Surgical treatment of malignant involvement of the inferior vena cava

Surgical Resection of Tumors Invading the Inferior Vena Cava at the Hepatic Vein and Thoracic Levels

BACKGROUND

Our aim was to describe the results of our program of surgical resection of tumors invading the inferior vena cava (IVC) at the hepatic and thoracic levels. We hypothesized that similar surgical outcomes may be obtained compared to tumor resection below the hepatic vein level if the liver function was preserved.

METHODS

We performed a single-center retrospective study of 72 consecutive patients who underwent surgical resection from 1996 to 2019 for tumors invading the IVC. We compared two groups based on tumor location below (group I/II) or above (group III/IV) the inferior limit of hepatic veins.

RESULTS

Tumor histology was similarly distributed between groups. In group III/IV (n = 35), sterno-laparotomy was used in 83% of patients, cardiopulmonary bypass in 77%, and deep hypothermic circulatory arrest in 17%; 23% underwent liver resection. Corresponding proportions in group I/II were 3%, 0%, 0%, and 8%. In group III/IV, 4 patients required emergency resection. Mortality on day 30 was 17% (n = 6) in group III/IV and 0% in group I/II (P = 0.01). There was no liver failure among the 66 postoperative survivors and 5 out of 6 patients who died postoperatively presented a preoperative or postoperative liver failure (P < 0.001). Overall survival was not significantly different between groups with a median follow-up of 15.1 months. R0 resection was achieved in 66% of group I/II and 49% of group III/IV patients (P = 0.03).

CONCLUSION

Surgical resection of tumors invading the inferior vena cava at hepatic vein and thoracic levels should be reserved to carefully selected patients without preoperative liver failure to minimize postoperative mortality.

Lessons learned from the study of soft tissue sarcoma

Soft tissue sarcoma is a rare disease. We began a prospective database for in-patients treated on the surgical service at Memorial Sloan-Kettering in 1982. We now celebrate 30 years of this database which has been reviewed and cataloged constantly on a weekly basis. We approach 10,000 treated patients. The study of this heterogeneous group of diverse pathology rising in the soft tissue has been fascinating. We have learned about demographics, prevalence, incidence, and have recognized the value of such databases in describing not just outcome but biology. Site is an important determinant of outcome and illustrates the complexities of including all sites in any staging system. For example, local recurrence in the extremity, while associated with a decrease in survival, is clearly not causative. Conversely, retroperitoneal sarcoma, particularly liposarcoma, is a common locally recurring disease with local progression often the cause of disease-specific mortality. Genetic predispositions have been defined. Radiation therapy and lymphedema, both alone and in combination, predispose to the development of sarcoma. These observations have important relevance as we increasingly utilize radiation therapy to minimize local recurrence in early stage breast cancer and ductal carcinoma in situ. It is clear that outcome is histology specific and wide variations in outcome, depending on the underlying histological types and subtypes, are evident. We have established very clearly that limb preservation as opposed to amputation is equally efficacious and does not diminish survival. Radiation therapy can limit local recurrence but must be balanced against side effects. Unfortunately, the majority of chemotherapeutic regimens have had minimal benefit.

A cylindrical femoral vein panel graft for caval reconstructions

This report describes a simple venous reconstructive technique that results in an autogenous vascular graft with sufficient luminal diameter for replacing the vena cava. The majority of vena caval reconstructions are performed using prosthetic grafts; however, graft infection is a concern in clean-contaminated hepatobiliary and retroperitoneal resections.

Primitive neuroectodermal peripheral tumour of the retroperitoneum

Retroperitoneal primitive neuroectodermal tumour is an uncommon disease. The main treatment consists of surgical resection, which can require resection of great vessels, depending on the location. We present a single case of a 19-year-old male with a large tumour. To achieve R0 resection we needed to remove the vena cava. Venous flow reconstruction was performed with a cava prosthesis.

Combined resection of the pancreas and inferior vena cava for pancreatic metastasis from renal cell carcinoma

Indications for pancreatic resections for metastatic disease have not yet been defined to date, and few guidelines exist for the management of these lesions. However, most authors recommend surgery as the treatment of choice for pancreatic metastasis (PM). Resection of the inferior vena cava (IVC) is rarely done during removal of peripancreatic cancer. This report presents the first case of metachronous PM from renal cell carcinoma (RCC) with IVC involvement successfully treated by en-bloc resection in a 70-year-old asymptomatic woman. The abdominal computed tomography (CT) scan showed a 4.0-cm mass in the tail and a 5.0-cm mass in the head of the pancreas with a suspected involvement of vena cava. An en-bloc total pancreatectomy was performed with excision of the involved portion of the cava vein. Histology confirmed the presence of two metastases from RCC with neoplastic infiltration of the IVC and without lymph node involvement. All surgical margins were tumor-free. At most recent follow-up 12 months after pancreatectomy, the patient has no evidence of disease. We believe that a multidisciplinary approach and careful evaluation and treatment of these patients is a mandatory component for patient selection. IVC resection should be performed only when a margin-negative resection is expected to be achieved.

Resection of malignant tumors invading the vena cava: perioperative complications and long-term follow-up

OBJECTIVE

Invasion of the vena cava by malignant tumors is generally considered an absolute contraindication for surgery as a result of high surgical risk. Surgical treatment with resection of the vena cava may be beneficial for selected patients. This study was performed to evaluate our experiences with resection of the vena cava for malignant tumors, with a special focus on secondary tumors involving the inferior caval vein.

METHODS

A total of 35 patients underwent extended resection of malignant tumors invading the vena cava. Prosthetic repair was performed in 13 patients by using a ringed polytetrafluoroethylene graft. Preoperative risk factors, mortality and morbidity, and long-term follow-up and graft patency rates were examined.

RESULTS

The operative mortality rate was 6%. Minor complications occurred in 12 patients (34%). The graft patency rate was 85%, and there was no graft-related perioperative morbidity. The 1-, 3-, and 5-year survival rates were 76%, 32%, and 21%, respectively, with a median survival of 29 months. Incomplete resection and cardiopulmonary risk have a significant negative effect on survival.

CONCLUSIONS

Radical resection of the vena cava is a feasible procedure in highly selected patients, with low morbidity and mortality and acceptable survival rates, especially in patients with complete resection of the tumor.