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Goronzy IN, Yearwood A, Drews E, Brundage T, Ranade M, Moriarty JM. Endovascular thrombectomy provides durable, symptomatic relief in iliocaval tumor thrombosis. Clin Radiol 2024:S0009-9260(24)00345-3. [PMID: 39084932 DOI: 10.1016/j.crad.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 08/02/2024]
Abstract
AIMS Iliocaval venous tumor thrombus is a morbid condition associated with chronic venous stasis, lower extremity edema/pain, extensive thrombus burden and high mortality secondary to critical flow obstruction, intracardiac thrombus extension and tumor embolization. Typically resistant to medical therapy, management is primarily surgical, presenting challenges for medically complex patients with widespread or end-stage disease. Mechanical or aspiration thrombectomy represents an appealing treatment strategy but data are lacking. MATERIALS AND METHODS We performed a single-center, 10-year, retrospective review of patients with pathology-confirmed, iliocaval tumor thrombus who underwent thrombectomy. 14 patients met inclusion criteria and were managed by 18 procedures over this period. RESULTS The most common malignancy was renal-cell carcinoma (n=7; 50%); other types included germ cell (n=2; 14%), other genitourinary (n=2; 14%), neuroendocrine (n=1; 7%), soft tissue (n=1; 7%), and skin cell malignancies (n=1; 7%). All patients had thrombus involving the distal inferior venous cava (IVC), 50% had bilateral iliac involvement and 29% atrial involvement. Common indications were venous obstruction symptoms (n=11; 65%) and evidence of embolism (n=6; 35%). All patients tolerated the procedures without acute complication. The technical success rate was 94%, with marked improvement of flow and reduction in thrombus burden, and 79% had subjective symptomatic improvement. All patients survived for >2 weeks and 50% had long-term survival of >1 year, with 86% of these patients having renal-cell carcinoma (RCC). Three patients underwent multiple thrombectomies within days to weeks, with ultimate symptomatic improvement. CONCLUSIONS Overall, our study results suggest mechanical or aspiration thrombectomy as a safe and efficacious treatment for patients with iliocaval tumor thrombus.
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Affiliation(s)
- I N Goronzy
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA
| | - A Yearwood
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - E Drews
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - T Brundage
- Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA
| | - M Ranade
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA
| | - J M Moriarty
- David Geffen School of Medicine, University of California, Los Angeles, CA 90095, USA; Department of Radiology, Los Angeles, CA 90095, USA.
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Komarov RN, Rapoport LM, Belov YV, Germagenova EK, Chernyavskii SV, Ismailbaev AM, Tlisov BM, Zhong B, Zavaruev AV, Tsarichenko DG, Korolev DO. Surgical treatment of renal cell carcinoma with tumor thrombosis of the inferior vena cava and the right heart: How we do it. Urologia 2023:3915603221143566. [PMID: 36803097 DOI: 10.1177/03915603221143566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
OBJECTIVE Renal cell carcinoma with inferior vena cava thrombosis is a rare disease with a poor prognosis without surgical treatment. We report our 11-year experience in the surgical treatment of renal cell carcinoma with extension of the inferior vena cava. METHODS We conducted a retrospective analysis of patients undergoing surgical treatment for renal cell carcinoma with invasion of the inferior vena cava in two hospitals from May 2010 to March 2021. To assess the spread of the tumor process invasion, we used the Neves and Zincke classification. RESULTS A total of 25 people underwent surgical treatment. Sixteen patients were men, nine were women. Thirteen patients underwent cardiopulmonary bypass (CBP) surgery. The following postoperative complications were recorded: two cases of disseminate intravascular coagulation (DIC), two cases of acute myocardial infarction (MI) and one case of coma of unknown reason, Takotsubo syndrome and postoperative wound dehiscence. Three patients deceased (16.7%) of DIC syndrome and AMI. After discharge, one of the patients had a recurrence of tumor thrombosis 9 months after surgery, and another patient had the same 16 months later, presumably due to the neoplastic tissue in the adrenal gland on the contralateral side. CONCLUSION We believe that this problem should be dealt with by an experienced surgeon with a multidisciplinary team in the clinic. The use of CPB provides benefits and reduces blood loss.
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Affiliation(s)
| | | | - Yuri V Belov
- Institute of Clinical Medicine, Chair of department Hospital Surgery, Sechenov University, Moscow, Russia
| | - Ekaterina K Germagenova
- Institute of Clinical Medicine, Chair of department Hospital Surgery, Sechenov University, Moscow, Russia
| | | | | | - Boris M Tlisov
- Departament of Cardiovascular Surgery, Sechenov University, Moscow, Russia
| | - Baojun Zhong
- Departament of Cardiovascular Surgery, Sechenov University, Moscow, Russia
| | - Artem V Zavaruev
- Institute of Clinical Medicine, Department of Faculty Surgery, Sechenov University, Moscow, Russia
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Baia M, Naumann DN, Wong CS, Mahmood F, Parente A, Bissacco D, Almond M, Ford SJ, Tirotta F, Desai A. Dealing with malignancy involving the inferior vena cava in the 21st century. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:664-673. [PMID: 36239927 DOI: 10.23736/s0021-9509.22.12408-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
INTRODUCTION Malignancies involving the inferior vena cava (IVC) have historically been considered not amendable to surgery. More recently, involvement of the IVC by neoplastic processes in the kidney, liver or in the retroperitoneum can be managed successfully. EVIDENCE ACQUISITION In this systematic review we summarize the current evidence regarding the surgical management of the IVC in cases of involvement in neoplastic processes. Current literature was searched, and studies selected on the base of the PRISMA guidelines. Evidence was synthesized in narrative form due to heterogeneity of studies. EVIDENCE SYNTHESIS Renal cell carcinoma accounts for the greatest proportion of studied patients and can be managed with partial or complete vascular exclusion of the IVC, thrombectomy and direct closure or patch repair with good oncological prognosis. Hepatic malignancies or metastases may involve the IVC, and the joint expertise of hepatobiliary and vascular surgeons has developed various strategies, according to the location of tumor and the need to perform a complete vascular exclusion above the hepatic veins. In retroperitoneal lymph node dissection, the IVC can be excised en-block to guarantee better oncological margins. Also, in retroperitoneal sarcomas not arising from the IVC a vascular substitution may be required to improve the overall survival by clearing all the neoplastic cells in the retroperitoneum. Leiomyoma can have a challenging presentation with involvement of the IVC requiring either thrombectomy, partial or complete substitution, with good oncological outcomes. CONCLUSIONS A multidisciplinary approach with specialist expertise is required when dealing with IVC involvement in surgical oncology. Multiple techniques and strategies are required to deliver the most efficient care and achieve the best possible overall survival. The main aim of these procedures must be the complete clearance of all neoplastic cells and achievement of a safe margin according to the perioperative treatment strategy.
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Affiliation(s)
- Marco Baia
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK -
- Sarcoma Service, Department of Surgery, IRCCS Istituto Nazionale Tumori Foundation, Milan, Italy -
| | - David N Naumann
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Chee S Wong
- Department of General Surgery, Glasgow Royal Infirmary, Glasgow, UK
| | - Fahad Mahmood
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Alessandro Parente
- Unit OF HPB and Transplant, Department of Surgical Science, Tor Vergata University, Rome, Italy
- Department of Hepatopancreatobiliary and Liver Transplant Surgery, Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Daniele Bissacco
- Unit of Vascular Surgery, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Max Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Fabio Tirotta
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
| | - Anant Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), Queen Elizabeth Hospital, University Hospital Birmingham NHS Trust, Birmingham, UK
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Wang JL, Xu CY, Geng CJ, Liu L, Zhang MZ, Wang H, Xiao RT, Liu L, Zhang G, Ni C, Guo XY. Anesthesia and perioperative management for giant adrenal Ewing’s sarcoma with inferior vena cava and right atrium tumor thrombus: A case report. World J Clin Cases 2022; 10:643-655. [PMID: 35097090 PMCID: PMC8771399 DOI: 10.12998/wjcc.v10.i2.643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Revised: 08/01/2021] [Accepted: 12/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ewing’s sarcoma of the adrenal gland with inferior vena cava (IVC) and right atrium thrombus is extremely rare. Here, we report a case of giant adrenal Ewing’s sarcoma with IVC and right atrium tumor thrombus and summarize the anesthesia and perioperative management.
CASE SUMMARY A young female was admitted to the Department of Urology with intermittent pain under the right costal arch for four months. Enhanced abdominal computed tomography revealed a large retroperitoneal mass (22 cm in diameter), which may have originated from the right adrenal gland and was closely related to the liver. Transthoracic echocardiography showed a strong echogenic filling measuring 70 mm extended from the IVC into the right atrium and ventricle. After preoperative preparation with cardiopulmonary bypass, sufficient blood products, transesophageal echocardiography and multiple monitoring, tumor and thrombus resection by IVC exploration and right atriotomy were successfully performed by a multidisciplinary team. Intraoperative hemodynamic stability was the major concern of anesthesiologists and the status of tumor thrombus and pulmonary embolism were monitored continuously. During transfer of the patient to the intensive care unit (ICU), cardiac arrest occurred without external stimulus. Cardiopulmonary resuscitation was performed immediately and cardiac function was restored after 1 min. In the ICU, extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were provided to maintain cardiac, liver and kidney function. Histopathologic examination confirmed the diagnosis of Ewing’s sarcoma. After postoperative treatments and rehabilitation, the patient was discharged from the urology ward.
CONCLUSION An adrenal Ewing’s sarcoma with IVC and right atrium thrombus is extremely rare, and its anesthesia and perioperative management have not been reported. Thus, this report provides significant insights in the perioperative management of patients with adrenal Ewing’s sarcoma and IVC tumor thrombus. Intraoperative circulation fluctuations and sudden cardiovascular events are the major challenges during surgery. In addition, postoperative treatments including ECMO and CRRT provide essential support in critically ill patients. Moreover, this case report also highlights the importance of multidisciplinary cooperation during treatment of the disease.
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Affiliation(s)
- Ji-Lian Wang
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Chuan-Ya Xu
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Chun-Jing Geng
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Lei Liu
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Ming-Zhu Zhang
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hua Wang
- Department of Pathology, School of Basic Medical Sciences, Peking University Health Science Center, Beijing 100191, China
| | - Ruo-Tao Xiao
- Department of Urology, Peking University Third Hospital, Beijing 100191, China
| | - Lu Liu
- Intensive Care Unit, Peking University Third Hospital, Beijing 100191, China
| | - Geng Zhang
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
| | - Cheng Ni
- Department of Anesthesiology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Xiang-Yang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
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Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus. Surg Today 2022; 52:1125-1133. [PMID: 34977987 DOI: 10.1007/s00595-021-02429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The present report discusses the indications of cardiopulmonary bypass (CPB) in open nephrectomy and surgical outcomes of conventional and minimally invasive surgical techniques for treating advanced renal cell carcinoma with inferior vena cava tumor thrombus. METHODS The present study involved a comprehensive retrieval of pertinent literature from the most recent two decades. RESULTS Comparisons between radical nephrectomy procedures in terms of open, laparoscopic and robotic-assisted surgeries revealed that open surgery had more blood loss, a longer operation time and higher mortality rates than laparoscopic and robotic-assisted surgeries. Furthermore, surgery with CPB was associated with more blood loss than non-CPB surgery. Rates of early and late deaths were much higher in patients with CPB than in those without CPB. CONCLUSIONS Different surgical techniques had different indications in terms of levels of inferior vena cava tumor thrombus. The laparoscopic, robotic-assisted, open surgical techniques and CPB with deep hypothermic circulatory arrest were indicated for Levels I, II, III and III-IV inferior vena cava tumor thrombus, respectively. Laparoscopic and robotic-assisted surgeries cause less trauma than open surgery but require more complicated equipments to support the procedure. CPB should be avoided in radical nephrectomy whenever possible. The increased application of laparoscopic and robotic techniques in the future is anticipated.
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Ghoreifi A, Djaladat H. Surgical Tips for Inferior Vena Cava Thrombectomy. Curr Urol Rep 2020; 21:51. [PMID: 33090290 DOI: 10.1007/s11934-020-01007-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy. RECENT FINDINGS RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.
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Affiliation(s)
- Alireza Ghoreifi
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA
| | - Hooman Djaladat
- Institute of Urology, Norris Comprehensive Cancer Center, University of Southern California, 1441 Eastlake Ave. Suite 7416, Los Angeles, CA, 90089, USA.
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7
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Wu JY, Mi Y, Liu S, Yao L, Tang Q, He ZS, Wang XY. [Evaluating inferior vena cava wall invasion in renal cell carcinoma tumor thrombus with MRI]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:673-677. [PMID: 31420620 DOI: 10.19723/j.issn.1671-167x.2019.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the diagnostic performance of MRI for the assessment of inferior vena cava (IVC) wall invasion by IVC thrombus in patients with renal cell carcinoma (RCC). METHODS We retrospectively collected patients who underwent radical nephrectomy and thrombectomy for RCC between 2010 and 2018 at Peking University First Hospital. All the patients underwent imaging on a 1.5 Tesla or 3.0 Tesla MRI scanner. Fifty-six patients met the inclusion criteria. Preoperative imaging was reviewed by two radiologists blinded to details of the patient's surgical procedure and histopathology. Two radiologists measured the maximum anterior-posterior diameter and coronal diameters of the IVC and renal vein, and the craniocaudal extent of tumor thrombus, and evaluated the MRI features of IVC thrombus, including occlusion of the IVC lumen, the margin of the tumor thrombus (smooth vs. irregular), contact of the IVC thrombus and IVC wall, and altered signal of the IVC wall. Univariable and multivariable associations of clinical and radiographic features with IVC wall invasion were evaluated by Logistic regression. RESULTS Of the 56 patients [male: 43, female: 13, mean age: (55.64±0.43) years], 17 (30.36%) were detected with IVC wall invasion, and most were clear cell carcinoma. Tumor thrombus with IVC wall invasion showed an increase in length of IVC thrombus [(7.91±3.59) cm vs. (5.94±3.57) cm, P=0.049], and more features of complete occlusion of the IVC lumen (P=0.002), irregular margin of the IVC thrombs (P=0.005), contact of the IVC thrombus and IVC wall (P=0.001), and altered signal of the low-intensity vessel wall (P<0.001), with a sensitivity of 94.12% and a specificity of 79.49%. CONCLUSION The present study indicates that MRI could be a means of evaluating RCC with IVC wall invasion, and the combination of tumor thrombus length and subjective impression of IVC wall invasion achieved a high sensitivity and specificity for diagnosis.
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Affiliation(s)
- J Y Wu
- Department of Radiology, Peking University First Hospital, Beijing 100034, China
| | - Y Mi
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - S Liu
- Department of Radiology, Peking University First Hospital, Beijing 100034, China
| | - L Yao
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Q Tang
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - Z S He
- Department of Urology, Peking University First Hospital, Beijing 100034, China
| | - X Y Wang
- Department of Radiology, Peking University First Hospital, Beijing 100034, China
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Diagnostic Accuracy of MRI for Detecting Inferior Vena Cava Wall Invasion in Renal Cell Carcinoma Tumor Thrombus Using Quantitative and Subjective Analysis. AJR Am J Roentgenol 2019; 212:562-569. [DOI: 10.2214/ajr.18.20209] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Hamblen V. Sonographic Evaluation of Inferior Vena Cava Tumor Thrombus in Renal Cell Carcinoma: A Case Study of a Rare Condition. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2018. [DOI: 10.1177/8756479318774766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Inferior vena cava (IVC) tumor thrombus in renal cell carcinoma is a rare entity that suggests heightened biologic behavior and a surgical challenge during the course of treatment. Tumor thrombus can extend from the renal vein to the right atrium. This cephalad extension is classified by four different levels. These levels determine which surgical approach is used, whether a thoracoabdominal incision is needed, and whether a patient needs to be placed in circulatory arrest. Complete surgical resection of the tumor is potentially the only curative treatment, although it supposes a challenge because of operative difficulty and the potential for massive bleeding or tumor pulmonary thromboembolism. IVC tumor thrombus presents with a few differentials that need to be assessed, including bland thrombus, primary IVC leiomyosarcoma, hepatocellular carcinoma, adrenal cortical carcinoma, primary lung carcinoma, and Wilms tumor. The importance of diagnosing IVC tumor thrombus secondary to renal cell carcinoma is demonstrated as well as a sonographic protocol for assessing IVC tumor thrombus.
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Affiliation(s)
- Viyana Hamblen
- Diagnostic Medical Sonography Program, El Centro College, Dallas, TX, USA
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Palacios-Zertuche J, Rodríguez-Briseño J, Martínez-Zarazúa R, Reyna-Sepúlveda F, Muñoz-Maldonado G. Resección de vena cava y colocación de injerto de dacrón con reimplante de vena renal izquierda debido a trombosis tumoral de vena cava por carcinoma de células renales. ANGIOLOGIA 2017. [DOI: 10.1016/j.angio.2016.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Jiménez-Romero C, Conde M, de la Rosa F, Manrique A, Calvo J, Caso Ó, Muñoz C, Marcacuzco A, Justo I. Treatment of caval vein thrombosis associated with renal tumors. Cir Esp 2017; 95:152-159. [PMID: 28242025 DOI: 10.1016/j.ciresp.2017.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Renal carcinoma represents 3% of all solid tumors and is associated with renal or inferior caval vein (IVC) thrombosis between 2-10% of patients, extending to right atrial in 1% of cases. METHODS This is a retrospective study that comprises 5 patients who underwent nephrectomy and thrombectomy by laparotomy because of renal tumor with IVC thrombosis level iii. RESULTS Four patients were males and one was female, and the mean age was 57,2 years (range: 32-72). Most important clinical findings were hematuria, weight loss, weakness, anorexia, and pulmonary embolism. Diagnostic confirmation was performed by CT scanner. Metastatic disease was diagnosed before surgery in 3 patients. Suprahepatic caval vein and hepatic hilium (Pringle's maneouver) were clamped in 4 patients, and ligation of infrarrenal caval vein was carry out in one patient. Five patients developed mild complications (Clavien I/II). No patient died and the mean hospital stay was 8,6 days. All patients were treated with chemotherapy, and 3 died because distant metastasis, but 2 are alive, without recurrence, at 5 and 60 months, respectively. CONCLUSIONS Nephrectomy and thrombectomy in renal tumors with caval thrombosis can be curative in absence of metastasis or, at less, can increase survival or quality of live. Then these patients must be treated in liver transplant units because major surgical and anesthesiologic expertise. Adjuvant treatment with tyrosin kinase inhibitors must be validate in the future with wider experiences.
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Affiliation(s)
- Carlos Jiménez-Romero
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España.
| | - María Conde
- Servicio de Cirugía General, Hospital Universitario Lucus Augusti, Lugo, España
| | | | - Alejandro Manrique
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Jorge Calvo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Óscar Caso
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Carlos Muñoz
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Alberto Marcacuzco
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
| | - Iago Justo
- Unidad de Cirugía Hepato-Bilio-Pancreática y Trasplante de Órganos Abdominales, Hospital Universitario Doce de Octubre, Universidad Complutense de Madrid, Madrid, España
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Komarov RN, Belov YV, Chernyavsky SV, Galnykina EK. [Surgical treatment of patient with right kidney cancer and tumoral thrombosis of inferior vena cava and right atrium after previous coronary artery bypass grafting]. Khirurgiia (Mosk) 2016:64-66. [PMID: 27070879 DOI: 10.17116/hirurgia2016364-66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- R N Komarov
- Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of Postgraduate Education ,acad. B.V. Petrovsky Russian Research Center of Surgery, University's Clinical Hospital #1, I.M. Sechenov First Moscow State Medical University, Moscow
| | - Yu V Belov
- Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of Postgraduate Education ,acad. B.V. Petrovsky Russian Research Center of Surgery, University's Clinical Hospital #1, I.M. Sechenov First Moscow State Medical University, Moscow
| | - S V Chernyavsky
- Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of Postgraduate Education ,acad. B.V. Petrovsky Russian Research Center of Surgery, University's Clinical Hospital #1, I.M. Sechenov First Moscow State Medical University, Moscow
| | - E K Galnykina
- Chair of Cardiovascular Surgery and Interventional Cardiology, Institute of Postgraduate Education ,acad. B.V. Petrovsky Russian Research Center of Surgery, University's Clinical Hospital #1, I.M. Sechenov First Moscow State Medical University, Moscow
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Abstract
OBJECTIVE In most cases of inferior vena cava (IVC) surgery, IVC clamping is required owing to several factors, including renal cell carcinoma with IVC thrombus extension and IVC leiomyosarcoma. Various clinical results were compared following IVC clamping by classifying clamping levels into juxtarenal, infrahepatic, and suprahepatic. In particular, the risk factors of postoperative thrombosis after IVC clamping were assessed comparatively. METHODS Eighty-four patients who underwent IVC clamping owing to IVC pathology between 2002 and 2012 were retrospectively reviewed with regard to RBC transfusion, operation time, clamping time, liver and kidney functions, duration of hypotension, blood pressure (BP) drops, pulmonary thromboembolism (PTE), venous thrombosis, ICU stay duration, hospital stay duration, 30-day morbidity, and 30-day mortality. In addition, various clinical results were compared when postoperative thrombosis occurred after IVC clamping. RESULTS Values for operation time, clamping time, units of RBC transfused, duration of hypotension, severity of BP drops, use of cardiopulmonary bypass (CPB), aspartate aminotransferase, the use of inotropes, IVC patency, ICU stay, and hospital stay duration were significantly higher in the suprahepatic clamping group than in the other clamping groups. In addition, CPB use and IVC clamping level were significant risk factors for postoperative thrombosis after IVC clamping. CONCLUSIONS Although IVC clamping is a prerequisite for IVC surgery, operative durations, units of RBC transfused, and length of hospital stays increase with higher clamping levels. In addition, CPB use and IVC clamping level are significant risk factors for postoperative thrombosis. In IVC surgery with higher clamping levels, prompt hemodynamic support and proper anticoagulation therapy are important.
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Transoesophageal echocardiography reduces invasiveness of cavoatrial tumour thrombectomy. Wideochir Inne Tech Maloinwazyjne 2014; 9:479-83. [PMID: 25337178 PMCID: PMC4198655 DOI: 10.5114/wiitm.2014.44281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Revised: 02/10/2014] [Accepted: 04/20/2014] [Indexed: 11/17/2022] Open
Abstract
The traditional approach to cavoatrial thrombus excision requires median sternotomy, cardiopulmonary bypass with or without hypothermia and circulatory arrest and is associated with significant morbidity and mortality. We describe a transoesophageal echocardiography guided balloon catheter assisted technique for cavoatrial thrombectomy that avoids thoracotomy, extracorporeal circulation and circulatory arrest as an alternative to traditional methods. A 74-year-old man presented with a right solid renal mass confined to the kidney with thrombus extension through the right renal vein and the inferior vena cava into the right atrium. A right radical nephrectomy with cavoatrial thrombectomy under transoesophageal echocardiography guidance was successfully achieved using a balloon catheter-assisted technique with minimal intra-and postoperative morbidity. Cavoatrial tumour thrombectomy can be successfully performed without cardiopulmonary bypass, hypothermia and circulatory arrest.
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Calero A, Armstrong PA. Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon. Semin Vasc Surg 2014; 26:219-25. [PMID: 25220330 DOI: 10.1053/j.semvascsurg.2014.06.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Venous invasion is a common characteristic of renal cell carcinoma, manifesting as tumor thrombus with possible extension into the renal vein and, in extensive cases, the thrombus can reach from the renal vein to the right atrium. Currently, cytoreductive nephrectomy and tumor thrombectomy are the foundations for improving quality of life and survival in the treatment of renal cell carcinoma, and a role has emerged for a vascular specialist to become an integral part of operative planning and therapy.
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Affiliation(s)
- Aurelia Calero
- Division of Vascular and Endovascular Surgery, University of South Florida, USF Health Building 7th Floor, 2 Tampa General Circle, Tampa, FL 33606
| | - Paul A Armstrong
- Division of Vascular and Endovascular Surgery, University of South Florida, USF Health Building 7th Floor, 2 Tampa General Circle, Tampa, FL 33606.
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Krabbe LM, Bagrodia A, Margulis V, Wood CG. Surgical management of renal cell carcinoma. Semin Intervent Radiol 2014; 31:27-32. [PMID: 24596437 DOI: 10.1055/s-0033-1363840] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Surgical resection of renal cell carcinoma (RCC) is the benchmark for long-term cure of the disease. Although open or laparoscopic radical nephrectomy is considered the gold standard for stage T1b-T4 tumors, nephron-sparing surgery is the preferred operative modality for small renal masses demonstrating equivalent oncologic efficacy and improved renal function outcomes compared with complete nephrectomy. With the advance of minimally invasive surgery, nephron-sparing procedures can safely be conducted laparoscopically with or without robotic assistance. RCC with intravenous tumor thrombus presents a surgical challenge, but multidisciplinary surgical approaches can provide long-term benefit in these patients. The role of cytoreductive nephrectomy and metastasectomy in patients with metastatic RCC (mRCC) is controversial, but seems to be beneficial for patients in the era of targeted therapy.
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Affiliation(s)
- Laura-Maria Krabbe
- Department of Urology, the University of Muenster Medical Center, Muenster, Germany ; Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Aditya Bagrodia
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
| | - Vitaly Margulis
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas
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Kwon T, Lee JL, You D, Jeong IG, Song C, Ahn H, Kim CS, Hong JH. Impact of surgery on the prognosis of metastatic renal cell carcinoma with IVC thrombus received TKI therapy. J Surg Oncol 2014; 110:145-50. [PMID: 24706355 DOI: 10.1002/jso.23612] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 03/08/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES To evaluate the impact of surgery on the prognosis of metastatic renal cell carcinoma (mRCC) with inferior vena cava (IVC) thrombus. METHODS In this retrospective study, the medical records of 45 patients who presented with synchronous mRCC with IVC thrombus, between 2005 and 2012, were reviewed. Twenty-eight patients underwent radical nephrectomy with IVC thrombectomy followed by targeted therapy (group 1) and 17 received targeted therapy alone (group 2). Cox proportional hazards regression models served to estimate the prognostic significance of variables. RESULTS The median progression-free survival of group 1 and group 2 was 4.1 and 3.5 months, respectively (P = 0.672). Their median overall survival was 17.3 and 19.7 months, respectively (P = 0.353). Multivariate analysis revealed that non-clear cell type RCC (HR = 3.46, P = 0.007) and lymph node metastasis (HR = 2.31, P = 0.003) independently predicted progression-free survival, and Karnofsky performance status (HR = 3.82, P = 0.013) and non-clear cell type RCC (HR = 4.01, P = 0.003) independently predicted overall survival. Surgical resection of the primary renal mass with IVC thrombus did not affect the probability of progression or overall mortality. CONCLUSIONS Our limited data set would suggest a limited role for surgery in this patient population and that a prospective study in this group may define the role of surgery.
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Affiliation(s)
- Taekmin Kwon
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Shin S, Han Y, Park H, Chung YS, Ahn H, Kim CS, Cho YP, Kwon TW. Risk factors for acute kidney injury after radical nephrectomy and inferior vena cava thrombectomy for renal cell carcinoma. J Vasc Surg 2013; 58:1021-7. [DOI: 10.1016/j.jvs.2013.02.247] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Revised: 02/20/2013] [Accepted: 02/27/2013] [Indexed: 11/24/2022]
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The perioperative management of an inferior vena caval tumor thrombus in patients with renal cell carcinoma. Urol Oncol 2013; 31:517-21. [DOI: 10.1016/j.urolonc.2011.03.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 01/08/2023]
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Kim KH, You D, Jeong IG, Kwon TW, Cho YM, Hong JH, Ahn H, Kim CS. Type II papillary histology predicts poor outcome in patients with renal cell carcinoma and vena cava thrombus. BJU Int 2012; 110:E673-8. [PMID: 22973869 DOI: 10.1111/j.1464-410x.2012.11498.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
UNLABELLED What's known on the subject? and What does the study add? In patients with pRCC, the presence of venous tumour thrombus is known to be a predictor of poorer outcomes. However, a paucity of data is available regarding the prognostic significance of histology in patients with RCC and IVC thrombus. In our series, we found that patients with type II pRCC had significantly poorer outcomes when compared to those with cRCC. Although the lack of effective treatment for patients with metastatic pRCC may have contributed to these adverse outcomes, type II papillary histology was independent predictor not only of CSS but also of RFS. OBJECTIVE • To analyze the prognostic impact of papillary histology on oncological outcomes in patients with renal cell carcinoma (RCC) and inferior vena cava (IVC) thrombus. PATIENTS AND METHODS • We reviewed the medical records of 74 patients who underwent radical nephrectomy and IVC thrombectomy between 1990 and 2010 for clear cell or papillary RCC. • We compared the clinicopathological features and clinical outcomes of 62 patients with clear cell RCC (cRCC) and 12 with papillary RCC (pRCC). • All cases of pRCC were subdivided into type I or type II. • The prognostic role of papillary histology on recurrence-free survival (RFS) and cancer-specific survival (CSS) was estimated using Cox's regression models. RESULTS • Upon reclassification of the pRCC subtype, all 12 patients with pRCC had type II tumours. • Patients with type II pRCC were significantly younger (P=0.028) and were more probably women (P=0.025) than those with cRCC • The 2- and 5-year CSS rates were 81.1% and 53.6% in cRCC patients, and 28.1% and 0% in type II pRCC patients, respectively. All eight patients with non-metastatic type II pRCC developed disease recurrence at a median interval of 6 months after surgery, whereas 25 of 44 (56.8%) patients with non-metastatic cRCC experienced such recurrence at a median interval of 10 months after surgery. • Patients with type II pRCC showed significantly lower CSS (P<0.001) and RFS (P=0.002) than those with cRCC. • On multivariate analysis, type II papillary histology was an independent predictor of CSS (hazard ratio, 3.73; P=0.003) and RFS (hazard ratio, 3.15; P=0.015). CONCLUSIONS • Type II papillary histology appears to be predominant in cases of pRCC with IVC thrombus. • Patients with type II pRCC who presented with IVC thrombus had significantly worse outcomes than those with cRCC, and histology is an important prognostic factor in patients with RCC and IVC thrombus.
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Affiliation(s)
- Kwang Hyun Kim
- Department of Urology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Lawindy SM, Kurian T, Kim T, Mangar D, Armstrong PA, Alsina AE, Sheffield C, Sexton WJ, Spiess PE. Important surgical considerations in the management of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumour thrombus. BJU Int 2012; 110:926-39. [DOI: 10.1111/j.1464-410x.2012.11174.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Current world literature. Curr Opin Urol 2011; 21:166-72. [PMID: 21285721 DOI: 10.1097/mou.0b013e328344100a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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