Prosthetic replacement of the inferior vena cava after resection of a pheochromocytoma

A large pheochromocytoma requiring aortic and inferior vena caval reconstruction: A case report

RATIONALE

It is difficult to discriminate malignant pheochromocytoma (PCC) from benign PCC. The requirement of abdominal aortic and inferior vena cava reconstruction is extremely rare.

PATIENT CONCERNS

We here report a case of a large pheochromocytoma in a 56-year-old woman who complained of only hand trembling and had no hypertension or other symptoms. The operation was difficult because of a tight adhesion to the circumference of great vessels. A replacement of the aortocaval vessels with grafts was necessary to remove the tumor completely.

DIAGNOSES

Ultrasonography, computed tomography (CT), and catecholamine assay revealed suspecting the retroperitoneal PCC.

INTERVENTIONS

Tumor excision and reconstruction of the abdominal aorta and inferior vena cava by externally supported polytetrafluoroethylene (ePTFE) vessels were successfully performed.

OUTCOMES

A follow-up CT angiography showed no recurrence and graft vessels presented good patency after 7years. Catecholamine in urine and serum assay was normal.

LESSONS

The complete resection of the tumor and infiltrated great vessels were necessary for the long-term survival of patients with a large PCC. The ePTFE graft is a good substitute for vessel reconstruction.

Phaeochromocytoma and Paraganglioma Excision Involving the Great Vessels

Objective/background

Phaeochromocytomas and paragangliomas are vascular neuroendocrine tumours distributed between the neck and the pelvis and may be associated with catecholamine secretion. The aim of the study was to describe the complex surgical management required to excise these tumours when in close proximity to the great vessels (aorta and vena cava).

Methods

This was a retrospective case series. Patients included those undergoing surgical excision of a phaeochromocytoma or paraganglioma involving the great vessels. Data on clinical presentation; genetic mutations; tumour location; catecholamine/metanephrine secretion; surgical strategy; pre-, intra-, and post-operative course were collated.

Results

Five patients (age range 16–60 years) were identified; three had thoracic paragangliomas located under the arch of the aorta, one had an abdominal paraganglioma invading the aorta, and one had a massive phaeochromocytoma invading the inferior vena cava via the adrenal vein. Three patients had predisposing germline mutations. All patients had adrenergic blockade prior to surgery. A diverse range of complex surgical techniques were employed to excise tumours, including cardiopulmonary bypass, aortic resection, grafting and venotomy of the vena cava. Early post-operative complications were limited.

Conclusions

Excision of phaeochromocytomas and paragangliomas involving the great vessels is high risk surgery optimally undertaken within a multidisciplinary setting in a tertiary referral centre. Comprehensive radiological and biochemical assessment, meticulous pre-operative preparation and close intra- and post-operative monitoring are essential. Radiological imaging may be unable to resolve the tumour extent and anatomy pre-operatively and direct visualisation of the tumour may be the only way to clarify the surgical strategy. Pre-operative knowledge of the genetic predisposition may influence surgical management.

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Highly vascular tumours which may be associated with catecholamine secretion.

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Comprehensive pre- and intra-operative preparation is essential.

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Final surgical strategy often requires direct tumour visualisation.

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The surgical strategy may alter for germline associated tumours.

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Management should be delivered by experienced multidisciplinary teams.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical management of a neuroendocrine tumor of the inferior vena cava

Neuroendocrine tumors occurring outside of the gastrointestinal tract or lungs are very few, and to find a primary neuroendocrine tumor of the infrahepatic inferior vena cava (IVC) is extremely rare. We present a case of a patient with a large, 7 × 4 cm neuroendocrine tumor of the IVC, where the IVC and renal veins were completely extirpated and not reconstructed. As a result, the liver was anastomosed to the intrapericardial IVC, and the patient relied on collateral drainage. After an initial postoperative period of anasarca and weight gain, she ultimately recovered fully with no evidence of recurrence in the IVC.

Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies

OBJECTIVE

To evaluate the feasibility and results of prosthetic venous replacement, as inferior vena cava (IVC) and iliofemoral vein resection and replacement are sometimes necessary when they are extensively involved by a large and fixed tumour thrombus from renal cell carcinoma (RCC) or other urological malignancies.

PATIENTS AND METHODS

Five men and two women (age range 41-75 years) were treated over a 10-year period (1991-2001) by aggressive venous surgery to achieve complete tumour resection, with prosthetic graft replacement to re-establish venous flow. The tumours included RCC of the right kidney (two), retroperitoneal liposarcoma (two), bladder cancer (one), retroperitoneal fibrosarcoma (one) and inguino-pelvic lymphoma (one). Two patients had a vena caval replacement, of whom one had a circular reinforced PTFE and one a Dacron silver graft; five patients had either an iliofemoral or an ilio-iliac circular reinforced PTFE graft. The prosthetic diameter was 18-20 mm for the IVC grafts and 8-10 mm for the iliac grafts. In all the patients, graft patency was evaluated during the follow-up by colour flow duplex imaging, and in one it was determined by angio-computed tomography scan and venography.

RESULTS

One patient died 30 days after surgery; of the remaining six patients one had no evidence of regional recurrence or metastatic disease at 12 months, and five died from recurrent tumour 8-30 months after surgery. The mean time to death was 23 months. At 3 months all six prosthesis were patent; at 6 months four were patent and at 12 months three of five prostheses were patent.

CONCLUSION

Resecting and replacing the IVC allows complete tumour resection and avoids renal failure, providing durable relief from the symptoms of venous obstruction. Iliofemoral prosthetic reconstruction for urological-related malignancies represents a viable option to avoid venous engorgement and lower extremity swelling, at least in the early postoperative period. The mean time to death for the present patients must be considered the limit for these aggressive operations.

High-porosity expanded polytetrafluoroethylene grafts for thoracic vena cava replacement with or without an omentum wrap

We previously reported that, in a short-term thoracic inferior vena cava (IVC) replacement, a high-porosity expanded polytetrafluoroethylene (ePTFE) graft (fibril length 60 microm) performed well without altering the short-term patency, and that the healing of the high-porosity ePTFE graft was accelerated by an omentum wrap. The purpose of this study was to examine the long-term performance of the high-porosity ePTFE graft with or without an omentum wrap. Eighteen grafts were placed as a thoracic IVC replacement in dogs. Nine of the grafts were wrapped in an omental pedicle flap while the other 9 were not. At 1 month and 6 months, the grafts were harvested and examined for a pathological analysis. During the observation period, one dog died of a viral infection, while the other 17 dogs survived. At 1 month and 6 months, the patency rates of the 17 grafts were 100% regardless of the presence or absence of an omentum wrap. The healing of the grafts without omentum wrap was incomplete 6 months after implantation; granulation tissue was present in the center of the pseudointima. The grafts healed completely by the addition of an omentum wrap. Our data suggest that, with an omentum wrap, the high-porosity ePTFE graft is fully expected to show a good long-term function.

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

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

Aggressive surgical management of fibrolamellar hepatocellular carcinoma in puberty

Extensive right hepatectomy and replacement of the invaded inferior vena cava were performed in a 14-year-old girl with fibrolamellar liver carcinoma. Despite the graft thrombosis the patient was discharged on the 50th post-operative day. After 3 years a solitary lung metastasis was resected and the patient remains with no sign of intra-abdominal or intrathoracic recurrence.

Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience

PURPOSE

The operative management and followup of vena caval resection for bulky metastatic germ cell tumors have been previously described in 3 series. In 1989 Ahlering and Skinner described their experience with 12 patients. We now update this experience with the most recent followup on 19 patients.

MATERIALS AND METHODS

From April 1978 to May 1995, 19 men underwent retroperitoneal lymph node dissection for stage B3 (N3) or C (N3, M+) germ cell tumor after induction chemotherapy. In all cases the inferior vena cava was resected because of extensive thrombosis or direct involvement of the vessel wall by a tumor. The inferior vena cava was resected from just below the renal veins to beyond the level of disease involvement. Complete resection of retroperitoneal disease was accomplished in all patients. Morbidity and mortality were examined.

RESULTS

The mean hospital stay was 10 days (range 7 to 13) for uncomplicated recoveries (9 patients) versus 19 days (range 6 to 32) for complicated recoveries (10 patients). Followup ranged from 1 month to 16 years. Complications included prolonged ileus, small bowel obstruction, fascial dehiscence and pneumonia with pleural effusion. Chronic edema persisted in 3 of 11 patients with followup of greater than 6 months. Of the 6 patients who died of disease recurrence 4 did not have normalization of tumor markers before surgery, and all 4 had persistence of cancer in the resected specimen. Seven patients are without disease at followup of 24 months to 16 years. All survivors had normalized tumor markers before surgery. Only 1 patient (5%) had retroperitoneal recurrence.

CONCLUSIONS

En bloc vena caval resection for tumor involvement or extensive thrombosis can be associated with short and long-term morbidity, is feasible, and may contribute to a prolonged tumor-free interval and a chance for cure.

Pheochromocytomas with extension into central vascular structures

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