Surgical approach for removal of renal cell carcinoma extending into the vena cava and the right atrium

Critical Evaluation of a microRNA-Based Risk Classifier Predicting Cancer-Specific Survival in Renal Cell Carcinoma with Tumor Thrombus of the Inferior Vena Cava

(1) Background: Clear cell renal cell carcinoma extending into the inferior vena cava (ccRCCIVC) represents a clinical high-risk setting. However, there is substantial heterogeneity within this patient subgroup regarding survival outcomes. Previously, members of our group developed a microRNA(miR)-based risk classifier—containing miR-21-5p, miR-126-3p and miR-221-3p expression—which significantly predicted the cancer-specific survival (CSS) of ccRCCIVC patients. (2) Methods: Examining a single-center cohort of tumor tissue from n = 56 patients with ccRCCIVC, we measured the expression levels of miR-21, miR-126, and miR-221 using qRT-PCR. The prognostic impact of clinicopathological parameters and miR expression were investigated via single-variable and multivariable Cox regression. Referring to the previously established risk classifier, we performed Kaplan–Meier analyses for single miR expression levels and the combined risk classifier. Cut-off values and weights within the risk classifier were taken from the previous study. (3) Results: miR-21 and miR-126 expression were significantly associated with lymphonodal status at the time of surgery, the development of metastasis during follow-up, and cancer-related death. In Kaplan–Meier analyses, miR-21 and miR-126 significantly impacted CSS in our cohort. Moreover, applying the miR-based risk classifier significantly stratified ccRCCIVC according to CSS. (4) Conclusions: In our retrospective analysis, we successfully validated the miR-based risk classifier within an independent ccRCCIVC cohort.

Intraoperative detection of inferior vena caval tumor thrombus extending from metastatic lymph node of renal cell carcinoma using ultrasonography

A 67-year-old man consulted our department with gross hematuria. Computed tomography (CT) revealed a huge renal tumor with a paracaval metastatic lymph node (mLN). Right total nephrectomy was planned for the renal tumor diagnosed as renal cell carcinoma preoperatively. Just before the resection of the renal vein and artery, intraoperative ultrasonography revealed an inferior vena caval tumor thrombus (IVCTT) extending from the mLN. Ultrasonography clearly and dynamically demonstrated a rhythmic flapping movement of the IVCTT with blood flow in the inferior vena cava. Following right radical nephrectomy, IVCTT resection with the vessel wall was performed to reduce the risk of pulmonary tumor thrombus. Histopathological diagnosis of the renal tumor was clear cell renal cell carcinoma, and the resected IVCTT was confirmed histopathologically as tumor involvement from the mLN of the renal cell carcinoma. Intraoperative ultrasonography can detect IVCTT extending from the mLN, whereas CT cannot.

Intracaval Adrenocortical Carcinoma: A Case Report and a Review of the Operative Strategies

Adrenocortical carcinomas are rarely encountered tumors that have a ten dency to invade the inferior vena cava. The only effective therapy is complete surgical resection including the extraction of any intracaval tumor thrombus. A case of adrenal tumor with inferior vena caval involvement that manifested early as a pulmonary embolus is presented. The operative approach to intra caval extension is discussed, and operative maneuvers are illustrated.

Modified technique of cavoatrial tumor thrombectomy without cardiopulmonary by-pass and hypothermic circulatory arrest: a preliminary report

Introduction

Traditionally, tumor thrombi extending into the right atrium have been managed by open surgery with sternotomy, cardiopulmonary bypass circulation and hypothermic circulatory arrest, and are associated with significant morbidity and mortality rates. Here, we evaluate the results of cavoatrial thrombectomy using our own, Foley catheter assisted-technique, obviating the need for thoracotomy, extracorporeal circulation, and/or hypothermic circulatory arrest.

Material and methods

Between June 2013 and January 2015, 4 consecutive patients underwent cavoatrial thrombectomy performed with our own, Foley catheter assisted technique, via Chevron incision, with no need for extracorporeal circulation or hypothermy for renal cell carcinoma with tumor thrombus extending into the right atrium. Analyses of patients’ data from a prospectively maintained database with respect to perioperative characteristics, morbidity and mortality were performed.

Results

The total mean duration of surgery was 255 minutes. The mean time of total IVC (inferior vena cava) occlusion was 90 seconds. The average blood loss volume, timed from the beginning of cavotomy incision until its closure, was 1200 ml. The total mean intraoperative blood loss was 3,150 ml. There was no perioperative death. Postoperative complications included one transient acute kidney injury requiring one-off hemodialysis and one re-operation due to bleeding. The follow-up time ranged between 12 to 17 months. None of the patients developed disease recurrence. All patients were still alive at the time of study completion.

Conclusions

Obtained results support the validity of our own, Foley catheter assisted technique, without cardiopulmonary bypass and hypothermic circulatory arrest for the treatment of renal cell carcinoma with tumor thrombus extending into the right atrium.

Neoadjuvant targeted therapy in a primary metastasized renal cell cancer patient leads to down-staging of inferior vena cava thrombus (IVC) enabling a cardiopulmonary bypass-free tumor nephrectomy: a case report

BACKGROUND

We report on a 62-year-old gentleman presenting at our urological department with an advanced renal cell cancer of the right kidney (10 cm in diameter), with an extensive caval vein thrombus (level IV) and bilateral pulmonary metastases. Another suspicious lesion at the left hemithorax was radiologically described.

METHOD

A presurgical, neoadjuvant systemic therapy with sunitinib, a tyrosine kinase inhibitor, was initiated for 4 cycles in total (50 mg/day; 4 weeks on/2 weeks off). The cytoreductive nephrectomy was performed following the fourth cycle of sunitinib and after a 14-day break. Transesophageal echocardiography was used for intraoperative monitoring of the caval vein thrombus. Systemic treatment with sunitinib was continued 4 weeks after surgery.

RESULTS

A significant reduction in tumor size, metastatic sites and down-staging of IVC from level IV to level III according to Novick classification was achieved.

CONCLUSION

Significant down-staging of the tumor caval vein thrombus which initially reached the right atrium enabled us to perform surgery limited to the abdominal cavity without extracorporeal circulation nor hypothermia.

Benefits of liver transplantation surgical techniques in the management of extensive retroperitoneal tumors

BACKGROUND

The potential for massive hemorrhage imposes additional challenge in the management of retroperitoneal tumors. This report details technical considerations for the management of upper retroperitoneal tumors using principles of liver transplantation.

METHODS

A retrospective chart review of patients who underwent surgery for extensive retroperitoneal tumors using techniques for liver transplantation from December 2002 to November 2007 was done.

RESULTS

Twenty-four patients (14 males and 10 females with a mean age 57 years) underwent major retroperitoneal surgery. Renal cell carcinoma was the most common tumor seen in 17 patients. Mean tumor dimension was 12.4 cm. Abdominal exposure was achieved via bilateral subcostal incision with upper midline extension. Right hepatic lobe mobilization and isolation from the inferior vena cava (IVC) was performed in 23 cases. Fourteen patients had IVC involvement by tumor thrombus, which was infrahepatic in six, retrohepatic in five, and intra-atrial in three patients. Tumor thrombus was removed by cavotomy in seven cases, resection and plasty in four cases, IVC graft reconstruction in two cases, and one patient required IVC and atrial graft reconstruction. Liver resection was needed in seven patients to achieve R0 resection. The Pringle maneuver was used in three patients; total liver vascular isolation with venovenous bypass was required in two cases, transdiaphragmatic intrapericardial IVC control in one case, and cardiopulmonary bypass in one patient. There was no intraoperative or postoperative mortality and mean length of stay was 13 days.

CONCLUSION

Liver transplantation surgical principles help achieve exposure and vascular control of major vascular structures that enable safe resection of these extensive retroperitoneal tumors.

Analysis of renal cell carcinoma with subdiaphragmatic macroscopic venous invasion (T3b)

OBJECTIVE

To review our institutional experience of surgery for renal cell carcinoma (RCC) with subdiaphragmatic macroscopic venous invasion (T3b) and to assess variables associated with cancer-specific survival (CSS), as the stratification of RCC with venous involvement (T3b and T3c) is subject to debate.

PATIENTS AND METHODS

We retrospectively reviewed the hospital records of patients who underwent a radical nephrectomy with resection of subdiaphragmatic tumour thrombus (T T) between October 1990 and May 2006. The log-rank and Cox uni- and multivariate regression analysis were used to evaluate predictive factors for CSS.

RESULTS

In all, 101 cases were identified. In the N0M0 group, univariate Cox regression analysis confirmed that ipsilateral adrenal gland invasion, Mayo Clinic level of T T, histological subtype and fat invasion were significantly associated with worse CSS. In multivariate Cox regression analysis, only Mayo Clinic level of T T was an independent predictor for CSS. In the subgroup with renal vein involvement only, the median CSS was not reached. In the subgroups with level I, II and III T T involvement, the median CSS was 69, 26 and 21 months, respectively. In the N+ and/or M+ group, only tumour size and type were independent predictors of CSS, while the level of T T was not. Radical nephrectomy yielded poor results with a median CSS of 13 months.

CONCLUSION

The Mayo Clinic level of T T is an independent prognostic predictor for CSS in non-metastatic T3b RCC. We strongly support the need for re-classification of the currently applied 2002 Tumour-Node-Metastasis staging system, which in its present form does not discriminate between levels of subdiaphragmatic venous invasion.

Intravenous Uterine Leiomyosarcomatosis With Intracardial Extension

Uterine leiomyosarcoma is a rare malignant tumor of smooth muscle origin. We describe the case of a 64-year-old female with intravenous uterine leiomyosarcomatosis with the extension of the tumor mass into the inferior vena cava and right atrium. As initial tissue diagnosis of the tumor obtained from the uterine and right atrial masses suggested intravenous leiomyomatosis, surgical resection was carried out using a one-stage procedure via a laparotomy and median sternotomy with cardiopulmonary bypass and circulatory arrest. Subsequent histology revealed uterine leiomyosarcoma with an intravenous spread, which to our knowledge is only the second case that has been described.

Preoperative staging of renal cell carcinoma with inferior vena cava thrombus using multidetector CT and MRI: prospective study with histopathological correlation

OBJECTIVE

To evaluate the accuracy of multidetector computed tomography (CT) and magnetic resonance imaging (MRI) in staging and estimating renal carcinomas with caval thrombus.

METHODS

Initially, 23 patients with suspected caval thrombi were admitted into this prospective study. Triphasic CT imaging was performed using a multidetector CT with a reconstructed slice thickness of 2 mm. 3D CT reconstructions were used to improve surgical planning. MRI protocol included: a transversal T1-weighted GE sequence with and without Gd-DTPA, a transversal T2-weighted respiratory-gated TSE, and a coronal T1-weighted GE sequence with Gd-DTPA and fat saturation. In addition, a multiphase 3D angiography was performed after Gd-DTPA injection. Patients were divided into 3 groups: caval thrombus below the insertion of the hepatic veins, within the intrahepatic vena cava, and intra-atrial extension. The results the tumor thrombus extension and staging results of 2 independent readers were correlated with surgical and histopathological staging.

RESULTS

Of the 23 patients admitted, CT and MR scans of 14/13 patients respectively were correlated with histopathological workup. CT thrombus detection sensitivity and specificity for both readers was 0.93 and 0.8 respectively. MRI sensitivity and specificity for both readers was 1.0/0.85 and 0.75. Readers I and II evaluated the uppermost extension of the cranial tumor thrombus by both CT and MRI. CT and MR accuracy was 78% and 72%, 88% and 76% respectively.

CONCLUSION

In cases of a suspected tumor thrombus, MRI and multidetector CT imaging showed similar staging results. Consequently, these staging modalities can be used to assess the extension of the tumor thrombus.

Liver Harvesting Surgical Technique for the Treatment of Retro-Hepatic Caval Thrombosis Concomitant to Renal Cell Carcinoma: Perioperative and Long-Term Results in 15 Patients without Mortality

OBJECTIVE

Radical surgical treatment improves the prognosis of patients affected by Inferior Vena Cava (IVC) thrombosis concomitant to renal carcinoma. However, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable haemorrhages and tumor fragmentation. We report the results of an innovative surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. In the presence of retro-hepatic IVC thrombosis, this technique improves vascular control and allows to perform a large cavotomy with an en-bloc removal of the thrombus and the tumor.

METHODS

From January 1995 through June 2003, 15 patients with renal cancer and caval thrombosis were treated at our Institution. Four, ten and one patients were respectively affected by an infrahepatic (Level I), retro-hepatic (Level II) and atrial (Level III) IVC thrombosis.

RESULTS

All patients underwent radical surgical treatment. In presence of Level II caval thrombosis, the patients underwent the above reported surgical technique. Perioperative mortality was absent; major morbidity occurred in one patient (6.7%). The thrombus was radically removed in all cases. After a mean follow-up of 53.9 months (5-100 months) all patients but one are still alive. One patient died 9 months after surgery with multiple bilateral pulmonary metastases.

CONCLUSIONS

Isolation of the retro-hepatic IVC is a safe and effective manoeuvre to significantly reduce perioperative mortality and morbidity in patients affected by Level II caval thrombosis concomitant to renal carcinoma.

[Surgical management of renal cell carcinoma with vena cava-right atrium thrombus]

Historically the presence of a thrombus in vena cava was associated with worse prognosis in patients with renal cell carcinoma, and the effective of surgery limited. However a extensive tumor thrombi can be present without evidence of lymph node and distant metastasis, an aggressive surgical approach with curative intent is justified. We retrospectively reviewed 25 patients with renal cell carcinoma and thrombus in vena cava and they underwent radical nephrectomy and thrombectomy. The IRM allowed to know the level of the thrombus into vena cava in all patients: 56% level I, 8% level II, 26% level III. There were 14 pT3b, 8 pT3c, 3 pT4, and 48% N+. The rate of complications was 36% and there were 4 perioperative death (16%). Patients without lymph node and no distant metastasis had a mean survival of 64% 46%, 37% to 2, 3, 4 years respectively. Patients with lymph node invasive an distant metastasis the prognosis was poor. We no noted correlation between level thrombus and prognosis.

Surgical techniques for treating a renal neoplasm invading the inferior vena cava

PURPOSE

Historically inferior vena caval thrombus associated with renal cell carcinoma was a deterrent to surgery. During the last 3 decades there has been steady improvement in surgical techniques and perioperative care, which has dramatically improved the ability to resect safely these tumors. We acknowledge these improvements in chronological order.

MATERIALS AND METHODS

A comprehensive literature review of the different techniques used for resecting renal cell carcinoma with inferior vena caval involvement was performed using MEDLINE. Data focused on surgical techniques, including various incisions, exposures, adjuncts to surgery and outcomes.

RESULTS

Tumor thrombus associated with renal cell carcinoma is no longer considered to have a detrimental impact on survival. Patients who are acceptable surgical candidates have survival rates as high as 68%. Although there is a great deal of emphasis on the importance of an aggressive surgical approach, a uniform operative strategy based on the level of the tumor thrombus has not been established. Surgical techniques derived from liver transplant surgery and cardiac arrest with cardiopulmonary bypass have drastically decreased operative complications associated with extensive involvement of the inferior vena cava with tumor thrombus.

CONCLUSIONS

The only curative approach to renal cell carcinoma is surgery. An aggressive approach is warranted when tumor involves the renal vein and inferior vena cava. Surgical strategy depends on the level of the inferior vena caval thrombus. Patients with extension of the thrombus above the diaphragm are a greater technical challenge. Hypothermic circulatory arrest should be considered when treating vena caval-atrial tumor thrombus. Surgeons familiar with liver mobilization can greatly facilitate the exposure needed for safely operating in these cases.

[Renal surgery]

Predominantly during the past century. This review paper addresses the most relevant issues in the historic evolution of renal surgery and establishes the criteria that guide the current situation in the most prevalent and relevant renal conditions (neoplasia, lithiasis, infections and transplantation). Eventually, the attitudes which in the author's opinion will guide the future of renal surgery are established.

Assessment of tumor invasion of the vena caval wall in renal cell carcinoma cases by magnetic resonance imaging

PURPOSE

We evaluated the role of magnetic resonance imaging (MRI) in patients with renal cancer and inferior vena caval involvement with reference to its ability to characterize the extent and nature of inferior vena caval tumor extension and wall invasion.

MATERIALS AND METHODS

The study included 12 consecutive patients with renal cancer and inferior vena caval involvement. All patients underwent imaging on a 1.5 Tesla MRI unit. Coronal, axial T1 and axial T2-weighted images were performed in all cases, while in 6 3-dimensional gadolinium enhanced magnetic resonance angiography and venography were also performed. Images were assessed for the extent and nature of tumor extension, that is tumor versus thrombus, and invasion of the inferior vena caval wall. Imaging results were compared with operative findings.

RESULTS

On MRI the extent and nature of the inferior vena caval tumor was correctly defined in all cases. The sensitivity, specificity and accuracy of inferior vena caval wall invasion were 100%, 89% and 92%, respectively.

CONCLUSIONS

In patients with renal cancer and inferior vena caval involvement MRI defines the tumor level in the inferior vena cava. It is also a sensitive technique for detecting vessel wall invasion and provides important preoperative information for surgical planning.

Superior Vena Cava Syndrome Due to Metastatic Transitional Cell Carcinoma

Superior vena cava syndrome due to infradiaphragmatic tumor metastasis was detected in a 70-year-old man. A tumor attached to the right atrial wall was excised and subsequent transurethral resection of a bladder tumor revealed high-grade transitional cell carcinoma. The disease progressed and the patient died 6 months later.

Thoracoabdominal radical nephrectomy: is a postoperative thoracostomy tube necessary?

OBJECTIVES

To report our results of patients undergoing thoracoabdominal radical nephrectomy without intraoperative placement of a thoracostomy tube. It has been routine in our hospital to not place a thoracostomy tube in patients undergoing thoracoabdominal radical nephrectomy since 1988.

METHODS

We conducted a retrospective review of 47 thoracoabdominal radical nephrectomies performed from January 1988 through November 1998 at our institution. Of the 47 patients, 39 did not have a thoracostomy tube placed intraoperatively; the other 8 patients did. The development of all postoperative complications, length of hospital stay, and hospital charges were noted.

RESULTS

No postoperative mortality was noted in our study. Of the 47 patients in the study, 20 patients had a total of 29 complications. The overall number of complications was not increased in the group without a thoracostomy tube compared with the group with a thoracostomy tube (P = 0.104). No patient treated without a thoracostomy tube required subsequent placement of a tube for persistent pneumothorax. The mean length of hospital stay in patients with a thoracostomy tube after radical nephrectomy was 9.14 +/- 2.65 days; in patients without a thoracostomy tube, the mean length of stay was 7.07 +/- 3.97 days (P = 0.071).

CONCLUSIONS

In patients without parietal pleural injury, thoracoabdominal radical nephrectomy without the placement of a thoracostomy tube can be performed safely and effectively, with a low risk of postoperative complications and a decrease in the overall hospital stay and hospital charges.

Unusual abdominal tumors with intracardiac extension. Two cases with successful surgical resection

Abdominal tumors that can grow through vascular lumen and spread to the right heart are rare. Although these tumors have different histologic aspects, they may cause similar abdominal and cardiac symptoms and are a serious risk factor for pulmonary embolism and sudden death when they reach the right atrium and tricuspid valve. The best treatment is radical surgical resection of the entire tumor using cardiopulmonary bypass with or without deep hypothermia and total circulatory arrest. We report the cases of two patients, the first with leiomyosarcoma of the inferior vena cava and the other with intravenous leiomyomatosis of the uterus that showed intravascular growth up to right atrium and ventricle, who underwent successful radical resection in a one-stage procedure with the use of cardiopulmonary bypass. We discuss the clinical and histologic aspects and imaging diagnosis and review the literature.

Can duplex Doppler ultrasound replace computerized tomography in staging patients with renal cell carcinoma?

The purpose of this study was to evaluate the accuracy and reliability of duplex Doppler ultrasound (US) and computerized tomography (CT) in staging patients with renal cell carcinoma (RCC). Sixty-six patients were evaluated pre-operatively with duplex Doppler ultrasound and CT. The results were compared with the surgical and histopathological findings. T stage was determined correctly with duplex Doppler US and CT in 56 and 50 cases respectively. In 4 patients with nodal disease duplex Doppler US was correct in 2 patients, 1 was false positive. With CT, 3 patients were staged correctly and 3 were false positive. Of the 14 patients with vascular tumour thrombi, 13 were staged correctly with duplex Doppler US and 12 with CT scan. False positive vascular tumour invasion was seen only with CT in 4 cases. Based on these results we conclude that duplex Doppler US is at least as accurate as CT scanning in the staging of RCC. Also in patients with renal or caval thrombi, duplex Doppler US is highly accurate in establishing the diagnosis and in the determination of the extent of the thrombus.

Renal cell carcinoma extending to the renal vein and inferior vena cava: results of surgical treatment and prognostic factors

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.

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.

Renal cell carcinoma extending into the vena cava: surgical approach, technique and results

OBJECTIVE

To describe the technique and results of a thoraco-abdominal approach to removing the caval thombi in patients with renal cell carcinoma extending into the vena cava.

PATIENTS AND METHODS

Between 1970 and 1990 35 patients presenting with renal cell carcinoma extending into the vena cava were treated at the Department of Urology, Innsbruck. Twenty-three of these patients underwent radical tumour nephrectomy including cavotomy and thrombectomy or caval resection. A transabdominal approach had been used in this department for radical tumour nephrectomy including cavotomy and thrombectomy or caval resection until 1987. Since 1988, a thoraco-abdominal approach has been employed. In group I patients the approach was via the seventh intercostal space, whereas in group II and III patients the thoraco-abdominal incision was made through the fifth intercostal space. In the present study the anatomy of the thoraco-abdominal approach is described.

RESULTS

Tumour staging and grading yielded stage T3b in 15 patients (grade I, 1; grade II, 6; grade III, 8); another eight patients with stage T3b were found to have metastatic disease (N1, 6; N2, 2; M1, 3). On the basis of the extension of the caval thrombus the patients were classified as follows: group I, 16; group II, 3; group III, 4. In T3b N0 M0 patients the 5-year-survival rate was 62.5%, while in patients with positive lymph nodes the mean survival rate was 15.5 months.

CONCLUSION

Our results suggest that the thoracoa-abdominal approach is the method of choice for the safe removal of renal cell carcinomas associated with caval thombi. If resection of the caval tumour is complete, prognosis is dependent on known factors, such as tumour invasion, nodal involvement and distant metastases rather than the extension of the tumour thrombus. An aggressive approach is not warranted in patients with nodal involvement and/or distant metastases, as it does not improve survival.

Surgical management of renal carcinoma with extensive involvement of the vena cava and right atrium

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.

A strategy for resection of Wilms' tumor with vena cava or atrial extension

Resection of a Wilms' tumor that extends into the vena cava or right atrium results in excellent survival when combined with adjuvant therapy. Preoperative identification of the presence of intravascular tumor thrombus and the level of vascular involvement is essential. It facilitates safe surgical resection, with cardiopulmonary bypass immediately available for retrohepatic and atrial tumors. Six patients with intracaval or intracardiac tumor thrombus were treated over a 5-year period with no perioperative deaths. Preoperative chemotherapy was useful in two patients with extensive tumors and pulmonary metastases. Our results using an integrated management plan suggest that an aggressive surgical approach is justified for this extensive variant of Wilms' tumor.

Extension incision for renal carcinoma including invaded vena cava and right lobe of liver

We report on a thirty-five-year-old woman with renal cell carcinoma who successfully underwent right radical nephrectomy and extended right hepatic lobectomy with resection and reconstruction of inferior vena cava (IVC). A temporary bypass was placed between the infrarenal IVC and right atrium using a heparin-coated synthetic tube. The tumor was resected en bloc including right kidney, adrenal gland, hepatic lobe, and IVC. The IVC was reconstructed using an expanded polytetrafluoroethylene (EPTFE) graft. Her postoperative course was uneventful with no signs of recurrence four years after surgery.

Adrenal cortical carcinoma with vena cava tumor thrombus requiring cardiopulmonary bypass for resection

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.

Management of primary nonrenal parenchymal malignancies with vena caval thrombus

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.

Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi

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.

Resection of nonrenal retroperitoneal tumors with large vena caval thrombi using cardiopulmonary bypass and hypothermic circulatory arrest

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.

Cardiovascular evaluation before circulatory arrest for removal of vena caval extension of renal carcinoma

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.

Surgical management of renal cell carcinoma with intracaval neoplastic extension above the hepatic veins

Cardiopulmonary bypass, hypothermia, temporary cardiac arrest and exsanguination represent the next logical step in the evolutionary management of intracaval neoplastic extension with renal cell carcinoma. This method of management provides control of the circulation of the entire body and allows for careful dissection in a bloodless field with less risk of embolization. From 1981 to 1986, 15 patients were treated with intracaval neoplastic extension of renal cell carcinoma above the level of the most inferior hepatic veins. In 6 patients mobilization of the vena cava with division of the hepatic veins to the caudate lobe allowed excision of the tumor and tumor thrombus without cardiopulmonary bypass (group 1). The remaining 9 patients underwent cardiopulmonary bypass and hypothermia (group 2). There was 1 postoperative mortality in the entire group. Most patients had advanced regional disease but the feasibility of this technique has been demonstrated. Survival appeared to be less in the bypass group. Although some of the patients have had metastatic disease, the quality of life and survival have been prolonged in many of these acutely ill patients.

Resection of large inferior vena caval thrombi from renal cell carcinoma with the use of circulatory arrest

Removal of a large extension of renal cell carcinoma into the inferior vena cava can be a difficult operation. Circulatory arrest is an operative technique that recently has been used to assist in resection of tumors that extend into the vena cava above the level of the hepatic veins. At our clinic 18 patients were operated on with the intent of using circulatory arrest during radical nephrectomy and inferior vena caval thrombectomy. Of the 18 patients 13 ultimately underwent this procedure, since the remaining 5 had unresectable tumors. One patient died intraoperatively of an adverse reaction to protamine after technically successful removal of the tumor and thrombus. Resection was successful in 12 patients and 9 remained free of disease with short followup. We believe that the addition of circulatory arrest during resection of a large inferior vena caval thrombus allows for an opportunity to resect the tumor in a controlled situation that reduces the potential for sudden massive blood loss or a major vascular injury, and ultimately makes the operation safer.

Caval extension of renal cell carcinoma. Results of surgical treatment

Twenty-eight patients with renal cell carcinoma extending to the vena cava underwent surgical treatment consisting of radical nephrectomy and removal of tumor thrombus, which was at the level of the renal veins in 23 cases, the hepatic veins in 4, and extending above the diaphragm in 1 case. In 7 patients lymph nodes were invaded, and 8 had both positive nodes and extrarenal tumor diffusion discovered at surgery. The mean survival was 41.7 months for patients with only venous extension of the tumor, 16 months for patients with positive nodes, and 10.2 months for those with both nodal and extrarenal tumor diffusion.

Extension of renal cell carcinoma into the vena cava: clinical review and surgical approach

Between 1972 and 1983, 25 patients were treated for renal carcinoma with tumor extension into the vena cava but without other clinical evidence of disseminated disease. Of these patients 12 had vena caval tumor thrombus extension up to the level of the hepatic veins (group 1), 10 had extension into the intrahepatic vena cava (group 2) and 3 had tumor extending into the right atrium (group 3). A perioperative management plan and an anatomical surgical approach have been developed to allow safe en bloc removal of these extensive tumor thrombi without removal of the vena cava. Successful management is dependent upon preoperative evaluation to determine precisely the extent of the disease, prophylaxis against pulmonary embolism and a well planned surgical method. For patients without evidence of metastatic or perinephric disease, the 5-year actuarial survival rate of 33 per cent is comparable to that of other patients without thrombus. Complete resection was possible in 20 patients (80 per cent), with a 5-year actuarial survival rate of 36 per cent. While patients with metastatic tumor cannot be cured, short-term palliation can be achieved for patients who have an imminent risk of vena caval occlusion or pulmonary embolism by an en bloc removal of tumor and thrombus, even for those with intra-atrial extension. Over-all, operative intervention was successful, with 22 of 25 patients leaving the hospital alive.