Management of Renal Cell Carcinoma With Level III Thrombus in the Inferior Vena Cava

Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava

BackgroundRenal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51 years and tumor sizes were 7.5, 7.5, 15.0, and 6.5 cm, respectively. These patients were followed for 36, 24, 32, and 48 months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Perioperative and oncological outcomes of renal cell carcinoma with venous tumour thrombus

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.

Surgical treatment of renal cell carcinoma with right atrial thrombus: Early experience and description of a simplified technique

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.

Endoluminal occlusion of the inferior vena cava in renal cell carcinoma with retro- or suprahepatic caval thrombus

OBJECTIVE

To evaluate endoluminal occlusion of the inferior vena cava (IVC) during surgical treatment of renal cell carcinoma (RCC) with either retrohepatic (level II) or suprahepatic (level III) caval tumour thrombus.

PATIENTS AND METHODS

From January 2000 to February 2005, 31 patients with renal vein/IVC involvement (T3b/c) of 278 who had a radical nephrectomy, were selected for review. Of these 31, 13 consecutive patients with RCC presenting a thrombus level II or III were prospectively treated with endoluminal occlusion of the free IVC cranial to the thrombus, to avoid dissection of the suprahepatic IVC or the subdiaphragmatic IVC. The occlusion balloon was positioned using transoesophageal echocardiography (TEE) control through a cavotomy at the ostium of the renal vein. Thrombectomy and radical nephrectomy were then performed. The operative duration, peri-operative bleeding, and complications during and after surgery were assessed. Overall patient survival time, disease-free survival and development of metastasis were calculated.

RESULTS

Caval thrombectomy was successful in all patients. The IVC needed to be replaced with an expanded polytetrafluoroethylene graft in three patients and a patch closure after lateral cavectomy was used in four. There was no case of air embolism. One case of asymptomatic tumour migration was detected during the procedure by TEE. The mean (sd) and median (range) operative duration was 170 (29) and 170 (120-210) min, and the mean number of units of packed red cells transfused during hospitalization was 5 (5) and 3 (0-16). There was no peri-operative mortality. The complications were one splenectomy and one early thrombosis of the IVC. The mean (range) follow-up was 22.1 (2-50) months. Distant metastases occurred in seven patients; there was no local or IVC tumour recurrence. Four patients died from metastatic progression and six are alive with no progression.

CONCLUSION

Endoluminal occlusion of the IVC with TEE monitoring for level II and III thrombus avoided a suprahepatic or subdiaphragmatic approach to the IVC. This technique caused no major complications and was very reliable, due to TEE monitoring. Segmental resection and reconstruction of the IVC could also be used for adherent thrombi.

Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumour thrombus

OBJECTIVE

To describe our experience of excising the inferior vena cava (IVC) without a graft; en bloc resection of a renal cell carcinoma (RCC) with the renal vein and vena cava tumour thrombus and a segment of the entire abdominal IVC is technically feasible, but traditionally, after resection, attempts are made to restore continuity with the use of synthetic or homologous venous grafts.

PATIENTS AND METHODS

Between May 1997 and September 2004, 60 patients (mean age 62 years) underwent surgical resection of a renal tumour with a thrombus extending into the IVC. To resect the entire evident tumour, excision of the affected portion of the IVC was required in three patients (5%); the IVC was not reconstructed.

RESULTS

The three patients were aged 38, 39 and 74 years; the mean operative duration was 5.88 h, the mean (range) estimated blood loss was 833 (500-1000) mL, the mean number of blood units transfused was 3.3 (0-7) units, and the mean follow-up was 24 months. The course after surgery was uneventful; specifically, none of the patients had a venous thrombosis or a pulmonary embolus.

CONCLUSIONS

RCC has a propensity to invade the renal vein and IVC. Occasionally the thrombus invades the wall of the IVC and complete removal requires excision of a circumferential portion of the IVC; this can be done safely without a graft.

The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus

OBJECTIVE

To report the surgical management, complications and outcomes over three decades by tumour thrombus level for patients with renal cell carcinoma (RCC) and renal venous extension, as surgery is the most effective treatment.

PATIENTS AND METHODS

We assessed 540 patients who underwent surgical resection for RCC with renal venous extension between 1970 and 2000. Early and late surgical complications, including operative mortality, were compared with tumour thrombus level using the chi-square, Fisher's exact and Wilcoxon rank-sum tests. Cancer-specific survival was estimated using the Kaplan-Meier method and compared across tumour thrombus levels using log-rank tests.

RESULTS

There were 349 (64.6%) patients with level 0 thrombus and 191 (35.4%) with inferior vena cava thrombus, including 66 (12.2%) with level I, 77 (14.3%) with level II, 28 (5.2%) with level III, and 20 (3.7%) with level IV thrombus. Patients with a higher thrombus level had more early surgical complications (respectively for level 0 to IV, 8.6%, 15.2%, 14.1%, 17.9% and 30.0%, P < 0.001). However, there was no statistically significant difference in the incidence of late complications by thrombus level (P = 0.445). The incidence of any early surgical complication decreased from 13.4% for patients treated in 1970-1989 to 8.1% for those treated in 1990-2000 (P = 0.064); the respective operative mortality decreased from 3.8% to 2.0% (P = 0.260), and in patients with inferior vena cava thrombus, from 8.1% to 3.8% (P = 0.227). The respective duration of hospitalization decreased from a median of 8 to 7 days (P < 0.001) but the incidence of late complications increased significantly over time (P < 0.001.) Among patients with clear cell RCC, the respective estimated 5-year cancer-specific survival rates (Se, number still at risk) for patients with level 0 to IV thrombus were 49.1 (3.0)% (125), 31.7 (6.4)% (14), 26.3 (6.1)% (11), 39.4 (10.7)% (7) and 37.0 (12.9)% (5), (P = 0.028). There was a statistically significant difference in outcome for patients with level 0 vs those with level >0 thrombus (P = 0.002), but there was no significant difference in outcome by thrombus level among patients with inferior vena cava tumour thrombus (P = 0.868).

CONCLUSIONS

The surgical management of RCC with renal venous extension continues to develop. The incidence of early surgical complications and operative death have decreased in recent times with the introduction of improved imaging, surgical monitoring and vascular bypass techniques. There is significantly better cancer-specific survival for patients with renal vein involvement only than those with inferior vena cava involvement.

The Role of Transesophageal Echocardiography in Rapid Diagnosis and Treatment of Migratory Tumor Embolus

Transesophageal echocardiography (TEE) is sometimes used in renal cell carcinoma excision for evaluating the extension of tumor in the inferior vena cava (IVC), characterizing the tumor anatomy, monitoring the tumor during surgical mobilization, and assessing cardiac function. Although the risk for embolization is small, when embolization does occur, its consequences can be catastrophic. In this case report, we describe the crucial role of TEE in diagnosing an intraoperative migratory embolus from the IVC to the pulmonary artery and also provide both single-frame photographs and Internet-accessible videos of the event. Our case illustrates the key role that TEE played in the intraoperative management of a patient with renal cell carcinoma undergoing surgical excision of tumor. TEE aided in accurately defining the cephalad extent of the thrombus, provided continuous monitoring of the thrombus during surgical manipulation, and allowed immediate identification of its embolization and proper notification of the surgeons. This case illustrates the crucial role TEE played in the management of a migratory tumor embolus and argues for its routine use during excision of renal cell carcinomas invading the IVC.

Surgery for adrenal tumours with thrombus in the supra-diaphragmatic infra-atrial inferior vena cava, with no cardiopulmonary bypass

OBJECTIVES

To assess the result of surgery for adrenal neoplasia with thrombus in the supra-diaphragmatic infra-atrial inferior vena cava.

PATIENTS AND METHODS

Five patients with adrenal cortex carcinoma and three with phaeochromocytoma were reviewed. All the thrombi were removed through a right thoracophrenolaparotomy in the fifth intercostal space, with clamping of the intrathoracic portion of the inferior vena cava, with no cardiopulmonary bypass. In the first two cases the thrombi were removed in a second surgical procedure after resecting the tumours. In the other six the complete procedure was done in one surgical stage.

RESULTS

There were no surgery-related deaths. The major complications after surgery were pulmonary atelectasis, acute renal failure, a large retroperitoneal collection, deep vein thrombosis and pulmonary embolism, each in one patient. Of the five patients with adrenal cortex carcinoma one is still alive after 15 years with no evidence of disease, one is alive with pulmonary metastases 15 months after surgery and the other three died from widespread disease after 5, 12 and 15 months. Of the three patients with phaeochromocytoma, two show no evidence of the disease 2.5 and 11 years later and one died from myocardial infarction, with no evidence of the disease, 9 years later.

CONCLUSION

Thrombi from adrenal neoplasia in the supra-diaphragmatic infra-atrial inferior vena cava may be removed with no need for cardiopulmonary bypass and cardiac arrest, thus avoiding the associated morbidity and high cost.