Invited Commentary

Abstract

During a 12-year period, the authors have treated 102 patients with renal cell carcinoma [1Ciancio G. Shirodkar S.P. Soloway M.S. Livingstone A.S. Barron M. Salerno T.A. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass.Ann Thorac Surg. 2010; 89: 505-511Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The tumor thrombus in 12 patients extended into the supradiaphragmatic inferior vena cava and the right atrium (level 4 tumor). By combining the skill sets of liver transplantation, urologic oncology, cardiac surgery, and anesthesiology familiar with transesophageal echocardiography, these tumors were treated without sternotomy, cardiopulmonary bypass, or deep hypothermic circulatory arrest. An extended abdominal chevron incision was used. The inferior vena cava, liver, kidney, and right atrium were thoroughly mobilized to facilitate sequential clamping and tumor extraction. The surgical strategy is illustrated well in the figures. It is not surprising that the operations were time consuming (8 hours), with nearly 3 liters of blood loss and 9 units of transfusion per patient, despite use of a cell-saving device in 8 of the 12 patients. Obstruction of the hepatic veins with Budd-Chiari syndrome intensified bleeding problems. The postoperative intensive care unit stay was 7 days. There were 2 deaths: an 80-year-old patient died of a cardiac arrhythmia and another death was attributed to acute respiratory distress syndrome and multiple organ failure. Pulmonary metastases developed in 2 patients at 1 and 3 years after their operations, and local recurrence in the renal fossa was noted in 1 patient. These complications and deaths underscore the seriousness of the condition. The authors note a sobering 32% to 69% survival at 5 years in patients with tumor invading the inferior vena cava. This approach is novel, and some precautions seem warranted:1This technique will need intense preoperative planning based on imaging studies and pooling the skills of four physician teams involved in the procedure.2Findings during the assessment may suggest that cardiopulmonary bypass with hypothermia may be safer in view of caval or right atrial involvement.3If this technique is used, cell-saving devices and rapid infusion of shed blood will minimize blood requirements.4Great care is required in clamping the right atrium/inferior vena cava so that no tumor is left behind. Hand-held right atrial echocardiography scanning may be a useful adjunct and will, in addition, identify coronary sinus location.5Selective use of this new technique may be warranted in patients at high risk for cardiopulmonary bypass and possible hypothermic arrest. Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary BypassThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewRenal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Full-Text PDF