Management of primary nonrenal parenchymal malignancies with vena caval thrombus

Primary renal leiomyosarcoma with a tumor thrombus in the inferior vena cava

INTRODUCTION

We report a rare case of primary renal leiomyosarcoma with a tumor thrombus in the inferior vena cava.

CASE PRESENTATION

A 54-year-old woman presented with right flank pain and abdominal distension. Physical examination findings were unremarkable. Abdominal computed tomography revealed a heterogeneously enhancing right solid renal mass with a thrombus in the renal vein extending into the inferior vena cava. Magnetic resonance imaging demonstrated a renal tumor with a thrombus about 4 cm below the hepatic vein. Chest computed tomography and bone scintigraphy were negative. The patient underwent right radical nephrectomy and vena cava thrombectomy. Histophathologic evaluation of the resected tumor confirmed the diagnosis of leiomyosarcoma. She underwent no adjuvant therapy. Seven months after surgery, the patient died following a 2-month history of multiple pulmonary and hepatic metastases.

CONCLUSION

This report highlights the importance of considering the possibility of renal leiomyosarcoma invasion to the inferior vena cava, similar to renal cell carcinoma.

Urothelial carcinoma of the renal pelvis with renal vein and inferior vena cava tumor thrombus: case series and literature review

Background

Urothelial carcinoma (UC) of the renal pelvis with renal vein and inferior vena cava (IVC) tumor thrombus (TT) was extremely rare. We aimed to explore the clinical and pathological characteristics, diagnosis and treatment of renal pelvis UC with renal vein and IVC TT.

Methods

From March 2016 to January 2019, eight patients of renal pelvis UC with renal vein and IVC TT were diagnosed and underwent operation in our hospital. Clinical features, operative details, pathological outcomes, and prognosis data were reviewed and collected.

Results

There were five males and three females (52-84 years old). Their main symptoms were flank pain and hematuria. According to the Mayo classification, the TT was 4 level-0 (1 left and 3 right), 2 level-I (right), and 2 level-II (right). Half the patients underwent retroperitoneal laparoscopic radical nephroureterectomy with thrombectomy, and the other underwent open procedures. The mean operative time was 298.9 minutes. Pathological outcomes revealed high-grade UC, with positive lymph nodes in 6 cases. Four patients received adjuvant chemotherapy, one target therapy and one adjuvant chemotherapy combined with immunotherapy after surgery. The mean follow-up time was 11.1 months. Three patients are alive, and two of them developed recurrence and lung metastasis.

Conclusions

Preoperative differentiation between renal pelvis UC and renal cell carcinoma with venous TT was very important for the management. Radical nephroureterectomy with thrombectomy might be a reasonable method for renal pelvis UC with venous TT. The prognosis of such cases was poor even if adjuvant therapy was scheduled.

Transitional cell carcinoma with extension of the renal vein and IVC tumor thrombus: report of three cases and literature review

Background

Transitional cell carcinoma (TCC) originating from the renal pelvis with a venous tumor thrombus is a rare entity. However, clinicians should be aware of it because of its high malignancy and poor prognosis.

Case presentation

Here, we report three cases of pathologically confirmed TCC originating from the renal pelvis with extension into the renal vein or inferior vena cava (IVC). Of these patients, two are males and one is female (58~73 years old). Their main symptom is flank pain; besides, gross hematuria and weight loss is observed in one of the patients. Computed tomography (CT) scan of the first patient revealed multiple space-occupying lesions in the left renal pelvis and left medium and lower ureter with a tumor thrombus in the left renal vein. CT scan of the second patient revealed a right renal mass and extension into the IVC. Abdominal magnetic resonance imaging (MRI) of the third patient showed a soft tissue mass in the region of the left renal sinus, and the signal of the soft tissue was observed in the left renal vein. The preoperative diagnoses of the first and third patient were TCC, while the second patient was renal cell carcinoma (RCC). Two patients with the preoperative diagnosis of TCC underwent laparoscopic radical nephroureterectomy with thrombectomy, and the other patient underwent radical nephrectomy with thrombectomy. The surgeries were successful. Although two of our patients underwent chemotherapy and radiotherapy, they died 2 and 19 months after the surgery, respectively. The other patient refused any adjuvant therapy and died 3 months after the operation.

Conclusions

Compared to the extension of RCC to the renal vein or IVC, extension of TCC to the renal vein or IVC is rare. TCC with a venous tumor thrombus is often misdiagnosed as RCC. However, a correct preoperative or intraoperative diagnosis is of great importance to decide surgical strategy. Laparoscopic radical nephroureterectomy with thrombectomy may be a safe and feasible operative method in treatment of TCC with a renal vein thrombus. The prognosis of such cases is poor even if chemotherapy and radiotherapy are scheduled.

Update on the optimal management of patients with vascular extension of pheochromocytoma

AIM

Vascular extension of pheochromocytoma is extremely rare but highly resectable. The aim of this study was to review the available information in the literature for patients with this condition.

METHODS

A systematic literature search produced individual data for 29 treated patients with vascular extension of pheochromocytoma mainly to the inferior vena cava.

RESULTS

Out of 29 reported cases, 26 have been treated surgically. Nine of these patients required cardiopulmonary bypass. Two patients died untreated and one patient declined surgical treatment and discharged to follow-up. In 24 patients including nine with primarily missed diagnosis, surgery was documented as curative.

CONCLUSION

Surgeons need to be aware of this extremely rare characteristic feature of pheochromocytoma and indicated medical work-up in order to properly diagnose and manage this challenging group of patients.

Adrenocortical carcinoma extending into the inferior vena cava in a patient with right kidney agenesis: Surgical approach and review of literature

INTRODUCTION

Adrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery.

PRESENTATION OF CASE

We describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB).

DISCUSSION

We discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed.

CONCLUSION

Intracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory.

Adrenocortical carcinoma extending into the inferior vena cava: Presentation of a 15-patient series and review of the literature

BACKGROUND

Involvement of the inferior vena cava (IVC) is a controversial risk factor for surgical treatment of adrenocortical carcinoma (ACC). This study aims to assess the outcome of an aggressive surgical policy for ACC extending into the IVC and discuss treatment strategies based on a review of the literature.

METHODS

Over a 25-year period, 15 patients were treated for ACC extending into the IVC. The upper limit of the extension was the infrahepatic IVC in 2 patients, retrohepatic IVC in 6, and suprahepatic IVC in 7, including 4 with extension into the right atrium. Seven patients presented with concurrent metastases. The operative technique was thrombectomy (n = 13), partial resection with direct closure (n = 1), and total resection with replacement of the IVC (n = 1). Venous control was achieved by caval clamping alone (n = 4), hepatic vascular exclusion (n = 5), and the use of normothermic cardiopulmonary bypass or hypothermic circulatory arrest (n = 6).

RESULTS

Two patients died postoperatively. Ten patients died of metastatic complications at 4 to 31 months. Median survival time was 8 months. Three patients were still alive after 24, 25, and 45 months of follow-up, one of whom was reoperated at 17 months for a local recurrence. No evidence of recurrent intravenous involvement was found during follow-up in any patient in whom complete resection was achieved.

CONCLUSIONS

Our findings suggest that surgical treatment can be effective for management of ACC with extension into the IVC. Long-term prognosis is poor owing to delay in diagnosis, frequent associated metastatic disease and lack of effective adjuvant treatment.

Computed Tomography and Magnetic Resonance Imaging of Inferior Vena Caval Thrombus Associated with Metastasis to the Kidney

The computed tomography and magnetic resonance imaging findings in 2 cases of inferior vena caval thrombus associated with metastases to the kidney are presented. In both cases, the radiologic findings were suggestive of renal cell carcinoma. Recognition that metastases to the kidney can be associated with inferior vena caval thrombus broadens the differential diagnosis in a patient with a renal mass, an inferior vena caval filling defect, and a known primary malignancy, potentially altering the diagnostic approach.

Use of veno-venous bypass for resection of malignant pheochromocytoma with vena caval thrombus

Surgical management of malignant pheochromocytoma with tumor-induced venous obstruction involving the entrance to the right atrium is challenging. The risk of marked hypotension and hemodynamic instability following clamping of the vena cava is increased as a consequence of the sudden decrease in circulating catecholamines. The use of cardiac bypass, however is burdened with additional operating time and coagulopathy. The present report illustrates that veno-venous bypass is a valuable tool during resection of phenochromocytoma with a large vena caval tumor thrombus.

Adrenal tumor with caval extension--case report and review of the literature

Extension of adrenal cortical carcinomas into the IVC is rare. We describe one such tumor that extended to the level of the right atrium. In an effort to aid recognition and guide work-up of an upper pole lesion, we review the literature comprised of 77 similar cases and analyze the data in terms of patient demographics, anatomic distribution, clinical and laboratory evidence of endocrine function. Our review suggests that over half of all adrenal lesions with IVC extension will be clinically nonfunctional, including up to 17% of pheochromocytomas.

Transitional cell carcinoma of the renal pelvis forming tumor thrombus in the vena cava

A 47-year-old man presented with a left renal incidentaloma without hematuria. The tumor was complicated by inferior vena cava (IVC) thrombus extending from Th11 to L4. A temporary IVC filter was introduced prior to surgery. A midline incision was used to perform a left radical nephrectomy and en bloc lymphadenectomy with excision of the inferior vena cava from above the level of the left renal vein to 2.5 cm above the confluence of the common iliac veins. The pathological diagnosis was invasive transitional cell carcinoma. The tumor thrombus consisted of transitional cell carcinoma that histologically invaded the walls of the IVC. He died of cancer 17 months after the operation for the liver metastases. This is the 18th case report of such a presentation in the literature.

Primary pheochromocytoma extending into the right atrium: report of a case and review of the literature

Pheochromocytoma rarely extends locally into the vena cava or the right atrium. We report a case of malignant pheochromocytoma with growth into the inferior vena cava, extending into the right atrium, address clinical aspects of this tumour and review the literature on this malignancy. Pre-operative work-up of this tumour should include measurements of urinary vanillyl mandelic acid and cathecholamine excretion, MRI and spiral CT of the abdomen and thorax. After the diagnosis is made the patient should be treated with catecholamine alpha-receptor blockade and if necessary with subsequent beta-receptor blockade. An aggressive surgical approach is always warranted, even in cases with very large localized tumours, because surgery has been shown to lead to relief of symptoms and to prolong survival in cases otherwise deemed irresectable. The optimal surgical exposure is obtained via a transsternal midline thoraco-laparotomy. If feasible, a combination of cardiopulmonary bypass, hypothermia, cardiac arrest and exsanguination procedures should be used. In case of local of tumour remnants after surgery or distant metastases treatment options are secondary surgery, tumour embolization, or treatment with radioactive labelled drugs, including(131)I-MIBG.

[Adrenal cortex carcinoma with right atrium involvement. Surgery with cardiopulmonary bypass]

INTRODUCTION

Primary adrenal carcinoma is a low incidence tumour. About 50% are functional and the majority result in Cushing's syndrome, while detection of the rest is commonly incidental. Surgical management is through radical surgery.

CASE REPORT

A 36-year old female who presented with a one-month old abdominal pain in the hypochondrium and the right lumbar fossa. Physical examination found a discretely painful mobile mass. Adrenal hormones values were normal. Ultrasound and CT studies detected a 14-cm adrenal tumour with cava vein thrombosis up to the right auricle. The surgical procedure included laparotomy, liver mobilisation and cardiopulmonary by-pass. The thrombus was completely removed by auriculotomy. Therapy with mitotane and 5-fluorouracil was then instituted. Thirteen months after surgery the patient is asymptomatic and tumour free.

REMARKS

Dissemination of adrenal tumours to veins ranges between 6 to 30%. Clinical manifestation of cava vein and auricle involvement is variable but it may develop with no symptoms due to collateral circulation. Pre-operative diagnosis is critical to plan for adequate surgical approach. Ultrasound and computerised tomography can adequately diagnose the process, but nuclear magnetic resonance provides more information on the thrombus extension and location. In the absence of node spread, local extension, or invasion of the cava wall prognosis is similar to that of patients with no vein involvement. The best therapeutic option is surgery with removal of the lesion and cardiopulmonary by-pass. Survival at 5 years is 43%. Post-operative administration of chemotherapy with mitotane is a useful and recommendable choice.

Clinical Features and Prognostic Factors Associated with Adrenocortical Carcinoma: Lahey Clinic Medical Center Experience

Adrenocortical carcinoma is a rare tumor associated with a commonly poor prognosis. However, data on the natural history and response to therapy of patients with this malignancy have often been conflicting. Our objective of this retrospective study was to evaluate the clinical course and survival of patients with adrenocortical carcinoma and to identify relevant prognostic factors. Between 1966 and 1996, 31 patients with histologically documented adrenocortical carcinoma were observed at the Lahey Clinic Medical Center. Patient information was obtained from chart review. At the time of diagnosis, 48 per cent of patients had endocrine symptoms with compatible hormonal studies, 19 per cent had involvement of the inferior vena cava by tumor thrombus, and 32 per cent had metastatic disease. The median survival time was 17 months (range, 1–205 months) for the entire group, and the 5-year survival rate was 26 per cent. Age <54 years, absence of metastatic disease at the time of diagnosis, and completeness of surgical resection were associated with better prognosis. Evaluation of survival with the Cox proportional hazards model suggested that age <54 years, absence of metastatic disease, and nonfunctioning tumor status were independently associated with improved survival. The prognosis of patients with adrenocortical carcinoma is poor but appears more favorable in patients <54 years, with localized disease, or nonfunctioning tumor status. Complete tumor resection may be associated with improved survival.

Long survival of a patient with paratesticular rhabdomyosarcoma with inferior vena cava involvement

A 13-year-old boy with a paratesticular embryonal rhabdomyosarcoma and a large thrombus into the inferior vena cava reaching the suprahepatic vein is presented. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to realize a complete exeresis of the tumor and thrombus, followed by systemic chemotherapy and radiotherapy. Ten years later the patient is alive and doing well without any sequelae.

Adrenocortical carcinoma with intracaval extension

PURPOSE

We describe the presenting features, treatment approach and prognosis of adrenocortical carcinoma with intracaval extension of tumor thrombus.

MATERIALS AND METHODS

In addition to 3 patients with adrenocortical carcinoma associated tumor thrombus treated at our institution, we reviewed an additional 26 patients described in the literature from 1972 to 1997 with regard to presentation, management and outcome.

RESULTS

We identified 23 female and 6 male patients 6 to 77 years old (mean age 41.3). Of the lesions 24 originated in the right adrenal gland. Mean tumor size was 10.1 cm. and 89% of lesions were at least 9 cm. in greatest dimension. Tumor thrombus extended to the atrium in 15 patients, retrohepatic cava in 7 and subhepatic cava in 7. Flank or abdominal discomfort was the most common presenting complaint and abnormal steroid metabolism was documented in 76% of patients. Cardiac bypass techniques were used in 14 patients and none of the 3 intraoperative mortalities, 2 thromboemboli and 1 exsanguination, occurred using this approach. Eight patients received postoperative mitotane, 6 of whom had no evidence of residual disease at the time of case description.

CONCLUSIONS

All patients with large adrenal tumors, especially those arising from the right gland, should undergo careful evaluation of the vena cava for thrombus. The best chance for survival is via complete surgical extirpation which is facilitated by the use of cardiac bypass techniques. There is evidence to support the early use of postoperative mitotane if there is a suspicion of residual or recurrent disease.

Hypervascular renal transitional cell carcinoma with extension into the renal vein and inferior vena cava

A rare case of transitional cell carcinoma (TCC) with extension into the renal vein and inferior vena cava (IVC) is presented. Computed tomography, magnetic resonance imaging, and angiography successfully delineated tumor thrombus in the right renal vein and IVC. TCC should be included in the differential diagnosis of renal tumors that can cause IVC thrombosis.

Pheochromocytoma: study of 50 cases

PURPOSE

We studied the clinical picture, sensitivity of the biochemical tests and imaging studies, pathological findings, surgical results and followup of patients with pheochromocytoma.

MATERIALS AND METHODS

The records of 50 patients with pheochromocytoma were identified. Hyperadrenergic symptoms and signs; urinary dopamine, epinephrine, norepinephrine and vanillylmandelic acid levels; serum dopamine, epinephrine and norepinephrine levels; ultrasonography; computerized tomography; magnetic resonance imaging and 131iodine-metaiodobenzylguanidine images were analyzed. The size, weight and malignancy of the tumors, as well as the operative mortality, survival rate and clinical condition of the patients were also studied.

RESULTS

The hyperadrenergic syndrome alone was found in 90% of the patients, Cushing's syndrome alone in 2%, both syndromes in 4%, a palpable abdominal tumor only in 2% and incidental tumors in 2%. The sensitivities of the urinary evaluation in the diagnosis were metanephrines 97%, vanillylmandelic acid 90%, epinephrine 64%, norepinephrine 93% and dopamine 66%. For serum assessment the sensitivities were epinephrine 67%, norepinephrine 93% and dopamine 63%. The sensitivities of the localization examinations were 89, 94, 100 and 88% for ultrasonography, computerized tomography, magnetic resonance imaging and 131I-metaiodobenzylquanidine, respectively. There was only 1 operative death. Of the patients with benign tumors 88% were cured and 12% remained hypertensive with no clinical or biochemical evidence of a hyperadrenergic profile. Of the 8 patients with malignant pheochromocytoma 1 was lost to followup and 3 died of widespread disease (1 without surgery and at 2, 24 and 78 months postoperatively). Of the 4 living patients 3 had no evidence of disease and 1 was well, although with pulmonary metastases.

Transitional cell carcinoma of the kidney with tumor thrombus into the vena cava

Transitional cell carcinoma of the upper urinary tract with inferior vena cava tumor thrombus is an unusual entity. We report the 16th such case and review the previous cases in the world literature. Preoperative diagnosis was correct in only 5 of the cases. This type of condition can be easily presumed to be renal cell carcinoma. Fifteen of the cases were managed with radical nephrectomy; 8 patients were managed with partial or complete resection of the vena cava due to adherence of the tumor thrombus to the vessel wall. Overall outcome was poor, with short postoperative survival. Correct preoperative diagnosis, although difficult, could allow more complete preoperative planning or appropriate nonoperative management.

Pheochromocytomas with extension into central vascular structures

Two cases of pheochromocytomas, 1 with extension into the inferior vena cava and the second with involvement of the right atrium, are reported. Both tumors were resected in toto, 1 using inferior to superior vena cava vein-to-vein bypass and the second with the aid of hypothermic circulatory arrest. Both patients are free of recurrences or metastasis 20 and 24 month postoperatively.

Sudden death caused by testicular germ cell tumour

Most cases of sudden unexpected 'natural' death are due to primary disorders of the cardiovascular, respiratory and central nervous system. Sudden death due to a previously undiagnosed malignancy is rare in young, apparently healthy subjects. We report an unusual cause of sudden unexpected death due to pulmonary tumour embolism complicating an undiagnosed germ cell tumour of the testis in a 37-year-old white male. Although death due to testicular tumours is not uncommon in young adult males, it rarely follows pulmonary embolism secondary to inferior vena cava (IVC) tumour invasion. A review of the literature revealed four other cases with a similar mechanism of death.

Thrombosis of the inferior vena cava by a testicular tumour

We report on an unusual case of testicular tumour presenting as thrombosis of the inferior vena cava. The inferior vena cava thrombosis due to tumour invasion is a rare presentation of testicular tumour. After four cycles of chemotherapy, the tumour which invaded and obstructed the vena cava was replaced by scar tissue.

Pulmonary tumour and inferior vena cava tumour thrombus: rare presentation of renal transitional cell carcinoma. Case report

A transitional cell carcinoma from the pyelocaliceal system, initially presenting as a pulmonary tumour, extended into the inferior vena cava, the tenth reported case of this type. The literature is reviewed with special reference to vena cava involvement by such tumours and immunohistochemical staining pattern.

Adrenal cortical carcinoma. Epidemiology and treatment with mitotane and a review of the literature

BACKGROUND

Adrenal cortical carcinoma is rare; the authors have treated only eight patients with the disease at Good Samaritan Regional Medical Center since 1974. No exhaustive collection of cases of this cancer has been done since 1952.

METHODS

The authors retrospectively reviewed the medical records of their eight patients with adrenal cortical carcinoma. They also searched the English literature from 1952 to 1992 for reports of patients with the disease. They treated each report as a series if two or more previously unreported patients were reported. They paid special attention to patients for whom stage of disease was noted at diagnosis, treatment with mitotane (o,p'-DDD) was used, and the outcome was reported.

RESULTS

Five were male and three were female patients. Five had nonfunctional tumors. None were pediatric. The authors found 1891 cases in the English literature. Adrenal cortical carcinomas are more common in women (58.6%) than in men (41.4%). The age distribution of tumors is bimodal, with peaks in the first and fifth decades. Tumors in children are more commonly functional (83.5% in female patients, 85.6% in male patients), although nonfunctional tumors are more common in older patients (84.7%). Most (68%) of these tumors are diagnosed late in disease when surgery is no longer curative. Only 35% of patients treated with mitotane had a clinical response.

CONCLUSIONS

Adrenal cortical carcinomas are diagnosed most often in children because of functionality and older men because of mass effect. Most tumors are discovered too late for curative resection. Treatment of metastatic disease with mitotane has limited success.

Non-Hodgkin's lymphoma can mimic renal adenocarcinoma with inferior vena caval involvement

Genitourinary involvement in both Hodgkin's and non-Hodgkin's lymphomas is common and can be confused with other benign and malignant urologic conditions. While lymphoma commonly produces vascular and ureteral encasement, intraluminal vascular involvement is rare. Indeed, there are no previous reports of renal lymphoma with tumor thrombus extending into both the renal vein and inferior vena cava. We describe the first reported case of lymphoma mimicking a Stage IIIA renal adenocarcinoma with tumor thrombus in the renal vein and the inferior vena cava. Renal lymphoma should be considered in the differential diagnosis even when tumor thrombus is present in the renal vein or vena cava.

Mature testicular teratoma with vena caval invasion presenting as pulmonary embolism

We report a case of mature testicular teratoma with invasion and thrombosis of the inferior vena cava that presented as recurrent pulmonary embolism. Treatment included radical orchiectomy, chemotherapeutic cytoreduction and, finally, resection of a massive retroperitoneal tumor with en bloc resection of the inferior vena cava using cardiopulmonary bypass and deep hypothermic circulatory arrest. Management is discussed and the literature is reviewed.

Transitional cell carcinoma of the kidney with vena caval involvement: report of 3 cases and a review of the literature

Vena caval tumor thrombus in association with transitional cell carcinoma of the kidney is uncommon, with only 9 cases having been reported to our knowledge. We report 3 additional cases and review this subject with particular attention to symptoms, radiographic evaluation and the importance of early diagnosis.