Vena cava resection for renal cell carcinoma

Surgical Resection of Neoplastic Thrombosis in the Inferior Vena Cava by Neoplasms of Renal-Adrenal Tract

Renal cell carcinoma extends to the inferior vena cava in six percent of the patients.5 Ten percent to twenty-two percent of these renal cell carcinoma are found to invade the right atrium.4 Although earlier reports attached a poor prognosis to renal carcinoma,10 it has been suggested recently that extended survival can be achieved following complete surgical extirpation. Therefore radical nephrectomy and thrombus removal represent the only possibility of survival in these patients. The classically elevated mortality of this procedure has been drastically transformed in our experience by the use of cardiopulmo nary by-pass and deep hypothermic circulatory arrest technique. We have had no operative deaths with carcinogenic tumor removal.

Cavectomy for the treatment of Wilms tumor with vascular extension

PURPOSE

Vascular extension to the vena cava occurs in 4% of Wilms tumor cases and can reach the right atrium in up to 1%. When this happens the thrombus is usually not adherent to the vessel wall, and there is blood flow around it. Preoperative chemotherapy can cause thrombus regression and even resolution. If the thrombus persists after chemotherapy, surgery will be a challenge. On the other hand, if the thrombus invades the vessel wall, its removal may not be feasible. In this situation cavectomy is a good surgical strategy because it provides complete resection. The prerequisite for cavectomy is the absence of blood flow in the vena cava on preoperative Doppler ultrasonography. We report 3 cases of Wilms tumor with vena caval invasion in which cavectomy was performed, and discuss the principles, indications and operative technique.

MATERIALS AND METHODS

A total of 171 patients with Wilms tumor were treated at our institution between 1984 and 2004. Of these patients 6 with intravascular extension of thrombus within the right atrium were treated with extracorporeal circulation, cardiac arrest and profound hypothermia, and 3 were treated with cavectomy.

RESULTS

There were no instances of surgical complications or postoperative renal failure in our patients who underwent cavectomy. All remain well and free of disease.

CONCLUSIONS

Cavectomy is a safe procedure for treating pediatric patients with Wilms tumor when there is extension and invasion of the vena cava wall without blood flow.

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.

Long-term experience with management of renal cell carcinoma involving the inferior vena cava

OBJECTIVES

To evaluate the long-term outcome and prognosis and influence of patient and tumor characteristics and therapeutic interventions on patients with renal cell carcinoma (RCC) extending to the inferior vena cava (IVC).

METHODS

The data of 75 patients (51 men and 24 women; age range 27 to 92 years) with RCC and involvement of the IVC, including 49 without and 26 with metastatic disease, treated between July 1973 and December 1998 were reviewed. The clinical presentation, laboratory and imaging investigations, extent and level of caval involvement, operative details, and estimated blood loss, as well as the postoperative course, morbidity, and actuarial and disease-free survival were analyzed.

RESULTS

Seventy-five patients between 27 and 92 years old with RCC involving the IVC were studied. Of the 54 operative patients, 48 had no metastasis and 6 had metastatic disease; 32 had IVC tumor extension to the infrahepatic or low retrohepatic IVC, 7 had high intrahepatic IVC extension, and 15 had right atrial extension. In 7 patients, tumor had invaded the IVC wall. Partial IVC wall excision was done in 4 patients and resection of a complete segment of the IVC in 3 patients. Tube graft to replace a segment of the IVC was used in 2 patients. Patients with intracardiac extension were initially treated with cardiopulmonary bypass. Subsequently, profound hypothermia and circulatory arrest were also used. Three patients died in the postoperative period: two with and one without metastatic disease. The follow-up period ranged between 25 and 144 months. Of the 48 patients without evidence of metastasis at surgery, the perioperative mortality rate was 2%. Twenty-two patients (47%) were alive without evidence of metastases, 4% developed solitary metastasis, and 36% eventually developed multiple metastases.

CONCLUSIONS

Our long-term experience confirms that of other investigators that nonmetastatic RCC with extension into the IVC is a potentially curable condition provided complete removal can be achieved. The level of extension of the tumor thrombus dictates the surgical techniques used for successful removal of the tumor thrombus. The treatment of patients with caval involvement and metastatic disease at presentation needs to be carefully individualized. Those with extensive multiorgan metastases continued to do poorly irrespective of the therapeutic approach chosen.

Wilms' tumor involving the inferior vena cava: preoperative evaluation and management

Neoplastic invasion of the inferior vena cava due to renal tumors (especially Wilms' tumor) is uncommon in children. The tumor thrombus, according to the aggressiveness of the original neoplasm, can extend in diverse ways, obliterate the vascular lumen completely, and even reach the right atrium. The luminal thrombus might be accompanied by the involvement of the caval wall, which requires wide vascular resection. The purpose of this paper is to present our experience with 7 children, aged 18 months and 6 years, affected by caval invasion due to Wilms' tumor. Furthermore, the diagnostic techniques and the surgical treatment in simple caval thrombosis and in associated invasion of the caval wall are described.

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.

Surgical management of renal cell carcinoma with extensive intracaval involvement using a venous bypass system suitable for rapid conversion to total cardiopulmonary bypass

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.

Surgical treatment of renal cell carcinoma with a tumor thrombus extending into the right atrium

We experienced surgical treatment on two patients having renal cell carcinoma with a tumor thrombus extending into the right atrium. In these patients, we performed nephrectomy, dissection of lymph nodes and removal of a tumor thrombus using cardiopulmonary bypass. One died of multiple organ failure 42 days postoperatively; the other was discharged from the hospital and is currently doing well 12 months after the operation. Cardiopulmonary bypass combined with hypothermia and low blood flow significantly facilitated removal of the tumor thrombus extending into the right atrium without the risk of pulmonary embolism or brisk hemorrhage.

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.

Surgery of hepatoma with intracavitary cardiac extension

A case of primary liver carcinoma with intracavitary cardiac extension is presented. A 36-year-old female was admitted to our surgical clinic with dyspnea and generalized edema. Echocardiography and superior vena cavography demonstrated a large filling defect in the right atrium. After a diagnosis of acute cardiac failure due to an intracardiac tumor, the patient was operated upon immediately. A right atriotomy exposed a large yellow mass within the right atrium, which was not adherent to the atrial wall. The mass was in continuity with similar material in the inferior vena cava and right hepatic vein. With a suspicion of hepatic malignancy, the atrial tumor was removed, and debulking of the mass in the inferior vena cava and right hepatic vein was performed. A postoperative histological examination of the tumor showed hepatocellular carcinoma. Her postoperative course was uneventful, and she was discharged from the hospital. Intracardiac extension of hepatoma is rarely encountered. In this clinical setting, long-term survival cannot be anticipated from any surgery, but palliative clearing of the atrium and inferior vena cava may be of value in preventing cardiac arrest causing sudden death.

Renal cell carcinoma with intracaval tumor thrombus extending to the diaphragm: ultrasonography and surgical management

We describe the successful management of a patient with intracaval extension of renal cell carcinoma to the level of the diaphragm. Ultrasonography delineated clearly the upper extent of the tumor thrombus and revealed no invasion of the vena caval wall at or above the entrance of the main hepatic veins. To prevent severe hypotension caused by intrapericardial control of the inferior vena cava, the aorta was clamped temporarily just above the celiac axis. The tumor was removed completely en bloc with the thrombus. Blood loss was minimal and the patient recovered promptly.

Supradiaphragmatic renal cell carcinoma tumor thrombus: indications for vena caval reconstruction with pericardium

Supradiaphragmatic extension of tumor thrombus from a renal cell carcinoma presents a major surgical challenge. The use of cardiopulmonary bypass, hypothermia and cardiac arrest with temporary exsanguination has allowed for successful surgical excision of these tumors. A renal cell carcinoma on the right side with a supradiaphragmatic tumor thrombus still may only partially occlude the vena cava. The collateral venous circulation of the left renal vein may be developed poorly and a pericardial patch can allow successful reconstruction of the inferior vena cava. If the tumor arises on the left side continued venous drainage of the right kidney is mandatory to prevent venous infarction of the right kidney. The entire vena cava also might be reconstructed theoretically with pericardium.

Peroperative staging of renal carcinoma. A methodologic comparison

Angiography, computed tomography and ultrasonography were compared with respect to staging of renal carcinoma in 41 patients with 46 renal tumours. Angiography and ultrasonography gave correct staging in 52% and 48%, respectively, while correct staging was achieved with computed tomography in 80% of the tumours.

Surgery of renal cancer with extensive caval invasion. Suggestion for a new approach

Radical surgery for renal cancer with invasion of the inferior vena cava can improve the patient's quality of life and, in some cases, offer longer survival or even cure. With a carefully planned surgical approach it is possible to remove renal tumours with thrombotic extension to the most proximal part of the inferior vena cava without necessity for cardiopulmonary bypass and without undue risk to the patient. In the operative procedure, good access and visual control of the proximal vena cava and all the contributing veins seem to be crucially important.

Renal cell carcinoma extending into the inferior vena cava: the prognostic significance of the level of vena caval involvement

The records of 24 patients with renal cell carcinoma involving the inferior vena cava who were free of metastatic disease at presentation were reviewed retrospectively. The over-all 2-year survival for the group was 45.8 per cent, with a mean survival of 38.9 months. When the group was analyzed according to the level of extension of the vena caval thrombus marked differences in the rate of survival and of incidence of local progression of disease were found. The 10 patients with an infrahepatic vena caval thrombus had a 2-year survival rate of 80 per cent and a mean survival of 61.4 months. Two patients (20 per cent) had extension of tumor into the perinephric fat and none had involvement of the regional lymph nodes. The 14 patients with a vena caval thrombus extending to the level of the hepatic veins or beyond had a 2-year survival rate of 21 per cent and a mean survival of 22.9 months. Tumor was present in the regional lymph nodes and/or perinephric fat in 9 of these patients (64 per cent). These results suggest that the level of vena caval involvement by tumor thrombus in patients with renal cell carcinoma has prognostic significance.

Inferior vena caval replacement after resection of left renal tumor in canine model

An animal model simulating the necessity of replacing the inferior vena cava (IVC) with a prosthetic graft is described. Six dogs underwent replacement of the IVC with an expanded polytetrafluoroethylene (E-PTFE) graft using an interrupted-suture technique. Three dogs served as controls, undergoing resection and autograft of the native IVC. Distal side-to-side femoral arteriovenous fistulas were constructed in each case and allowed to remain for six weeks. Subcutaneous heparin and prophylactic antibiotics were administered in the early postoperative period. All grafts were patent at six months, indicating a potentially successful technique for reconstruction of the IVC involved in disease or trauma.

Irreversible renal failure following right nephrectomy and left renal vein ligation

Ligation of the left renal vein has been advocated in certain clinical situations and venous outflow then is dependent on an adequate collateral venous system. We report on a child who suffered complete renal failure after ligation of the left renal vein in association with right nephrectomy and, subsequently, died. The left renal vein should be repaired in the presence of a solitary left kidney to prevent renal vein thrombosis and subsequent renal failure. This is particularly true in children in whom venous collateral circulation of the left kidney may not be well developed.

Suprarenal vena caval occlusion. Principles of operative management

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.

A new technique for management of renal cell carcinoma involving the right atrium: hypothermia and cardiac arrest

A 36-year-old man presented with massive edema below the axillae, pleural effusion and renal cell carcinoma with a tumor thrombus extending up the vena cava to the right atrium. A metastatic evaluation was negative otherwise. Hypothermia, cardiac arrest and temporary exsanguination in conjunction with cardiopulmonary bypass were used to create a bloodless field for excision of the renal cell carcinoma and its tumor thrombus. The patient has had total resolution of all symptoms and edema. Hypothermia and cardiac arrest facilitated greatly surgical excision and may be a useful adjunct in the excision of malignancies with massive involvement of the great vessels or heart.

Renal cell carcinoma extending into inferior vena cava

Of 18 patients with renal cell carcinoma extending into the inferior vena cava 16 underwent radical nephrectomy with either venacavotomy and tumor thrombectomy or vena cava resection. Of 8 patients with no evidence of metastasis at the time of surgery 4 (50 per cent) are free of cancer for a mean duration of 93 months. Of 8 patients with known preoperative metastasis 7 died with cancer after a mean survival of 12 months. Operative mortality was 6.2 per cent and morbidity was minimal.

Simultaneous sonographic demonstration of tumor thrombus in the inferior vena cava and patient main renal vein in renal carcinoma

With the introduction of new imaging modalities the optimal protocol for the evaluation of renal tumors is under close review. Angiographers frequently are faced with the question of whether to proceed to inferior venacavography following a selective renal angiogram that demonstrates a patent renal vein. We report a case of renal cell carcinoma in which the main renal vein was shown by ultrasound to be unequivocally patent but at the same time there was considerable tumor extension into the inferior vena cava. The necessity of full examination of the inferior vena cava, either by venacavography or ultrasound, in all cases of renal cell carcinoma is stressed.

Surgery and immunotherapy in renal cell carcinoma involving inferior vena cava

We herein report 4 cases of renal cell carcinoma with vena caval extension. Appropriate diagnostic studies and a planned surgical approach is the most effective treatment for intravascular spread. Accurate preoperative staging is important for a successful outcome. Although the technical challenges involved in performing a nephrectomy are substantial, these cases illustrate that standard nephrectomy with evacuation of tumor thrombus, ligation of the left renal vein, and even partial resection of the inferior vena cava can be performed with an acceptably low morbidity.

Computerized tomography versus angiography in the staging of malignant renal neoplasm

A comparative diagnostic study was carried out on 40 patients with pathologically proven renal malignancies which were staged both by angiography and CT. CT is more accurate than angiography for the detection of both perirenal and pararenal extension of the primary tumour (T-staging), and angiography is only slightly superior to CT in the evaluation of intravascular extension of the malignancy. The diagnostic performance of CT is clearly superior to angiography in detecting malignant lymphatic spread (L-staging) and distant metastases (M-staging). CT is, therefore, becoming the primary diagnostic approach for the staging of renal malignant tumours.

Results of inferior vena cava resection for renal cell carcinoma

A total of 24 patients with renal cell carcinoma involving the inferior vena cava underwent thoracoabdominal radical nephrectomy with removal of tumor thrombus by an open or closed technique. The tumor extended in the inferior vena cava to the level of the renal or lower hepatic veins in 18 patients and it reached the level of the diaphragm or right atrium in 6. Of the 24 patients 3 with preoperative findings minimally suggestive of disseminated disease were shown later to have metastases in the questionable areas, 3 with disease at the level of the diaphragm had incomplete resections, 4 had metastases to regional lymph nodes and 1 had questionable preoperative findings and lymph node metastases. Only 13 of the 24 patients (54 per cent) did not have either disseminated or residual tumor postoperatively. The mean survival duration of this subgroup (20 months) was comparable to that of the group as a whole (21 months). However, 4 patients from this subgroup are free of disease, with a mean followup of 30 months. There was 1 postoperative death. Morbidity, including renal failure, intraoperative hypotension and sepsis, was common. The results in this series suggest that the prognosis for patients with renal cell carcinoma and inferior vena cava involvement is guarded.

Computed tomography staging of renal carcinoma

The ability of fast thire-and fourth-generation scanning devices to supply images of sufficient quality to delineate the kidney, its vascular supply, and surrounding fascial envelope has provided a modality which permits preoperative staging of tumors of the kidney with an accuracy of about 90% in limited series of 20 specimen cases. The unreliability of bolus injection to evaluate tumor extension to the renal vein accounted for two errors.

En bloc resection of inferior vena cava in cytoreductive surgery for bulky retroperitoneal metastatic testicular cancer

En bloc resection of the inferior vena cava (IVC) has been demonstrated to be of benefit in removing bulky retroperitoneal testicular tumor metastases. The major indications for its use have been to increase the amount of tumor resected, to allow access to large amounts of tumor located posterior to the aorta which would otherwise be inaccesible, to diminish the possibility of massive pulmonary embolism from clot or tumor located in the IVC, and to decrease the risk of major hemorrhage from injury to the IVC, aorta, or one of their branches. To date the surgical morbidity has been acceptable, and no direct mortality has been associated with it.

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

We report on a patient who underwent complete removal of a renal cell carcinoma extending into the vena cava and the right atrium. The importance of accurate preoperative definition of the supradiaphragmatic extent of disease is emphasized and the surgical approach for removing such a tumor is described.

Renal venography: anatomy, technique, applications, analysis of 132 venograms, and a review of the literature

Selective renal venography is a simple but important diagnostic procedure which has few complications. A thorough knowledge of renal venous anatomy is essential for its proper performance and clinical application. This is particularly true because renal venous variations are frequent and may interfere with the successful appraoch to retroperitoneal surgery. The method is widely accepted for the evaluation of the renal venous bed in patients with suspected renal vein thrombosis or hematuria of unknown etiology. It depicts the extent of renal venous involvement in renal carcinoma and clarifies the diagnosis in some patients with avascular tumors, renal pelvic carcinoma, and retroperitoneal tumors. It may also be useful in defining the morphologic abnormality when the kidney fails to visualize on urography, in delineating the extent and nature of renal parenchymal disease, and in enhancing the precision of renal vein renin collection.

Renal cancer invading the inferior vena cava: clinical review and anatomical approach

Renal cell carcinoma invades the inferior vena cava in approximately 5 per cent of the patients. The only effective therapy for intravascular renal cell carcinoma is radical nephrectomy and complete removal of the tumor thrombus. To formulate a reasonable operative approach to intracaval renal cell carcinoma we have reviewed our experience with 6 cases as well as the experience of other investigators. In addition, we studied the collateral circulation of the renal veins as described by various anatomists, and to this information we have added our experience with inferior venacavography and with intraoperative and autopsy dissections. Herein we describe a new preoperative staging system for intravascular renal cell carcinoma. The operative approach to each stage is discussed in detail beneficial intraoperative maneuvers are described and illustrated.

Intraoperative management of renal cell carcinoma with supradiaphragmatic caval extension

A new technique for inferior vena caval tumor thrombectomy is described. Vascular isolation of the cava from the right atrium to the pelvis is achieved by temporary circulatory arrest of the lower torso. Removal of the neoplastic thrombus under direct vision with minimal blood loss was accomplished in a patient with renal carcinoma, whose tumor extended into the intrapericardial vena cava.

Renal tumors involving the inferior vena cava: plan for management

Our experience in the management of 12 malignant renal tumors involving the inferior vena cava is analyzed and a plan to manage the different degrees of caval involvement is discussed. The use of Pringle maneuver to control hepatic circulation during removal of suprahepatic caval extensions is recommended. Followup to date supports aggressive operative management in these patients.

Nephroblastoma with right atrial extension: preoperative diagnosis and management

A 14-year-old black boy, with a large nephroblastoma of the right kidney, had preoperative identification of inferior vena cava and right atrial involvement. Renal arteriography revealed linear arterial channels in the anatomic distribution of the inferior vena cava and venography revealed total caval occlusion and a right atrial mass. Radical excision, using a cardiopulmonary bypass, resulted in a 6-month postoperative survival.

Regression of renal carcinoma following radiation therapy

A case of regression of a renal carcinoma involving the inferior vena carva is presented. After 6 weeks of radiation therapy there was considerable diminution in the size of the tumor, rendering its surgical excision amenable. The tumor thrombus in the inferior vena cava also was markedly diminished after 5,000 rads. Radiation therapy is a valuable tool in the primary or adjunctive treatment of renal cell carcinoma. Preoperative treatment should be considered with large tumors and vena cava involvement.

Renal cell carcinoma presenting as right atrial tumor with successful removal using cardiopulmonary bypass

A 58-year-old male presented with signs and symptoms of right sided heart failure. Diagnostic evaluation revealed a right renal cell carcinoma with extension into the vena cava and right atrium. Surgical management included radical right nephrectomy with retroperitoneal lymph node dissection, inferior vena caval resection, and removal of the intra-atrial tumor thrombus using a cardiopulmonary bypass. Two years after surgery the patient is alive and well with no evidence of recurrent disease.