1
|
Bokka S, Manikandan R, Dorairajan LN, Srivathsa K, Sreenivasan Sreerag K, Kalra S, Pottakat B. Perioperative and oncological outcomes of renal cell carcinoma with venous tumour thrombus. Urologia 2021; 89:31-37. [PMID: 33781146 DOI: 10.1177/03915603211007030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The aim of the present study is to report the perioperative and long-term surgical outcomes of renal cell carcinoma (RCC) with venous tumour thrombus (VTT). MATERIALS AND METHODS Data of 34 patients (males = 23, females = 11) from 2009 to 2020 who underwent radical nephrectomy with thrombectomy for RCC and VTT was retrospectively analysed. The parameters recorded include tumour laterality, size, level of thrombus, surgical approach, blood loss, transfusion rates, operative time, hospital stay, Clavien complications, tumour histology, follow-up duration, local recurrence, distant metastasis, overall and cancer-specific survival rates. RESULTS The extent of thrombus was level I in thirteen, level II in twelve, level III (a-1, b-2, c-1, d-2) in six and level IV in three patients respectively. Mean operative time was 320 (±145) min, mean blood loss was 1371.15 (±1020.8) ml and mean hospital stay was 9.6 (±7.4) days. Mean transfusion rate was 6.4 (±3.2) units. Three patients died within the first 30 days of surgery. Cardiopulmonary bypass (CPB) was utilized in three patients. Median follow-up period was 58 (Range: 4-101) months. A statistically significant correlation was found between operative time (p = 0.014) and median survival (p = 0.003) respectively and tumour thrombosis level. Nine patients died due to metastasis, and ten due to unrelated causes. The estimated actuarial survival rates at a median of 58 months were 35.3%. CONCLUSION An accurate preoperative assessment of the thrombus extent with the involvement of a multidisciplinary team approach is crucial in achieving optimal surgical outcomes in patients of RCC with VTT, particularly with level III and IV thrombus.
Collapse
Affiliation(s)
- Sriharsha Bokka
- Department of Urology and Renal Transplantation, JIPMER, Puducherry, India
| | | | | | - K Srivathsa
- Department of Cardiothoracic and Vascular Surgery, JIPMER, Puducherry, India
| | | | - Sidhartha Kalra
- Department of Urology and Renal Transplantation, JIPMER, Puducherry, India
| | - Biju Pottakat
- Department of Surgical Gastroenterology, JIPMER, Puducherry, India
| |
Collapse
|
2
|
Mastoraki A, Mastoraki S, Tsikala-Vafea M, Papanikolaou IS, Lazaris A, Smyrniotis V, Arkadopoulos N. Prognostic Benefit of Surgical Management of Renal Cell Carcinoma Invading the Inferior Vena Cava. Indian J Surg Oncol 2016; 8:14-18. [PMID: 28127177 DOI: 10.1007/s13193-016-0528-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 04/29/2016] [Indexed: 01/01/2023] Open
Abstract
Renal cell carcinoma (RCC) accounts for approximately 3 % of adult malignancies and 90-95 % of neoplasms arising from the kidney. One of the unique features of RCC is the tumor thrombus formation that migrates into the venous system including renal vein (RV) and inferior vena cava (IVC). Only 10 % of patients with RCC present with the classic triad of flank pain, hematuria and defined mass, while 25-30 % of affected patients are asymptomatic. Signs of para-neoplastic syndrome such as hypercalcemia, hypertension, anemia, cachexia and increased erythrocyte sedimentation rate (ESR) are often apparent. Extension of tumor thrombus into the venous system is depicted by radiological examinations, such as contrast enhanced Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and vena cavography. The level of the thrombus is mostly determined according to the Mayo classification. Despite recent research on the therapeutic strategies against advanced RCC, surgical resection appears the only potentially curative approach. Aggressive surgical management including nephrectomy with thrombectomy is currently the standard therapeutic approach for RCC patients with tumor thrombus extending to the RV or the IVC. Pre-surgical down-staging with the use of molecular targeted therapy has also been proposed. Alternative therapies, such as radio- and chemotherapy proved insufficient. The aim of this review is to evaluate the results of surgical treatment for RCC invading IVC with special reference to the extent of its histological spread. Review of recent world literature was accomplished to provide an update on the current concepts of surgical management of the disease.
Collapse
Affiliation(s)
- Aikaterini Mastoraki
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Sotiria Mastoraki
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Maria Tsikala-Vafea
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | | | - Andreas Lazaris
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Vassilios Smyrniotis
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| | - Nikolaos Arkadopoulos
- Athens University Medical School, Attikon University Hospital, Chaidari, Athens Greece
| |
Collapse
|
3
|
Combined resection of a tumor and the inferior vena cava: report of two cases. Surg Today 2012; 44:166-70. [PMID: 23001534 PMCID: PMC3898128 DOI: 10.1007/s00595-012-0337-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 06/07/2012] [Indexed: 11/24/2022]
Abstract
Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.
Collapse
|
4
|
Kulkarni J, Jadhav Y, Valsangkar RS. IVC Thrombectomy in Renal Cell Carcinoma-Analysis of Out Come Data of 100 Patients and Review of Literature. Indian J Surg Oncol 2012; 3:107-13. [PMID: 23730099 PMCID: PMC3392477 DOI: 10.1007/s13193-011-0114-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2011] [Accepted: 12/06/2011] [Indexed: 12/27/2022] Open
Abstract
To review our experience of RCC with IVC thrombus in terms of clinical presentation, principles of surgical management in contemporary era, also an impact of clinico-pathological factors on prognosis. Total 100 patients who underwent radical nephrectomy and IVC thrombectomy between 1991-2008 were included in this retrospective analysis. Data was analysed in terms of clinical pathological factors, survivals and compared with contemporary literature. The extent tumour thrombus was infrahepatic in 58 retro hepatic in 28 and suprahepatic in 14 patients including 6 with right atrial thrombus. The immediate postoperative mortality was 2% and incidence of major postoperative non fatal complications was 38%, which were managed conservatively. The overall and disease free 5 year survival was 63% and 55%. Further amongst the histological types, patients with clear cell tumours had the best (DFS- 71.42%), and those with papillary had the poor (DFS- 30.76%) outcome. Grade II tumors had better survivals as compared to grade IV (DFS 75.39% vs 23.52%, p < 0.05). Loco- regional extent wise 74% patients without perinephric fat invasion were free from disease at 5 years as compared to 30% of those who had perinephric fat invasion (p < 0.01). Similarly 5 year DFS was 76.11% in patients with negative nodes as compared to 12% in positive nodes (p < 0.01). In conclusion radical nephrectomy with IVC thrombectomy still remains the most effective therapeutic option in management in this clinical setting. Although this is complicated surgery success with multi disciplinary approach excellent survival outcome can be obtained. Further pathological factors, such as loco-regional spread and grade of tumor, rather than clinical factors influence long term survival.
Collapse
Affiliation(s)
- Jagdeesh Kulkarni
- Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra India
| | - Yogesh Jadhav
- Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra India
| | - Rohan S. Valsangkar
- Department of Urology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra India
| |
Collapse
|
5
|
Rötker J, Schmid Ç, Oberpennig F, Knichwitz G, Tjan T, Hertle L, Scheld H. Surgery of the inferior vena cava for tumor-related obstruction. Int J Angiol 2011. [DOI: 10.1007/bf01618394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
6
|
Bertini R, Roscigno M, Lapenna E, Pasta A, Petralia G, Strada E, Naspro R, Da Pozzo L, Colombo R, Rigatti P. Radical Nephrocapsulectomy and Caval Thrombectomy with Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest in Right Anterior Minithoracotomy: A Minimally Invasive Approach. Urology 2008; 71:957-61. [DOI: 10.1016/j.urology.2007.11.122] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2007] [Revised: 11/12/2007] [Accepted: 11/20/2007] [Indexed: 10/22/2022]
|
7
|
Zini L, Destrieux-Garnier L, Leroy X, Villers A, Haulon S, Lemaitre L, Koussa M. Renal Vein Ostium Wall Invasion of Renal Cell Carcinoma With an Inferior Vena Cava Tumor Thrombus: Prediction by Renal and Vena Caval Vein Diameters and Prognostic Significance. J Urol 2008; 179:450-4; discussion 454. [DOI: 10.1016/j.juro.2007.09.042] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Indexed: 10/22/2022]
Affiliation(s)
- Laurent Zini
- Department of Urology, Lille University Hospital, Lille, Cedex, France
| | | | - Xavier Leroy
- Department of Pathology, Lille University Hospital, Lille, Cedex, France
| | - Arnauld Villers
- Department of Urology, Lille University Hospital, Lille, Cedex, France
| | - Stephan Haulon
- Department of Vascular Surgery, Lille University Hospital, Lille, Cedex, France
| | - Laurent Lemaitre
- Department of Radiology, Lille University Hospital, Lille, Cedex, France
| | - Mohamad Koussa
- Department of Vascular Surgery, Lille University Hospital, Lille, Cedex, France
| |
Collapse
|
8
|
Rábago G, Rioja Zuazu J, Rodríguez-Rubio Cortadellas F, Zudaire Bergera J, Saiz Sansi A, Rosell Costa D, Robles García J, Berián Polo J. Cirugía con circulación extracorpórea e hipotermia en tumores con extensión a vena cava: 20 años de experiencia de la Clínica Universitaria de Navarra. Actas Urol Esp 2008. [DOI: 10.1016/s0210-4806(08)73853-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
9
|
Kirkali Z, Van Poppel H. A critical analysis of surgery for kidney cancer with vena cava invasion. Eur Urol 2007; 52:658-62. [PMID: 17548146 DOI: 10.1016/j.eururo.2007.05.009] [Citation(s) in RCA: 123] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Accepted: 05/11/2007] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Patients with kidney cancer with venous system involvement are at high risk of cancer recurrence even after the tumor thrombus is successfully removed. This review analyzes the impact on prognosis of the level of involvement of the inferior vena cava (IVC) in renal cell carcinoma (RCC). METHODS A literature search was done and relevant papers were reviewed. Relatively recent papers as well as large series or papers from expert centers are included in the reference list. RESULTS Venous invasion in RCC is a major challenge for urologists and patients with venous involvement have a worse prognosis. Although successful removal of a tumor thrombus in the renal vein and IVC may result in improved long-term survival in more than half of the affected patients, a higher level of thrombus appears to be a bad prognosticator for cancer recurrence. A complete IVC thrombectomy, even in the metastatic setting, provides a better quality of life and may prolong survival. CONCLUSIONS Because surgery still remains the most effective therapeutic option in patients wtih RCC, every attempt should be made to completely remove the IVC thrombus. New targeted agents could be promising as adjuvant therapy in this subset of patients.
Collapse
Affiliation(s)
- Ziya Kirkali
- Dokuz Eylul University School of Medicine, Department of Urology, Izmir, Turkey.
| | | |
Collapse
|
10
|
Rigaud J, Hetet JF, Braud G, Battisti S, Le Normand L, Glemain P, Karam G, Bouchot O. Surgical Care, Morbidity, Mortality and Follow-up after Nephrectomy for Renal Cancer with Extension of Tumor Thrombus into the Inferior Vena Cava: Retrospective Study Since 1990s. Eur Urol 2006; 50:302-10. [PMID: 16759789 DOI: 10.1016/j.eururo.2006.02.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2005] [Accepted: 02/08/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVES The aim of our survey was to evaluate surgical care, morbidity, mortality and follow-up of patients who had undergone surgical exeresis of a renal cancer with extension of tumor thrombus into the inferior vena cava. PATIENTS AND METHODS Between June 1991 and March 2003, 40 (5.4%) patients were operated on for an enlarged nephrectomy with thrombectomy. The upper limit of the tumor thrombus was below the sus-hepatic veins in 21 (52.5%) patients and above the sus-hepatic veins in 19 (47.5%) patients with six (15%) located in the right atrium. RESULTS Cardiopulmonary bypass (CPB) was used for 12 patients (30%). A per-operative embolism was noted for three (7.5%) patients: two cases of cruoric embolism and one case of gaseous embolism, systematically occurring in patients operated on without CPB. Early mortality was 7.5% (three patients) attributable to hemorrhagic complications. Overall survival at 2 and 5 years was 45.2% and 38.7%, respectively. Disease-free survival at 2 and 5 years was 28.3% and 8.9% respectively. Only the pN stage had a statistically significant prognosis value for overall survival but not for disease-free survival. At the end of the study, only one (2.5%) patient could be considered free of the disease with sufficient follow-up after the surgery. CONCLUSION Patients with renal cancer and tumor extension in the inferior vena cava need multidisciplinary cooperation to adapt a good surgical strategy, particularly with the use of CPB. However, the rate of patients free of disease after such surgery was low.
Collapse
Affiliation(s)
- Jérôme Rigaud
- Clinique Urologique, Hôtel Dieu, CHU Nantes, France.
| | | | | | | | | | | | | | | |
Collapse
|
11
|
Jibiki M, Iwai T, Inoue Y, Sugano N, Kihara K, Hyochi N, Sunamori M. Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg 2004; 39:829-35. [PMID: 15071451 DOI: 10.1016/j.jvs.2003.12.004] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.
Collapse
Affiliation(s)
- Masatoshi Jibiki
- Department of Surgery, Tokyo Medical and Dental University Graduate School, Japan.
| | | | | | | | | | | | | |
Collapse
|
12
|
[Malignant adrenocortical tumour with inferior vena cava invasion]. ANNALES DE CHIRURGIE 2003; 128:262-4. [PMID: 12853025 DOI: 10.1016/s0003-3944(03)00064-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Carcinoma of the adrenal cortex is a rare tumour. The incidence of vena cava involvement may be present in 15 to 20% of patients. The intra caval tumour thrombus can attain the right atrium. Even if some authors consider these lesions as a metastasis, long-term survival can be obtained after radical resection. The surgical tactical depend on the extension of thrombus into the vena cava inferior. The authors report a case with 4 years survival without recurrence after surgical treatment.
Collapse
|
13
|
Sener SF, Winchester DJ, Votapka TV, Mcguire MS, O'Connor B, Szokol JW. Continuing Experience with Liver Resection and Vena Cava Reconstruction using Cardiopulmonary Bypass and Hypothermic Circulatory Arrest. Am Surg 2002. [DOI: 10.1177/000313480206800409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.
Collapse
Affiliation(s)
- Stephen F. Sener
- Divisions of General
- Departments of Surgery, Northwestern University Medical School, Chicago, Illinois
| | - David J. Winchester
- Divisions of General
- Departments of Surgery, Northwestern University Medical School, Chicago, Illinois
| | - Timothy V. Votapka
- Cardiovascular-Thoracic, Northwestern University Medical School, Chicago, Illinois
- Departments of Surgery, Northwestern University Medical School, Chicago, Illinois
| | - Michael S. Mcguire
- Urologic Surgery of the Department of Surgery, Northwestern University Medical School, Chicago, Illinois
- Urology, Northwestern University Medical School, Chicago, Illinois
| | - Brent O'Connor
- Department of Anesthesia, Evanston Northwestern Healthcare, Evanston and the, Chicago, Illinois
- Anesthesia, Northwestern University Medical School, Chicago, Illinois
| | - Joseph W. Szokol
- Department of Anesthesia, Evanston Northwestern Healthcare, Evanston and the, Chicago, Illinois
- Urology, Northwestern University Medical School, Chicago, Illinois
| |
Collapse
|
14
|
Chan F, Ngan Kee WD, Low JM. Anesthetic management of renal cell carcinoma with inferior vena caval extension. J Clin Anesth 2001; 13:585-7. [PMID: 11755329 DOI: 10.1016/s0952-8180(01)00335-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We present a case of a patient with renal cell carcinoma extending into the inferior vena cava. Preoperative diagnosis was facilitated by transthoracic and transesophageal echocardiography (TEE), and inferior venacavography. Intraoperatively, monitoring with continuous TEE was used. Preparation was made for cardiopulmonary bypass but surgery was successfully completed using extracorporeal venous shunting. We discuss the important aspects of preoperative diagnosis and the intraoperative anesthetic management of this case.
Collapse
Affiliation(s)
- F Chan
- Department of Anaesthesia & Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
| | | | | |
Collapse
|
15
|
Harkin CP, Roberts PF, Nelson RS, Safwat AM. Re-evaluation of renal cell carcinoma tumor thrombus extension by intraoperative transesophageal echocardiography. J Cardiothorac Vasc Anesth 2000; 14:182-5. [PMID: 10794339 DOI: 10.1016/s1053-0770(00)90015-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C P Harkin
- Department of Anesthesiology, University of California, Davis, Sacramento, USA
| | | | | | | |
Collapse
|
16
|
Valbonesi M, Bruni R, Lercari G, Florio G, Carlier P, Morelli F. Autoapheresis and intraoperative blood salvage in oncologic surgery. TRANSFUSION SCIENCE 1999; 21:129-39. [PMID: 10747521 DOI: 10.1016/s0955-3886(99)00084-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Transfusion of predeposit or salvaged autologous blood has continued to grow since the 1980s. Issues such as the indications for use and cost effectiveness as well as the safety of autologous blood salvaged during cancer surgery have emerged and should be addressed. The concern for possible contamination of autologous RBC with cancer cells responsible for metastasis has limited the use of autologous salvaged blood in cancer patients. Nevertheless, clinical experience has been gained on the use of salvaged blood in patients with colorectal, gastric, renal, hepatic, breast, bladder and lung cancer. No evidence has been reported showing an increase in metastasis or a decrease in patient survival, in spite of the obvious demonstration that salvaged blood is contaminated with viable tumor cells which are not washed out of the RBC layer during intraoperative blood salvage (IOBS). However, a number of limitations have hampered the widespread use of IOBS in these patients and the technique is not well established. Increasing knowledge of the deleterious effects of allogeneic blood transfusion both in terms of the increased number of viral or bacterial infections and the down-regulation of the patient's immune system have recalled attention to IOBS and to the techniques such as filtration, which might reduce the risk of reinfusion of cancer cells, or totally eliminate the risks such as irradiation has been proposed by Hansen's group. This paper reviews the topic with some emphasis on our personal experience with gamma and X-ray irradiation of salvaged blood in a large reference hospital, where IOBS and filtration of salvaged blood were established for use in cancer patients in 1993 and 1996.
Collapse
Affiliation(s)
- M Valbonesi
- Immunohematology Services, San Martino University Hospital, Genova, Italy
| | | | | | | | | | | |
Collapse
|
17
|
Vogt PR, Ensner R, Prêtre R, Schmidli J, Reuthebuch O, Zünd G, Turina MI. Less invasive surgical treatment of renal cell carcinomas extending into the right heart and pulmonary arteries: surgery for renal cell carcinoma. J Card Surg 1999; 14:330-3. [PMID: 10875585 DOI: 10.1111/j.1540-8191.1999.tb01004.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Radical resection using deep hypothermic circulatory arrest improves the survival of patients with transvenous intracardiac tumor extension of renal cell carcinomas. A less invasive surgical approach avoiding deep hypothermia, circulatory arrest, and cross-clamping of the aorta is presented. METHODS Between 1987 and 1999, 12 patients (mean age 57+/-8 years) underwent resection of a renal cell carcinoma extending into the right atrium, right ventricle, or pulmonary arteries. After median sterno-laparotomy, normothermic cardiopulmonary bypass is used cannulating the ascending aorta, superior caval vein, and inferior caval vein below the renal veins. The tumor and the corresponding kidney are radically excised, including the renal vein. Tumor fragments from the inferior caval vein, the right heart, and pulmonary arteries are removed either on the fibrillating or beating heart. RESULTS Operative mortality was 0%. Mean cardiopulmonary bypass time was 53+/-27 minutes (median 36; range 32-110 minutes). Mean blood loss per patient was 1200 mL. Mean duration of postoperative mechanical ventilation was 36+/-12 hours (median 36; range 30-77 hours), mean intensive care stay 5.5+/-5 days (median 3; range 1-48 days), and mean duration of hospitalization 22+/-12 days (median 21; range 10-58 days). All patients were discharged home. Patients with multiple tumor manifestations outside the cardiovascular systems died within 9 months after the operation. CONCLUSIONS The use of normothermic cardiopulmonary bypass is a less invasive method for radical resection of renal cell carcinoma with intracardiac tumor extension. Radical resection does not improve survival in patients with multiple distant metastases.
Collapse
Affiliation(s)
- P R Vogt
- Clinic for Cardiovascular Surgery, University Hospital, Zurich, Switzerland.
| | | | | | | | | | | | | |
Collapse
|
18
|
Ohwada S, Satoh Y, Nakamura S, Tanahasi Y, Otani Y, Lino Y, Morishita Y, Kobayashi M, Yamanaka H. Left-sided approach to renal cell carcinoma tumor thrombus extending into suprahepatic inferior vena cava by resection of the left caudate lobe. Angiology 1997; 48:629-35. [PMID: 9242161 DOI: 10.1177/000331979704800710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
A new operative approach to resecting tumor thrombus originating from a right renal cell carcinoma extending into the suprahepatic inferior vena cava (IVC) is reported. Complete local control of the IVC must be obtained above and below the tumor thrombus to remove it under direct vision. The caudate lobe of the liver was resected to expose the retrohepatic IVC and open the lesser omentum. The subhepatic IVC was encircled just below the confluence of the hepatic veins. Caval tumor thrombus was removed en bloc, including the right kidney, by use of the total hepatic vascular exclusion technique (THVE) and IVC exclusion. The retrohepatic IVC was clamped just below the confluence of the hepatic veins once the thrombus was removed, and the suprahepatic IVC clamp was then released and the THVE was terminated. The sequential clamping from the suprahepatic IVC to the retrohepatic IVC below the confluence of the hepatic veins shortened the THVE time.
Collapse
Affiliation(s)
- S Ohwada
- Second Department of Surgery, Gunma University School of Medicine, Japan
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Fonseca P, Almassi H, Begun F. Resection of an adult intracardiac Wilms' tumor using hypothermic circulatory arrest. Ann Thorac Surg 1995; 60:1818-20. [PMID: 8787497 DOI: 10.1016/0003-4975(95)00658-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A 51-year-old woman underwent resection of a renal tumor with intracaval and intracardiac extension. Histologic examination demonstrated an adult Wilm's tumor. Cardiopulmonary bypass and deep hypothermic circulatory arrest were used in a combined abdominal and thoracic procedure to remove the tumor and extension in its entirety without complication.
Collapse
Affiliation(s)
- P Fonseca
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee 53226, USA
| | | | | |
Collapse
|
20
|
|
21
|
Tongaonkar HB, Dandekar NP, Dalal AV, Kulkarni JN, Kamat MR. Renal cell carcinoma extending to the renal vein and inferior vena cava: results of surgical treatment and prognostic factors. J Surg Oncol 1995; 59:94-100. [PMID: 7776659 DOI: 10.1002/jso.2930590205] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Forty-seven patients with renal cell carcinoma with tumor thrombus extension to the renal vein or inferior vena cava (IVC) were treated surgically over a 10-year period. There were 41 males and 6 females with a mean age of 45.7 years. Thirty-three patients had right-sided and 14 had left-sided tumors. Patients with renal vein or infrahepatic IVC thrombus were treated with radical nephrectomy with tumor thrombus excision after achieving conventional vascular control over the IVC and the opposite renal vein. Four patients with retrohepatic IVC thrombus were treated with venacavotomy and thrombectomy after achieving vascular control above the thrombus but below the hepatic veins while two other patients with retrohepatic and one with suprahepatic thrombus required a bifemoroatrial partial venous bypass prior to tumor thrombectomy. There was one postoperative death due to pulmonary embolism. The actuarial 5-year survival for all patients with venous extension was 50% and the median survival was 4.35 years. Perinephric spread and lymph node metastases were significant prognostic factors affecting survival. This suggests that it is the locoregional spread of renal cell carcinoma rather than the level of the thrombus which governs the prognosis of patients with tumor thrombus extension to the renal vein or IVC.
Collapse
Affiliation(s)
- H B Tongaonkar
- Department of Uro-Oncology, Tata Memorial Hospital, Bombay, India
| | | | | | | | | |
Collapse
|
22
|
Singh I, Jacobs LE, Kotler MN, Ioli A. The utility of transesophageal echocardiography in the management of renal cell carcinoma with intracardiac extension. J Am Soc Echocardiogr 1995; 8:245-50. [PMID: 7640016 DOI: 10.1016/s0894-7317(05)80033-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The accurate assessment of the distal extent of vena caval invasion of renal cell carcinoma into the hepatic veins, inferior vena cava, and right atrium is critical before surgical resection. We present two cases of renal carcinoma with vena caval extension in which preoperative transesophageal echocardiography accurately assessed tumor extent and guided surgical therapy. The role of transesophageal echocardiography in comparison to other diagnostic modalities is discussed.
Collapse
Affiliation(s)
- I Singh
- Department of Medicine, Albert Einstein Medical Center, Philadelphia, PA 19141, USA
| | | | | | | |
Collapse
|
23
|
Matthews PN, Evans C, Breckenridge IM. Involvement of the inferior vena cava by renal tumour: surgical excision using hypothermic circulatory arrest. BRITISH JOURNAL OF UROLOGY 1995; 75:441-4. [PMID: 7788252 DOI: 10.1111/j.1464-410x.1995.tb07261.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the immediate and long-term results of a radical surgical technique in the treatment of renal tumours with extensive involvement of the inferior vena cava (IVC). PATIENTS AND METHODS Seven patients with extensive involvement of renal tumours into the IVC were operated upon using a cardiopulmonary by-pass, hypothermia and cardiac arrest to facilitate surgery. Wide exposure of the IVC in a bloodless field permitted complete removal of all visible tumour in each case. Histological sections confirmed renal cell cancer in six patients and Wilms tumour in a 15-year-old girl. RESULTS All patients recovered well from their surgery with no major complications and spent one or two days in the Intensive Treatment Unit and an average of 13 days in hospital after the operation. Of the seven patients, four are alive and well with no obvious disease after an average follow-up time of 30 months (range 8-54). The other three patients have died from disseminated renal cancer. CONCLUSION This procedure provides good local control of the tumour and offers the only hope of cure in patients with this disease. In collaboration with the surgical cardiac team it can be safely carried out with acceptable morbidity and mortality.
Collapse
|
24
|
Fabre JM, Domergue J, Fagot H, Guillon F, Souche B, Joswik M, Baumel H. Leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome. Vena cava replacement under veno-venous bypass and liver hypothermic perfusion. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 1995; 21:86-7. [PMID: 7851563 DOI: 10.1016/s0748-7983(05)80076-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We report the first case of leiomyosarcoma of the middle and upper part of the vena cava successfully treated by surgical resection, complete vena cava replacement and disobliteration of the hepatic veins under veno-venous bypass and liver hypothermic perfusion as described in "ex situ, in vivo liver surgery".
Collapse
Affiliation(s)
- J M Fabre
- Department of Surgery, Saint Eloi Hospital, Montpellier, France
| | | | | | | | | | | | | |
Collapse
|
25
|
Hannukainen J, Salenius JP, Kulmala R, Tarkka M. Deep hypothermia and circulatory arrest in the surgical management of renal cell carcinoma with vena caval involvement. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1995; 29:101-4. [PMID: 8614775 DOI: 10.3109/14017439509107213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Six patients operated on for renal cell carcinoma with vena caval involvement were prospectively studied. The mean age of the four men and two women was 58 (range 51-77) years. In four of them the tumour was excised during cardiopulmonary bypass and deep hypothermic circulatory arrest. The operation was radical in three of these patients and palliative in one. There were no major complications or deaths during hospitalisation averaging 9 (7-17) days. The mean follow-up was 9 (4-14) months, during which two patients had died of metastatic disease. The surgical approach with cardiopulmonary bypass and deep hypothermic circulatory arrest is well tolerated and can be used to facilitate complete tumour thrombectomy, with low operative risk. Need for caval tumour thrombectomy was found in 5% of all patients with renal cell carcinoma during the study period.
Collapse
Affiliation(s)
- J Hannukainen
- Department of Surgery, Central Hospital Pori, Finland
| | | | | | | |
Collapse
|
26
|
Langenburg SE, Blackbourne LH, Sperling JW, Buchanan SA, Mauney MC, Kron IL, Tribble CG. Management of renal tumors involving the inferior vena cava. J Vasc Surg 1994; 20:385-8. [PMID: 8084030 DOI: 10.1016/0741-5214(94)90136-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE We reviewed our experience of the resection of renal tumors involving the inferior vena cava (IVC) from 1987 to 1992 with the hypothesis that retrohepatic IVC involvement of renal tumors can be managed without cardiopulmonary bypass (CPB) and circulatory arrest with acceptable morbidity and mortality rates. METHODS We retrospectively reviewed our experience of radical nephrectomies for renal tumors from 1987 to 1992 (n = 69). Of these, 13 had involvement of the IVC (19%). Three of the patients had right atrial extension requiring CPB with circulatory arrest. Three patients had retrohepatic involvement, and seven had infrahepatic involvement. All thirteen patients underwent operative removal of the tumor and tumor thrombus. RESULTS The patients with atrial extension who were treated with CPB and circulatory arrest had hospital and 1-year survival rates of 100% (three of three). The patients with retrohepatic extension treated without CPB and circulatory arrest had hospital and 1-year survival rates of 100% (three of three). The patients with infrahepatic extension treated without CPB and circulatory arrest had hospital and 1-year survival rates of 85% (six of seven) and 50% (three of six), respectively. There was no statistically significant difference between groups. The hospital death occurred in a patient who had a massive pulmonary embolism and disseminated intravascular coagulation before operation. The deaths that occurred before 1 year were due to metastatic disease and unresectable disease at the time of operation. CONCLUSION CPB with circulatory arrest is not required in patients with retrohepatic IVC extension of renal tumors, and aggressive resection can be performed in these patients with acceptable morbidity and mortality rates.
Collapse
Affiliation(s)
- S E Langenburg
- Department of Surgery, University of Virginia Health Sciences Center, Charlottesville 22908
| | | | | | | | | | | | | |
Collapse
|
27
|
Swierzewski DJ, Swierzewski MJ, Libertino JA. Radical nephrectomy in patients with renal cell carcinoma with venous, vena caval, and atrial extension. Am J Surg 1994; 168:205-9. [PMID: 8053528 DOI: 10.1016/s0002-9610(94)80069-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND From July 31, 1968, through August 31, 1992, 100 patients with renal cell carcinoma extending into the renal vein, vena cava, and right atrium were treated and evaluated at our institution. Each patient underwent radical nephrectomy with vena cavotomy and atriotomy as considered to be appropriate for each individual patient's tumor thrombus. METHODS The charts were retrospectively analyzed, and surveys were sent to survivors or nearest of kin. RESULTS The median age was 61 years, and two thirds of the tumors occurred in men (67 cases). Of the 100 patients with renal cell carcinoma resected, 13 patients (13%) had atrial extension; 75 patients (75%) had vena caval extension; and 12 patients (12%) had extension only into the renal vein. Seventy-two patients (72%) had no evidence of metastatic disease at the time of surgery and have a median survival of 21.1 years. Five-year survival is 64%, and 10-year survival is 57%. Twenty-eight patients (28%) had evidence of metastatic intraoperative and/or pathologically proven metastatic disease and have a median survival of 2.5 years with a 5-year survival of 20% and no patient living beyond 7.8 years. CONCLUSION We believe that an extended operation for renal cell cancer with involvement of the renal vein, vena cava, and right atrium is warranted in properly selected patients and ensures reasonable long-term survival.
Collapse
Affiliation(s)
- D J Swierzewski
- Department of Urology, Lahey Clinic, Burlington Massachusetts 01805
| | | | | |
Collapse
|
28
|
Swenson JD, Hullander RM, Nolan JF, York JK. Renal cell carcinoma in the inferior vena cava demonstrated by transesophageal echocardiography. J Cardiothorac Vasc Anesth 1993; 7:335-6. [PMID: 8518383 DOI: 10.1016/1053-0770(93)90017-f] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- J D Swenson
- Department of Anesthesiology, Naval Hospital, San Diego, CA 92134-5000
| | | | | | | |
Collapse
|
29
|
Burt JD, Bowsher WG, Joyce G, Peters JS, Wood A, White A, Costello A. The management of renal cell carcinoma with inferior vena-caval involvement. THE AUSTRALIAN AND NEW ZEALAND JOURNAL OF SURGERY 1993; 63:25-9. [PMID: 8466455 DOI: 10.1111/j.1445-2197.1993.tb00028.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Seven patients with renal cell carcinoma involving the inferior vena cava underwent surgical resection between 1975 and 1991. Pre-operative staging defined five patients with stage T3bNoMo disease, one patient with stage T3bN1Mo, and one patient with stage T3bNoM1 disease. At operation one patient had tumour thrombus filling the right atrium. Two patients had tumour thrombus within the intrahepatic vena cava and four infrahepatic tumour thrombus. The mean follow-up is 34.4 months (median 40 months). Four patients have been followed for over 4 years. Three of these patients are survivors, two have remained disease-free since their initial surgery. The other patient had a liver resection at 49 months for a solitary metastases; he is currently disease free. One patient died at 38 months from a gastrointestinal haemorrhage. Three patients are 12 months or less postoperation. Operative mortality was zero. The mean postoperative hospital stay was 14.7 days. Data suggests that 3-10% of renal cell carcinomas will involve the inferior vena cava. The small number of patients in this series suggests that many patients with renal cell carcinoma involving the inferior vena cava are not referred for surgical assessment. These patients are potential surgical candidates. Their survival after surgical resection, excluding the group with extension of tumour thrombus into the hepatic cava or above, is not reduced when compared with other patients with renal carcinoma.
Collapse
Affiliation(s)
- J D Burt
- Department of Urology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | | | | | | | | |
Collapse
|
30
|
Davits RJ, Blom JH, Schröder FH. Surgical management of renal carcinoma with extensive involvement of the vena cava and right atrium. BRITISH JOURNAL OF UROLOGY 1992; 70:591-3. [PMID: 1486383 DOI: 10.1111/j.1464-410x.1992.tb15825.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Between 1988 and 1990, 8 patients with a renal tumour extending into the vena cava and with supradiaphragmatic extension were treated by an operative technique involving extracorporeal circulation and deep hypothermic circulatory arrest. In 4 patients the thrombus extended into the right atrium. Six patients appeared to have a renal carcinoma. Intra-operatively one patient's tumour proved to be a metastasis of a squamous cell carcinoma of the lung and another patient was found post-operatively to have a leiomyosarcoma of the vena cava. Two of these 6 patients died from metastases 6 weeks and 8 months post-operatively. Four patients are symptom-free, although 3 of them have liver or lung metastases 10, 20 and 37 months post-operatively. One has no evidence of disease 18 months post-operatively. The use of extracorporeal circulation and deep hypothermic circulatory arrest provides optimal surgical exposure and gives the patients a considerable complaint-free interval post-operatively. How often cure is also achieved is as yet unclear.
Collapse
Affiliation(s)
- R J Davits
- Department of Urology, Erasmus University and Academic Hospital Dijkzigt, Rotterdam, The Netherlands
| | | | | |
Collapse
|
31
|
Pisters LL, Wajsman Z. Use of predeposit autologous blood and intraoperative autotransfusion in urologic cancer surgery. Urology 1992; 40:211-5. [PMID: 1523742 DOI: 10.1016/0090-4295(92)90476-d] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A total of 20 patients underwent major urologic cancer surgery with the combined use of predeposit autologous blood and intraoperative autotransfusion with the Haemonetics Cell Saver. The estimated blood loss ranged from 400 to 2,000 mL (mean 1,208 mL). Total transfusion requirements for the 20 patients were 85.5 units of which 82.5 (96%) were autologous. Predeposit autologous blood accounted for 53 percent, intraoperative autotransfusion blood 43 percent, and homologous blood 4 percent of the total transfusion requirements. Of the 20 patients in the study, only 1 received homologous blood. There were no complications related to either modality of autotransfusion. Our data suggest that using the combined modalities of predeposit autologous blood donation and intraoperative autotransfusion, major urologic cancer surgery can be performed without homologous blood in most cases.
Collapse
Affiliation(s)
- L L Pisters
- Department of Surgery, University of Florida, Gainesville
| | | |
Collapse
|
32
|
Leo ME, Petrou SP, Barrett DM. Transitional cell carcinoma of the kidney with vena caval involvement: report of 3 cases and a review of the literature. J Urol 1992; 148:398-400. [PMID: 1635146 DOI: 10.1016/s0022-5347(17)36610-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
Collapse
Affiliation(s)
- M E Leo
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905
| | | | | |
Collapse
|
33
|
|
34
|
Moul JW, Hardy MR, McLeod DG. Adrenal cortical carcinoma with vena cava tumor thrombus requiring cardiopulmonary bypass for resection. Urology 1991; 38:179-83. [PMID: 1877139 DOI: 10.1016/s0090-4295(05)80083-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We believe this is the fifteenth case report of adrenal cortical carcinoma with tumor thrombus to the vena cava, and the fourth reported case of a left-side tumor propagating thrombus to the vena cava. The patient underwent successful resection which required cardiopulmonary bypass. The caval tumor thrombus was very friable and gelatinous, unlike many renal cell thrombi, and required special surgical considerations.
Collapse
Affiliation(s)
- J W Moul
- Urology Service, Walter Reed Army Medical Center, Washington, D.C
| | | | | |
Collapse
|
35
|
Janosko EO, Powell CS, Spence PA, Hodges WE, Lust RM. Surgical management of renal cell carcinoma with extensive intracaval involvement using a venous bypass system suitable for rapid conversion to total cardiopulmonary bypass. J Urol 1991; 145:555-7. [PMID: 1997709 DOI: 10.1016/s0022-5347(17)38395-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Renal cell carcinoma involves the vena cava in approximately 4% of the patients. Presently surgical extirpation is the only form of therapy that can result in cure. Recently management of extensive vena caval involvement has involved the use of cardiopulmonary bypass with circulatory arrest and hypothermia. We describe a technique using a venous bypass pump system (femoral vein to right atrium) for resection of renal cell carcinoma with suprahepatic vena caval extension (type II), which avoids the risks and complications of cardiac arrest and hypothermia but allows for rapid conversion to total cardiopulmonary bypass should the intraoperative need arise.
Collapse
Affiliation(s)
- E O Janosko
- Division of Urology, Vascular and Cardiothoracic Surgery, Pitt County Memorial Hospital, Greenville, North Carolina
| | | | | | | | | |
Collapse
|
36
|
Concepcion RS, Koch MO, McDougal WS, Stewart JR, Merrill WH. Management of primary nonrenal parenchymal malignancies with vena caval thrombus. J Urol 1991; 145:243-7. [PMID: 1988710 DOI: 10.1016/s0022-5347(17)38303-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report our experience with the management of 7 primary nonrenal parenchymal malignancies with vena caval tumor thrombus. Included are 3 cases of adrenal cortical carcinoma and 1 each of transitional cell carcinoma, embryonal cell testicular carcinoma, pheochromocytoma and primary small cell carcinoma of the lung with metastases to the kidney. Surgical treatment and followup are presented, as well as a review of the literature. An aggressive surgical approach is warranted because prolonged survivals free of disease are possible.
Collapse
Affiliation(s)
- R S Concepcion
- Department of Urology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | | | | | | |
Collapse
|
37
|
Hatcher PA, Anderson EE, Paulson DF, Carson CC, Robertson JE. Surgical management and prognosis of renal cell carcinoma invading the vena cava. J Urol 1991; 145:20-3; discussion 23-4. [PMID: 1984092 DOI: 10.1016/s0022-5347(17)38235-6] [Citation(s) in RCA: 282] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerota's fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.
Collapse
Affiliation(s)
- P A Hatcher
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710
| | | | | | | | | |
Collapse
|
38
|
Goldfarb DA, Novick AC, Lorig R, Bretan PN, Montie JE, Pontes JE, Streem SB, Siegel SW. Magnetic resonance imaging for assessment of vena caval tumor thrombi: a comparative study with venacavography and computerized tomography scanning. J Urol 1990; 144:1100-3; discussion 1103-4. [PMID: 2231879 DOI: 10.1016/s0022-5347(17)39668-4] [Citation(s) in RCA: 87] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We assessed the accuracy of magnetic resonance imaging in demonstrating the presence and extent of vena caval tumor thrombi. The study group included 20 patients with vena caval thrombi from renal cell carcinoma (18), renal pelvic transitional cell carcinoma (1) and adrenal pheochromocytoma (1). Preoperative diagnostic studies included magnetic resonance imaging in all patients, inferior venacavography in 16 and computerized tomography scanning in 15. All patients underwent an operation in which the presence and extent of the vena caval thrombus were confirmed. Magnetic resonance imaging accurately delineated the presence and extent of the thrombus in all 20 patients (100%). Venacavography was accurate in 15 patients (94%) but 8 (50%) required a retrograde and antegrade study. Computerized tomography scanning demonstrated the presence of a tumor thrombus in all 15 patients but accurately delineated the cephalad extent of the thrombus in only 5 (33%). In patients with vena caval tumor thrombi magnetic resonance imaging can provide accurate information regarding the extent of vena caval involvement while avoiding the need for an invasive contrast imaging study.
Collapse
Affiliation(s)
- D A Goldfarb
- Department of Urology, Cleveland Clinic Foundation, Ohio 44106
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Novick AC, Kaye MC, Cosgrove DM, Angermeier K, Pontes JE, Montie JE, Streem SB, Klein E, Stewart R, Goormastic M. Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg 1990; 212:472-6; discussion 476-7. [PMID: 2222013 PMCID: PMC1358282 DOI: 10.1097/00000658-199010000-00010] [Citation(s) in RCA: 171] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
From June 1984 to September 1989, 43 patients with large vena caval tumor thrombi from retroperitoneal malignancies underwent surgical treatment with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The primary malignancies were renal cell carcinoma (RCC) (n = 39), renal pelvic transitional cell carcinoma (n = 1), adrenal pheochromocytoma (n = 1), and renal (n = 1) or retroperitoneal (n = 1) sarcoma. The level of the caval thrombus was either suprahepatic (n = 27), intrahepatic (n = 14), or subhepatic (n = 2). In all cases the primary tumor and caval thrombus were completely removed. Concomitant procedures included coronary artery bypass grafting (n = 5), pulmonary resection (n = 2), and hepatic lobectomy (n = 1). The time of circulatory arrest ranged from 10 to 44 minutes (mean, 23.5 minutes). There were two operative deaths (4.7%), neither of them due to to the use of DHCA. Major postoperative complications occurred in 13 patients (30.2%). There were no ischemic or neurologic complications and no cases of perioperative tumor embolization. The median postoperative hospital stay was 9 days. Twenty-two patients (51%) are alive and enjoying a good quality of life. The 3-year patient survival rates in patients with localized (n = 24) versus metastatic (n = 15) RCC are 63.9% and 10.9%, respectively (p = 0.02). We conclude that CPB with DHCA facilities excision of retroperitoneal malignancies with large caval thrombi and provides the potential for cure with low morbidity and mortality rates.
Collapse
Affiliation(s)
- A C Novick
- Department of Urology, Cleveland Clinic Foundation, OH 44195
| | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Angermeier KW, Ross JH, Novick AC, Pontes JE, Cosgrove DM. Resection of nonrenal retroperitoneal tumors with large vena caval thrombi using cardiopulmonary bypass and hypothermic circulatory arrest. J Urol 1990; 144:735-9. [PMID: 2388341 DOI: 10.1016/s0022-5347(17)39570-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Cardiopulmonary bypass with deep hypothermic circulatory arrest is a useful adjunct in the operative management of renal cell carcinoma associated with large vena caval thrombi. We present 2 patients with nonrenal retroperitoneal tumors and extensive vena caval thrombi who underwent successful surgical treatment with this method. The primary tumor was a leiomyosarcoma of the vena cava in 1 patient and a pheochromocytoma with hepatic invasion in 1. Cardiopulmonary bypass with deep hypothermic circulatory arrest is effective in decreasing the operative risk and improving the feasibility of resection in complex surgical cases. Consideration should be given to its use in a wider range of indicated procedures.
Collapse
Affiliation(s)
- K W Angermeier
- Department of Urology, Cleveland Clinic Foundation, Ohio 44106
| | | | | | | | | |
Collapse
|
41
|
Rifkin MD. Prostate sonography: clinical indications and implications. UROLOGIC RADIOLOGY 1989; 11:238-40. [PMID: 2692274 DOI: 10.1007/bf02926524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The current status of transrectal prostate sonography is reviewed with the clinical experience of the author relating its use in cancer detection, staging, and biopsy guidance.
Collapse
Affiliation(s)
- M D Rifkin
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| |
Collapse
|
42
|
Welch M, Bazaral MG, Schmidt R, Pontes JE, Cosgrove DM, Montie JE, Novick AC. Anesthetic management for surgical removal of renal carcinoma with caval or atrial tumor thrombus using deep hypothermic circulatory arrest. JOURNAL OF CARDIOTHORACIC ANESTHESIA 1989; 3:580-6. [PMID: 2520937 DOI: 10.1016/0888-6296(89)90156-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Twenty cases of renal carcinoma with tumor thrombus extending into the vena cava or atrium, in which cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used, are reviewed. Arterial, central venous (n = 9), or pulmonary artery catheters (n = 11), ECG, and rectal or bladder and pharyngeal temperatures were used for monitoring. The anesthetic was a high-dose narcotic supplemented with a nondepolarizing relaxant and a volatile agent. The surgery consisted of mobilization of the kidney followed by CPB via atrial and aortic cannulae, cooling via CPB, exsanguination, and removal of thrombus during DHCA. Duration of cooling was 21 +/- 7 minutes to a pharyngeal temperature of 15.8 degrees +/- 2.6 degrees C with alpha-stat pH management; DHCA lasted 26 +/- 10 minutes, and rewarming was continued to a mean pelvic temperature of 36.2 degrees C. Duration of surgery was 8.1 +/- 1.6 hours. The mean initial hematocrit was 33.5%, mean lowest Hct during CPB was 16.9%, and mean Hct at the end of surgery was 30%. Intraoperatively, 9.0 +/- 6.4 units of blood were used, and most patients received component therapy. Average crystalloid use was 7 L, and albumin or hetastarch (1.3 +/- 0.9 L) was used in 13 patients. One patient with severe cardiac disease could not be weaned from CPB. In the 19 operative survivors, there were no neurological deficits. There was one late death from pulmonary complications. The use of thiopental (n = 13), dexamethasone (n = 11), or mannitol (n = 19) was not clearly related to outcome. Hypothermia, hemodilution, alpha-stat pH management, and normoglycemia are believed to be important aspects of perioperative care.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Anesthesia Recovery Period
- Anesthesia, General/adverse effects
- Anesthesia, General/methods
- Anesthesia, Inhalation/adverse effects
- Anesthesia, Inhalation/methods
- Anesthesia, Intravenous/adverse effects
- Anesthesia, Intravenous/methods
- Blood Loss, Surgical
- Carcinoma, Renal Cell/pathology
- Carcinoma, Renal Cell/surgery
- Cardiopulmonary Bypass/adverse effects
- Cardiopulmonary Bypass/methods
- Diaphragm/blood supply
- Erythrocyte Count
- Heart Arrest, Induced/adverse effects
- Heart Arrest, Induced/methods
- Heart Atria/pathology
- Heart Neoplasms/pathology
- Heart Neoplasms/surgery
- Hepatic Veins/pathology
- Humans
- Hypothermia, Induced/adverse effects
- Hypothermia, Induced/methods
- Kidney Neoplasms/surgery
- Middle Aged
- Neoplastic Cells, Circulating/pathology
- Respiratory Insufficiency/etiology
- Time Factors
- Vena Cava, Inferior/pathology
- Vena Cava, Inferior/surgery
Collapse
Affiliation(s)
- M Welch
- Department of Cardio-Thoracic Anesthesiology, Cleveland Clinic Foundation, OH 44106
| | | | | | | | | | | | | |
Collapse
|
43
|
London NJ, Messios N, Kinder RB, Smart JG, Osborn DE, Watkin EM, Flynn JT. A prospective study of the value of conventional CT, dynamic CT, ultrasonography and arteriography for staging renal carcinoma. BRITISH JOURNAL OF UROLOGY 1989; 64:209-17. [PMID: 2679958 DOI: 10.1111/j.1464-410x.1989.tb05999.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The value of dynamic CT scanning for staging renal carcinoma was studied prospectively in 28 patients and the results compared with those of ultrasonography, arteriography and conventional CT. Arteriography correctly staged 48% of tumours; ultrasonography and conventional CT correctly staged 50% and dynamic CT correctly staged 72%. Dynamic CT staged renal carcinoma more accurately than ultrasonography, conventional CT or arteriography and it is suggested that arteriography should be restricted to specific indications such as the mapping of arterial anatomy and therapeutic renal artery embolisation.
Collapse
Affiliation(s)
- N J London
- Department of Urology, Leicester General Hospital
| | | | | | | | | | | | | |
Collapse
|
44
|
Belis JA, Pae WE, Rohner TJ, Myers JL, Thiele BL, Wickey GS, Martin DE. Cardiovascular evaluation before circulatory arrest for removal of vena caval extension of renal carcinoma. J Urol 1989; 141:1302-7. [PMID: 2724426 DOI: 10.1016/s0022-5347(17)41288-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The use of cardiopulmonary bypass, deep hypothermia and circulatory arrest has decreased the risks of hemorrhage, tumor embolization, incomplete thrombus resection, and warm hepatic and renal ischemia associated with resection of renal cell carcinoma extending into the inferior vena cava above the hepatic veins. Patients about to undergo this operation frequently have significant coronary artery and carotid artery disease, and are at risk for perioperative myocardial infarction and stroke. Preoperative evaluation of the coronary artery and carotid artery circulation by coronary angiography, duplex carotid artery scan and digital subtraction carotid angiography is recommended. Depending upon the severity and location of the cardiovascular disease a sequential or simultaneous operation may be performed. This surgical approach can be used in selected patients to facilitate complete tumor thrombectomy with a low operative risk.
Collapse
Affiliation(s)
- J A Belis
- Department of Surgery, Milton S. Hershey Medical Center, Pennsylvania State University, Hershey 17033
| | | | | | | | | | | | | |
Collapse
|
45
|
Vogt PR, Ensner R, Precirc;tre R, Schmidli J, Reuthebuch O, Zünd G, Turina MI. Less Invasive Surgical Treatment of Renal Cell Carcinomas Extending into the Right Heart and Pulmonary Arteries: Surgery for Renal Cell Carcinoma. Echocardiography 1985. [DOI: 10.1111/j.1540-8175.1985.tb01301.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
|