Ultrasonic detection of renal tumor extension into the inferior vena cava

Internal jugular vein patency after functional neck dissection: venous duplex imaging

We present a retrospective study performed to determine jugular patency after functional neck dissection (FND). Twenty-six patients, 16 females and 10 males, ranging in age from 16 to 78 were examined. These patients underwent either unilateral FND or bilateral FND for cervical lymph node metastases. Cervical duplex and pulsed Doppler imaging were chosen to determine internal jugular vein (IJV) patency. The examination was performed after a minimum postoperative period of 2 months and a maximum one of 22 years. Thirty-one IJVs were examined. All but 4 IJVs examined were found patent postoperatively. The preservation rate of patency of the IJV in FND was found to be high (27 of 31 or 87%). These results favor the use of FND for IJV preservation, particularly in bilateral neck dissection.

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.

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.

Planned delayed nephrectomy after ethanol embolization of renal carcinoma

Planned delayed nephrectomy after preoperative ethanol infarction was done in 6 patients with renal carcinoma. Three patients had intracaval extension of tumor, 2 had renal vein but no vena caval extension and 1 had no renal vein or vena caval involvement. Nephrectomy was delayed 22 to 44 days after embolization. In the patients with inferior vena caval extension shrinkage of tumor thrombus after embolization allowed for easier surgical resection. Furthermore, delay of nephrectomy after preoperative infarction was of value in improving the clinical status of high risk patients.

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.

The accuracy and limitations of ultrasound in the assessment of venous extension in renal carcinoma

Ultrasound was used to assess venous extension in 28 patients with renal carcinoma, with particular reference to involvement of the inferior vena cava. The findings were correlated with surgical findings in all except two patients who had gross caval involvement and metastatic disease and in whom surgery was considered inappropriate. In 10 of the 28 patients (36%), a diagnostic ultrasound examination of the cava from the renal veins to the diaphragm was obtained. In four of these, ultrasound showed tumour involvement of the vena cava. In 12 cases (43%) only the intrahepatic part of the cava was seen, but the examination nonetheless excluded tumour involvement of the upper cava. Visualisation of the vena cava was impossible in six cases (21%), usually because of bowel gas or obesity; CT scanning provided valuable additional information in two of these cases. Inferior vena cavography confirmed the findings of the less invasive imaging procedures in 10 patients and was falsely positive once. Cavography is now seldom necessary in the assessment of renal carcinoma.

Ultrasound of Wilms' tumor

The grey scale ultrasound features of 30 cases of Wilms' tumour examined using a water delay scanner are presented. Eighty-seven percent of masses were of uniform texture, with echogenicity equal to or slightly greater than that of liver with small hypo-echoic areas. There were no totally cystic tumours in the series. In 21 cases the mass was clearly arising from the ipsilateral kidney, but in 9 cases the ipsilateral kidney could not be distinguished from the tumour. The state of the intrahepatic inferior vena cava (IVC) was correctly diagnosed in 27 cases and further evaluation was needed in two patients in whom this segment could not be demonstrated. If this segment is sonographically normal, then the IVC need not be evaluated further. Differential diagnosis is discussed, with particular reference to neuroblastoma. In the majority of patients ultrasound is the only modality needed to diagnose Wilms' tumour pre-operatively.

Two-dimensional, gray-scale abdominal ultrasonography. General interpretation and abdominal masses

The techniques of and general interpretive principles of gray-scale, two-dimensional abdominal ultrasonography in small animals are described. Using case examples, commonly encountered imaging artifacts and categories of disease are integrated with a description of what was obtained by radiography. Tissue echogenicity as a basis for general assessment of organ abnormalities as well as the expectations (interpretive and prognostic) one should have of abdominal ultrasonography are presented.

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.

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.

Transitional cell carcinoma of the kidney with invasion into the renal vein

Eight cases of transitional cell carcinoma with extension into the renal vein are presented. In 2 cases the tumor had also invaded the inferior vena cava. Venous invasion represents an uncommon, late finding of transitional cell carcinoma and is associated with a poor prognosis. The excretory urogram usually demonstrates nonfunction or a pelvic mass with extensive renal invasion. As these findings are nonspecific, definitive preoperative diagnosis is dependent on direct visualization of the renal vein utilizing sonography, computed tomography, or venography. Since vascular invasion is a late finding, venous evaluation is required only in advanced cases of transitional cell carcinoma.

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.

Cytologic diagnosis of renal carcinoma in the presence of inferior vena cava obstruction: case report

Diagnostic work-up and staging of patients with renal tumors usually includes inferior vena cavography. In this case, complete occlusion of the cava was demonstrated by cavography while catheter aspiration yielded tumor fragments diagnostic of renal adenocarcinoma. Transcatheter aspiration in the presence of caval obstruction can provide preoperative tissue diagnosis as well as accurate tumor staging information.

Papillary renal cell carcinoma: ultrasonic/pathologic correlation

Papillary renal cell carcinoma represents a separate clinicopathologic entity distinguished from nonpapillary renal cell carcinoma by angiography, microscopic pathology, and biological behavior. We correlated retrospectively 11 surgically proven papillary renal cell carcinomas with ultrasound patterns and gross pathologic findings. In addition, we reviewed retrospectively 65 surgically proven cases of nonpapillary renal cell carcinoma for sonographic patterns. Seven of 11 (64%) of the papillary tumors were less echogenic than the ipsilateral renal cortex (hypoechoic). Only 23% of the nonpapillary tumors were hypoechoic. These data suggest that renal papillary carcinoma tends to be hypoechoic on ultrasound. In most of the papillary cases, this hypoechoic pattern was due to a large central area of cystic necrosis within the tumor.

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.

Primary malignant renal tumors in the second decade of life: Wilms tumor versus renal cell carcinoma

Primary renal malignancies occur least frequently in the second decade of life. Of the 4,798 cases of renal cell carcinoma and Wilms tumor referred to the Armed Forces Institute of Pathology 53 renal cell carcinomas and 56 Wilms tumors occurred in the 10 to 20-year age group. Pathologically, both tumors in this age range are similar to those occurring at a more typical age, and histologic differentiation between renal cell carcinoma and Wilms tumor is seldom a problem. While radiographic evaluation is useful to characterize the neoplasm, evaluate the contralateral kidney and detect the presence of tumor extension, current imaging techniques cannot confidently distinguish these 2 tumors.

Computed tomography, angiography and ultrasound in staging of renal carcinoma

Preoperative evaluation of the extent of the renal tumor is of value in determining the prognosis of the patient and the most suitable therapy. CT and angiography were reviewed in 27 cases of renal carcinoma to evaluate tumor involvement of lymph nodes, renal vein, vena cava, and the perinephric space. In 26 of these cases the ultrasound examination was similarly reviewed. Comparison of ultrasound, CT, and angiography demonstrated that staging of renal tumors with ultrasound is mainly limited by its inability to demonstrate extrarenal infiltration. Both CT and ultrasound proved reliable in the demonstration of tumor spread to the renal vein and inferior vena cava. CT and angiography were equally effective in the evaluation of tumor extension; since CT is easier to perform, less invasive and less time consuming than angiography it should be the primary method for staging of renal neoplasms. Angiography offers detailed information on the vascular supply of the tumor important for the choice of surgical approach and should be performed only on special indications.

Ultrasound features of tumour thrombus in the IVC in retroperitoneal tumours

Tumour invasion of the inferior vena cava (IVC) is a complication of retroperitoneal tumours that can be identified at the time of ultrasound B scanning. We have recognized nine patients with proven IVC tumour thrombus from such tumours and have noted several common ultrasound features. Six of these cases were associated with renal carcinoma, two with metastatic teratoma and one with rhabdomyosarcoma. The typical appearance included abnormal echogenic solid material in the lumen of the vessel. In sagittal section the anterior wall was domed as it stretched over the thrombus, and on real time scanning there was loss of the normal venous pulsations. Although similar abnormalities occur with non-tumour thrombus, the presence of these typical features in association with a retroperitoneal tumour is likely to represent tumour invasion of the IVC, an important observation for accurate staging and subsequent management.

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.

Ultrasonic detection of renal tubular carcinoma extending into the inferior vena cava

Extension of renal tubular carcinoma into the ipsilateral renal vein and vena cava has been reported to occur in about 5 per cent of the cases. In those patients without demonstrable metastases the 5-year survival rate with aggressive surgical management is 50 per cent. The preoperative diagnosis of tumor extension into the vena cava is important when planning a surgical procedure. A high degree of clinical suspicion, coupled with invasive preoperative roentgenographic evaluation has been the mainstay of diagnosis. We report a case in which gray scale ultrasonography proved to be an important diagnostic test for delineating the extent of a vena cava tumor thrombus.