT-scan, and can be detected during follow-up when using these same imaging modalities. For thyroid cancer, four different causes of occlusion of the IJV can be identified: venous thrombosis associated with a hypercoagulable state, tumor thrombus in the vein, compression or invasion of the IJV by thyroid disease or lymph node metastases, and fibrotic collapse of the IJV following lateral neck dissection. Clinicians managing patients with thyroid cancer need to be aware of and able to diagnose each of these conditions. The overall patient impact and appropriate management of each will be discussed.
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Affiliation(s)
- Dana M Hartl
- Department of Surgery, Gustave Roussy, Villejuif, France.
| | - Mark E Zafereo
- Head and Neck Endocrine Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Kerry D Olsen
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
| | | | - Iain J Nixon
- Department of Otorhinolaryngology Head and Neck Surgery, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Ashok R Shaha
- Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Peter Angelos
- Department of Surgery and Surgical Ethics, University of Chicago Medicine, Chicago, IL, USA
| | - Jatin P Shah
- Head and Neck Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Alfio Ferlito
- International Head and Neck Scientific Group, Padua, Italy
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LeGout JD, Bailey RE, Bolan CW, Bowman AW, Chen F, Cernigliaro JG, Alexander LF. Multimodality Imaging of Abdominopelvic Tumors with Venous Invasion. Radiographics 2020; 40:2098-2116. [PMID: 33064623 DOI: 10.1148/rg.2020200047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A broad range of abdominal and pelvic tumors can manifest with or develop intraluminal venous invasion. Imaging features at cross-sectional modalities and contrast-enhanced US that allow differentiation of tumor extension within veins from bland thrombus include the expansile nature of tumor thrombus and attenuation and enhancement similar to those of the primary tumor. Venous invasion is a distinctive feature of hepatocellular carcinoma and renal cell carcinoma with known prognostic and treatment implications; however, this finding remains an underrecognized characteristic of multiple other malignancies-including cholangiocarcinoma, adrenocortical carcinoma, pancreatic neuroendocrine tumor, and primary venous leiomyosarcoma-and can be a feature of benign tumors such as renal angiomyolipoma and uterine leiomyomatosis. Recognition of tumor venous invasion at imaging has clinical significance and management implications for a range of abdominal and pelvic tumors. For example, portal vein invasion is a strong negative prognostic indicator in patients with hepatocellular carcinoma. In patients with rectal cancer, diagnosis of extramural venous invasion helps predict local and distant recurrence and is associated with worse survival. The authors present venous invasion by vascular distribution and organ of primary tumor origin with review of typical imaging features. Common pitfalls and mimics of neoplastic thrombus, including artifacts and anatomic variants, are described to help differentiate these findings from tumor in vein. By accurately diagnosing tumor venous invasion, especially in tumors where its presence may not be a typical feature, radiologists can help referring clinicians develop the best treatment strategies for their patients. ©RSNA, 2020.
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Affiliation(s)
- Jordan D LeGout
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Ryan E Bailey
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Candice W Bolan
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Andrew W Bowman
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Frank Chen
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Joseph G Cernigliaro
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
| | - Lauren F Alexander
- From the Department of Radiology, Mayo Clinic Florida, 4500 San Pablo Rd, Jacksonville, FL 32224
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Sada A, Glasgow AE, Lyden ML, Thompson GB, Dy BM, McKenzie TJ, Habermann EB. Positive Lymph Nodes in Adrenocortical Carcinoma: What Does It Mean? World J Surg 2020; 45:188-194. [PMID: 33034710 DOI: 10.1007/s00268-020-05801-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The role of lymphadenectomy in adrenocortical carcinoma resection is controversial. Therefore, we conducted a population-based study to assess the association between positive lymph nodes (LN) and survival. METHODS The Surveillance, Epidemiology, and End Results set of cancer registries were utilized. The associations between positive lymph nodes and tumor size, grade and laterality were assessed. Cancer specific survival (CSS) trends and factors affecting survival were analyzed. RESULTS A total of 2170 adult patients were identified; 60% underwent resection. Among those resected, LN were examined in 23% and were positive in 25% of patients with LN examined. Patients with positive LN tended to have smaller tumors compared to those with negative LN (12 ± 5 vs 15 ± 11 cm, p = 0.02). The rate of positive LN was higher in right ACC, p = 0.03. Median overall CSS was 21 months, with significant differences between resection (42 months) and no resection (4 months), p < 0.01. Median CSS did not change over time when comparing ACC patients who underwent surgery before 2000, 2000-2009, and 2010-2016. On multivariable analysis including resection group, advanced age, grades III and IV, regional and distant stage, in addition to positive LN were associated with worse survival, p < 0.05. CONCLUSION Lymphadenectomy is infrequently performed during ACC resection, and when performed, regional LN involvement tends to be associated with worse survival. Neoplasm size and grade were not associated with LN involvement and therefore, do not inform lymphadenectomy need. Further studies are needed to assess the indications for, and value of lymphadenectomy in ACC.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy E Glasgow
- Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Elizabeth B Habermann
- Department of Surgery, Mayo Clinic, Rochester, MN, USA. .,Surgical Outcomes Program, Robert D and Patricia E Kern Center for The Science of Health Care Delivery, Mayo Clinic, Rochester, MN, USA.
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Imaging and implications of tumor thrombus in abdominal malignancies: reviewing the basics. Abdom Radiol (NY) 2020; 45:1057-1068. [PMID: 31696267 DOI: 10.1007/s00261-019-02282-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Extension of tumor tissue within a vein is a recognized prognostic factor in abdominal malignancy because of its influence on tumor staging and selection of therapeutic management. With the advent of newer surgical techniques, and variable treatment strategies, imaging plays a crucial role in categorizing patients according to the tumor resectability and vascular reconstruction techniques during surgery. Understanding the clinical impact of tumor thrombus increases the awareness of the radiologist about the key findings in tumor staging and decision-making of surgical approach. Ultrasound (US), computed tomography (CT), and magnetic resonance imaging (MRI) can be used individually and in combination to accurately assess the tumor thrombus. In our pictorial review, we will discuss the imaging findings and clinical consequences of tumor thrombosis in abdominal malignancies, including hepatocellular carcinoma, pancreatic neuroendocrine tumor, renal cancer, and adrenal cortical carcinoma.
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13
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Abstract
Adrenocortical carcinomas (ACC) are rare and aggressive neoplasms. Due to their high rate of local recurrence and distant metastases (up to 85%) they are associated with a poor survival. The 5‑year survival in ACC patients with lymph node metastasis or local infiltration is 50% and with distant metastasis less than 15%. An R0 resection with locoregional and para-aortic/paracaval lymphadenectomy is the only curative option and reasonable treatment possibility. The treatment of these patients should therefore be planned and carried out in centers. Local recurrences and distant metastases should also be treated with R0 resection when feasible, combined with neoadjuvant/adjuvant chemotherapy and/or radiation. In the case of an asymptomatic non-resectable ACC, debulking operations cannot be recommended. The primary operation can also be done in a minimally invasive procedure if principles of oncological surgery are followed (radical resection, no damage of the tumor capsule, lymphadenectomy), since survival after open and minimally invasive laparoscopic resection was comparable. Palliative resections are only indicated in symptomatic patients.
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Affiliation(s)
- S Schimmack
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - O Strobel
- Klinik für Allgemein‑, Viszeral und Transplantationschirurgie, Universität Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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14
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Shapero KS, Jelani QUA, Mena C. Endovascular Treatment of Inferior Vena Cava Thrombosis in Metastatic Malignancy: A Case Report and Review of Literature. Vasc Endovascular Surg 2019; 53:507-511. [DOI: 10.1177/1538574419857992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Inferior vena cava (IVC) thrombosis is a specific form of thromboembolism that occurs at a rate of 1.5% in all patients hospitalized with a deep vein thrombosis. Malignant IVC thrombosis may occur due to compression from a tumor mass or metastasis or may also occur through tumor invasion of the venous vasculature. Obstruction of the IVC can lead to IVC syndrome, marked by ascites, lower extremity edema, and even congestive hepatic failure. We present a case of extensive IVC thrombosis in a 69-year-old female with metastatic adrenal cell carcinoma, presenting with severe bilateral lower extremity edema and ascites. Computed tomography showed IVC compression by the caudate lobe due to a metastatic liver mass and extensive clot burden of the IVC extending from the renal veins to the right atrium (RA). She underwent percutaneous IVC stenting with 4 stents placed in tandem from the IVC to the RA. Her hospital course was complicated by gastrointestinal bleed requiring clipping, acute liver failure, and hypophysitis due to trial therapy. Although her IVC symptoms were partially relieved with percutaneous intervention, her acute liver failure worsened and she was ultimately transitioned to hospice care.
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Affiliation(s)
- Kayle S. Shapero
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Qurat-Ul-Ain Jelani
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Carlos Mena
- Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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15
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Dickson PV, Kim L, Yen TWF, Yang A, Grubbs EG, Patel D, Solórzano CC. Evaluation, Staging, and Surgical Management for Adrenocortical Carcinoma: An Update from the SSO Endocrine and Head and Neck Disease Site Working Group. Ann Surg Oncol 2018; 25:3460-3468. [DOI: 10.1245/s10434-018-6749-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Indexed: 08/30/2023]
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16
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Marincola Smith P, Kiernan CM, Tran TB, Postlewait LM, Maithel SK, Prescott J, Pawlik T, Wang TS, Glenn J, Hatzaras I, Shenoy R, Phay J, Shirley LA, Fields RC, Jin L, Weber S, Salem A, Sicklick J, Gad S, Yopp A, Mansour J, Duh QY, Seiser N, Votanopoulos K, Levine EA, Poultsides G, Solórzano CC. Role of Additional Organ Resection in Adrenocortical Carcinoma: Analysis of 167 Patients from the U.S. Adrenocortical Carcinoma Database. Ann Surg Oncol 2018; 25:2308-2315. [PMID: 29868977 DOI: 10.1245/s10434-018-6546-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Adrenocortical carcinoma (ACC) is a rare and aggressive cancer. This report describes factors and outcomes associated with resection of extra-adrenal organs en bloc during index adrenalectomy. METHODS Patients who underwent ACC resection for non-metastatic disease from 1993 to 2014 at 13 participating institutions of the US-ACC Group were included in the study. Factors associated with en bloc resection were assessed by uni- and multivariate analysis. The primary end point was overall survival. RESULTS In this study, 167 patients were included and categorized as adrenalectomy with en bloc resection (AdEBR) if they had extra-adrenal organs removed or adrenalectomy (Ad) if they did not. The demographics were similar between the AdEBR (n = 68, 40.7%) and Ad groups, including age, gender, race, American Society of Anesthesiology (ASA) class, and body mass index (BMI). The AdEBR group had larger tumors (13 vs. 10 cm), more open operations (97.1 vs. 63.6%), and more lymph node dissections (LNDs) (36.8 vs. 12.1%). The most common organs removed were kidney (55.9%), liver (27.9%), and spleen (23.5%). Multiple organs were removed in 38.2% (n = 26) of the patients. Margin-negative resections were similar between the two groups. In the multivariate Cox regression adjusted for T and N stages, LND, margin, size, and hormone hypersecretion, en bloc resection was not associated with improved survival (hazard ratio [HR], 1.42; p = 0.323). CONCLUSION The study findings validated current practice by showing that en bloc resection should occur at index adrenalectomy for ACC when a T4 lesion is suspected pre- or intraoperatively, or when it is necessary to avoid tumor rupture. However, in this study, when a negative margin resection was otherwise achieved, removal of extra-adrenal organs en bloc was not associated with additional survival benefit.
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Affiliation(s)
- Paula Marincola Smith
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Colleen M Kiernan
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA
| | - Thuy B Tran
- Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren M Postlewait
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA
| | - Jason Prescott
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy Pawlik
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tracy S Wang
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jason Glenn
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Rivka Shenoy
- New York University School of Medicine, New York, NY, USA
| | - John Phay
- Department of Surgery, The Ohio State University, Columbus, OH, USA
| | | | - Ryan C Fields
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Linda Jin
- Barnes-Jewish Hospital and the Alvin J. Siteman Comprehensive Cancer Center, Washington University School of Medicine, St Louis, MO, USA
| | - Sharon Weber
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ahmed Salem
- Department of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jason Sicklick
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Shady Gad
- Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Adam Yopp
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - John Mansour
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Natalie Seiser
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Edward A Levine
- Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Carmen C Solórzano
- Division of Surgical Oncology, Department of Surgery, Vanderbilt University Medical Center, 597 Preston Research Building 2220 Pierce Ave, Nashville, TN, 37232, USA.
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17
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Sharma RM, Sinha S, Kishan HB, De Padua M. Delayed presentation of a virilising, pure testosterone-secreting adrenocortical carcinoma with coexistent composite myelolipoma and a venous thrombus extending to the heart. BMJ Case Rep 2018; 2018:bcr-2017-223117. [PMID: 29367375 DOI: 10.1136/bcr-2017-223117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 40-year-old normotensive woman presented with abnormal facial hair for 4 years and amenorrhoea for 13 years. Hormonal, biochemical and haematological evaluation showed isolated elevation of serum testosterone and free testosterone. Her follicle-stimulating hormone and luteinising hormone were in the premenopausal range. Until recently she had reconciled to early 'menopause' and visited beauty clinics but never sought medical evaluation. Imaging revealed an enhancing left adrenal mass with fat densities and venous thrombus extending through the inferior vena cava to a 7 cm mass in the right atrium. She underwent left kidney-preserving surgery utilising hypothermic cardiopulmonary bypass with early clamping of the pulmonary artery without circulatory arrest. Histology showed adrenocortical carcinoma with composite incidental myelolipoma and neoplastic thrombus. At 2 months, testosterone has normalised and she is doing well. Isolated testosterone-secreting adrenocortical carcinoma with massive venous thrombus is rare as is coincidental composite macroscopic myelolipoma.
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Affiliation(s)
- Rakesh M Sharma
- Department of Urological Oncology, Basavatarakam Indo-American Cancer Institute and Research Centre, Hyderabad, Telangana, India
| | - Sanjay Sinha
- Department of Urology, Apollo Hospitals, Hyderabad, Telangana, India
| | - Hari B Kishan
- Department of Medicine, Apollo Hospitals, Hyderabad, Telangana, India
| | - Michelle De Padua
- Department of Pathology, Apollo Hospitals, Hyderabad, Andhra Pradesh, India
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18
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Jiang M, Ding H, Li C, Xiang K, Tang J, Guo Y, Zhang S. Surgical resection of adrenocortical carcinoma with invasion into the inferior vena cava: a case report and literature review. Clin Case Rep 2017; 5:1934-1937. [PMID: 29225829 PMCID: PMC5715596 DOI: 10.1002/ccr3.1205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 08/15/2017] [Accepted: 08/26/2017] [Indexed: 01/25/2023] Open
Abstract
Adrenocortical carcinoma (ACC) is a malignant endocrine tumor. Moreover, ACC with invasion into the inferior vena cava is rare. Early diagnosis and treatment are crucial for such cases. Radical surgical resection is the key therapeutic option in ACC.
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Affiliation(s)
- Minchun Jiang
- Department of Endocrinology and Metabolism Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
| | - Huanyu Ding
- Vascular center Guangdong Cardiovascular Institute Guangdong General Hospital Guangdong Academy of Medical Sciences Guangzhou China
| | - Cheng Li
- Department of Radiology Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
| | - Kexu Xiang
- Department of Endocrinology and Metabolism Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
| | - Juying Tang
- Department of Endocrinology and Metabolism Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
| | - Ying Guo
- Department of Endocrinology and Metabolism Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
| | - Shaoling Zhang
- Department of Endocrinology and Metabolism Sun Yat-sen Memorial Hospital Sun Yat-sen University Guangzhou China
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19
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Yunoki K, Wada T, Miyawaki I, Yamazaki K, Mima H. Anesthetic management of one-stage scheduled surgery for adrenal cortical carcinoma complicated by massive pulmonary tumor embolism. JA Clin Rep 2017; 3:48. [PMID: 29457092 PMCID: PMC5804644 DOI: 10.1186/s40981-017-0115-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/16/2017] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kazuma Yunoki
- 1The Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe city, Hyogo 6500047 Japan
| | - Tsutomu Wada
- The Department of Anesthesiology, Rinku General Medical Center, Rinku Ourai Kita 2-23, Izumisano city, Osaka, 5988577 Japan
| | - Ikuko Miyawaki
- 1The Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe city, Hyogo 6500047 Japan
| | - Kazuo Yamazaki
- 1The Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe city, Hyogo 6500047 Japan
| | - Hiroyuki Mima
- 1The Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe city, Hyogo 6500047 Japan
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