Tumor thrombus of the inferior vena cava resulting from renal carcinoma. A report on 12 autopsied cases

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.

Imaging the inferior vena cava: a road less traveled

A broad spectrum of congenital anomalies and pathologic conditions can affect the inferior vena cava (IVC). Most congenital anomalies are asymptomatic; consequently, an awareness of their existence and imaging appearances is necessary to avoid misinterpretation. Imaging also plays a central role in the diagnosis of Budd-Chiari syndrome secondary to membranous obstruction of the intrahepatic IVC. Primary malignancy of the IVC is far less common than intracaval extension of malignant tumors arising in adjacent organs, and imaging can accurately help determine the presence and extent of tumor thrombus, information that is crucial for surgical planning. However, the radiologist should be aware that artifactual filling defects at computed tomography and magnetic resonance imaging can mimic true thrombus in the IVC and must be able to differentiate true from pseudo filling defects. Other imaging findings such as flat IVC and early enhancement of the IVC are useful in limiting the differential diagnosis. Familiarity with the imaging features of the various congenital and pathologic entities that can affect the IVC is paramount for early diagnosis and management.

Leiomyosarcoma of the uterus with intravascular tumor extension and pulmonary tumor embolism

We report the case of a 48-year-old woman presenting with recurrent uterine leiomyosarcoma (LMS) associated with right iliac vein and inferior vena cava (IVC) invasion and left lower lobe pulmonary tumor embolus. Because the prognosis and treatment differ from that of thrombotic pulmonary emboli, the differentiating imaging characteristics of intravascular tumor embolism are reviewed. To our knowledge, only two other cases of intravenous uterine leiomyosarcomatosis have been described in the existing literature, and this is the first reported case of the entity with associated intravascular tumor embolism.

Liver Harvesting Surgical Technique for the Treatment of Retro-Hepatic Caval Thrombosis Concomitant to Renal Cell Carcinoma: Perioperative and Long-Term Results in 15 Patients without Mortality

OBJECTIVE

Radical surgical treatment improves the prognosis of patients affected by Inferior Vena Cava (IVC) thrombosis concomitant to renal carcinoma. However, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable haemorrhages and tumor fragmentation. We report the results of an innovative surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. In the presence of retro-hepatic IVC thrombosis, this technique improves vascular control and allows to perform a large cavotomy with an en-bloc removal of the thrombus and the tumor.

METHODS

From January 1995 through June 2003, 15 patients with renal cancer and caval thrombosis were treated at our Institution. Four, ten and one patients were respectively affected by an infrahepatic (Level I), retro-hepatic (Level II) and atrial (Level III) IVC thrombosis.

RESULTS

All patients underwent radical surgical treatment. In presence of Level II caval thrombosis, the patients underwent the above reported surgical technique. Perioperative mortality was absent; major morbidity occurred in one patient (6.7%). The thrombus was radically removed in all cases. After a mean follow-up of 53.9 months (5-100 months) all patients but one are still alive. One patient died 9 months after surgery with multiple bilateral pulmonary metastases.

CONCLUSIONS

Isolation of the retro-hepatic IVC is a safe and effective manoeuvre to significantly reduce perioperative mortality and morbidity in patients affected by Level II caval thrombosis concomitant to renal carcinoma.

Helical and electron beam CT scanning in the evaluation of renal vein involvement in patients with renal cell carcinoma

PURPOSE

The purpose of this study was to assess helical and electron beam CT scanning in the evaluation of renal vein involvement in patients with renal cell carcinoma (RCC).

METHOD

Seventy-three patients with 76 pathologically proven RCC who underwent surgical resection or autopsy were evaluated for the accuracy of helical and electron beam CT scanning in the detection of renal vein tumor thrombus in patients with RCC. Patients were entered into the study only if they were scanned on either electron beam or helical CT scanners with intravenous contrast medium enhancement. The tumors involved the right kidney in 38 cases and the left kidney in 38 cases, with tumor size ranging from 1.5 to 19 cm (mean 7 cm). The pathologic grade of the tumor was Grade I in 21, Grade II in 37, Grade III in 15, and Grade IV, in 3 patients.

RESULTS

The accuracy of preoperative CT evaluation of the renal vein for presence or absence of tumor thrombus was 96%. The negative predictive value was 97% and the positive predictive value was 92%. Sensitivity was 85% with a specificity of 98%. In two cases we were unable to detect small intrarenal venous thrombus, although this was present on a microscopic level and did not affect surgical resection. A single false-positive CT result occurred secondary to unopacified blood flow from a capsular vein into the affected renal vein, resulting in a small flow void on CT.

CONCLUSION

The data show that preoperative staging of the renal vein in the patients with RCC is effectively provided with helical and electron beam CT scanning.

Successful management of intracardiac extension of tumor thrombus in a patient with advanced nonseminomatous germ cell testicular cancer

A young patient with testicular germ cell tumor presenting with inferior vena cava thrombus extending into the right heart with free-floating thrombus in the right ventricle and a simultaneous epidural spinal cord compression is presented. Due to the perceived high risk of embolization and the urgent need to begin systemic chemotherapy, he was managed with tumor thrombectomy utilizing cardiopulmonary bypass and hypothermic circulatory arrest followed shortly thereafter by systemic chemotherapy. There were no perioperative complications, and he is alive and without recurrence 24 months following four cycles of systemic chemotherapy.

Percutaneous transcaval tumour biopsy using a 'road-map' technique

The 'road-map' facility available on some of the commercially available digital subtraction angiography units is usually used to aid in the selective catheterization of a vessel during arteriography. We describe its use in the percutaneous transcaval biopsy of tumour within the inferior vena cava (IVC).

Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension

Between 4 and 10% of patients with renal cell carcinoma have tumor involving the inferior vena cava and many of these patients have suprahepatic extension. In patients with intracaval neoplastic extension precise definition of the superior aspect of the tumor thrombus is critical. Transabdominal ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI) and inferior venacavography are all currently used to evaluate the inferior vena cava in these patients. Intraoperative transesophageal echocardiography was used to image the inferior vena cava in 5 patients with renal cell carcinoma and intracaval neoplastic extension. In each patient transesophageal echocardiography correctly revealed the superior extent of tumor thrombus. In 3 patients tumor thrombus was found at a higher level by transesophageal echocardiography than by CT, MRI and inferior venacavography. In all patients tumor imaging by transesophageal echocardiography correlated well with the gross appearance and extent of tumor found at operation. Echocardiography also documented the absence of residual gross tumor after resection. Transesophageal echocardiography was also useful to assess left ventricular function. Although each of these patients had a pulmonary artery catheter as well transesophageal echocardiography can be useful in situations when right atrial tumor thrombus prevents right heart catheterization. This small series demonstrates that intraoperative transesophageal echocardiography can accurately evaluate the extent of tumor thrombus and provides a means to assess myocardial function complementary to the pulmonary artery catheter.

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.

Metastatic patterns of renal carcinoma: an analysis of 687 necropsies

The metastatic behaviour of renal cell carcinoma has been studied in a series of 687 necropsies. The observations were consistent with the concept of "metastatic inefficiency", in that in 295 cases, including 25 with renal vein invasion, there were no detectable metastases. In the present series, renal vein involvement was not an important prognostic factor in stage 1 or 2 disease. In 73% of cases without lung metastases there were none in other sites, and in 84% of those with lung metastases there were others elsewhere, consistent with a metastatic "cascade" in which metastases first developed in the lungs and were later detected in other organs. However, the observations did not permit discrimination between anatomic cascades, in which other organs were seeded from metastasizing pulmonary metastases, and temporal cascades, in which the other were seeded at the same time as the lungs, but with fewer cancer cells. The patterns of arterial metastasis were consistent with the "seed-and-soil" hypothesis, and a novel index was developed to quantify differential organ "soils". The contralateral kidney was not the best soil for metastases from renal carcinoma. Given the presence of lymph node metastasis, the probability of heamatogenous metastasis is 90%. However, in the absence of nodal metastasis, approximately half the cases had haematogenous metastasis.

Surgical approach to inferior vena caval extension of renal carcinoma

Between 1979 and 1985, 10 patients were treated for renal carcinoma with extension into the inferior vena cava but without evidence of disseminated disease. Two of these had tumour thrombus extension up to the level of the hepatic veins and in four the extension was above the level of the diaphragm, two of which entered the atrium. Thrombus was removed en bloc at radical nephrectomy. Six patients are still alive, with a mean survival of 22 months. There was no correlation between the level of tumour thrombus and perinephric extension or indeed any correlation between tumour thrombus level and overall survival. It is suggested that tumour thrombus in the inferior vena cava, in the absence of metastatic disease, should be managed by radical surgery.

Metastatic Wilms' tumor causing acute hepatic-vein occlusion (Budd-Chiari syndrome)

We describe a case of Wilms' tumor in a 6-yr-old girl which extended from the right kidney and completely obstructed the inferior vena cava and hepatic veins to the level of the right atrium, producing an acute Budd-Chiari syndrome. After an initial course of chemotherapy, the primary tumor was excised and, using cardiopulmonary bypass, the tumor thrombus was removed from the inferior vena cava and hepatic veins. The Budd-Chiari syndrome resolved and after triple-drug chemotherapy and radiotherapy under the National Wilms' Tumor Study-2 protocol the child has remained disease-free for 5 yr.

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.

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.

Extracorporeal circulation for renal cell carcinoma with supradiaphragmatic vena caval thrombi

Extension of tumor into the vena cava occurs in 5 to 10 per cent of the cases of renal cell carcinomas. Of these cases 14 to 39 per cent may extend to or into the right atrium. Acceptable techniques for dealing with this situation include cross-clamping the atrium, using positive pressure ventilation and extracting the thrombus with a Fogarty or Foley catheter, and extracorporeal circulation or a cardiopulmonary bypass with open excision of the tumor extension. Since 1974 we have seen 2 men and 2 women, mean age 56 years, with clear cell renal carcinomas and supradiaphragmatic vena caval tumor extension (1 with additional pulmonary embolism). None had other evidence of metastatic disease determined on staging evaluation by celiac and renal angiography, liver scan, bone scan and chest tomography. Each patient was explored with the planned use of extracorporeal circulation or cardiopulmonary bypass, Greenfield vena caval filter insertion and standard radical nephrectomy. Resection was not done in 1 patient with biopsy proved tumor eroding through the right atrial wall. He died of disease in 8 months. Of the remaining 3 patients who had the tumors completely resected 1 is alive with recurrent disease in the retroperitoneum at 44 months, 1 died of metastatic disease to the bones and liver at 39 months, and 1 died 1 day postoperatively of technical complications with no evidence of residual disease at autopsy. In the absence of metastatic disease it seems reasonable to pursue a radical surgical approach in patients with renal cell carcinoma and supradiaphragmatic tumor thrombus. The use of extracorporeal circulation and post-extraction insertion of the Greenfield vena caval filter offers the surgeon the advantage of direct visualization and better vascular control in removing the thrombus, as well as protection from the possibility of post-extraction pulmonary embolism. With the combined use of these techniques, the previously hopeless situation for these patients has been improved.

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.

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.

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 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.

Inferior caval venography in the assessment of renal carcinoma

Inferior caval venography by a non-catheter technique was carried out in 30 cases of renal cell carcinoma. Occlusion of the renal vein was shown in 15 of these and occlusion of the inferior vena cava in a further three. Deformity of the vena cava by adjacent growth was found in nine instances. Renal arteriography was performed in 27 of these patients and the demonstration of the renal vein by this method has been compared with that of caval venography. The incidence of collateral veins on the arteriogram and the finding of impaired renal function as an index of renal vein occlusion has been discussed.

Pulmonary embolus presenting as initial manifestation of renal cell carcinoma

Pulmonary emboli from renal cell carcinoma may be more common than previously suspected. A case is reported of renal cell carcinoma presenting with a massive pulmonary embolus. Pulmonary embolectomy followed by radical nephrectomy with venocavotomy and tumor thrombectomy was successfully performed.

Surgery for renal cell carcinoma extending into the inferior vena cava

We have reviewed 26 patients with renal cell carcinoma extending into the inferior vena cava, 21 of whom underwent radical nephrectomy with either venacavotomy and tumor thrombectomy, or vena cava resection. Of 12 patients who presented with localized neoplasm 6 (50 per cent) are currently alive. Poor results were obtained in 9 patients who had preoperative metastatic disease. Over-all operative mortality was 14 per cent and morbidity was minimal, with no pulmonary emboli intraoperatively or postoperatively.

Renal carcinoma presenting with pulmonary emboli: a review of two cases

Two patients with renal carcinoma presenting with pulmonary emboli are discussed. Pulmonary emboliform renal carcinoma may be more common than previously supposed. Evaulation for such tumours should be done in patients with pulmonary emboli of obscure origin.

Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma

Recent literature suggests that pulmonary embolus secondary to renal cell carcinoma may by more common than previously suspected. Renal tumors are known for their ability to metastasize early, often before the primary lesion is apparent. A patient with renal cell carcinoma and having massive pulmonary tumor embolus is presented. Attention was called to the occult tumor by the identification of clear cell carcinoma in the pulmonary embolic material. Pulmonary embolectomy and surgical extirpation of the primary tumor resulted in long-term survival.

Extrarenal manifestations of renal cell carcinoma

Renal cell adenocarcinoma can be one of the great masqueraders in medicine. More common extrarenal manifestations of renal cell carcinoma include fever, anemia and gastrointestinal symptoms. Other rarer systemic symptoms are caused by amyloidosis, neuromyopathy and tumor thrombus. Humoral manifestations include polycythemia, hypercalcemia, galactorrhea and Cushing's syndrome. Metastatic disease commonly presents as the initial symptom.