Invited Commentary

Abstract

Fabiani and colleagues [1Fabiani J.-N. Raux M. Alsac J.-M. et al.Deep hypothermia and low flow for surgery for abdominal or extraperitoneal tumors with cavoatrial extension.Ann Thorac Surgery. 2013; 95: 2036-2041Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar] report the removal of tumor thrombus into the inferior vena cava (IVC) by use of deep hypothermic low-flow cardiopulmonary bypass (CPB). There was no mortality at the 1-year follow-up of these patients. The authors conclude that this technique allows for safe and complete removal of tumor thrombus into the IVC while providing organ protection. It is not clear whether the authors placed an IVC filter when the IVC was partially obstructed at the end of the operation to avoid pulmonary emboli. Perhaps the only limitation of this report is the limited number of patients, making it difficult to standardize the surgical approach for removal of these tumors. The prevalence of patients with extensive IVC tumor thrombus is very low. However, the surgical procedure is associated with high morbidity and mortality (over 8%) when deep hypothermic circulatory arrest is used [2Shuch B. Crispen P.L. Leibovich B.C. et al.Cardiopulmonary bypass and renal cell carcinoma with level IV tumor thrombus: can deep hypothermic circulatory arrest limit perioperative mortality?.BJU Int. 2010; 107: 724-728Crossref Scopus (42) Google Scholar]. This underscores the importance of the experience of the surgical team performing the operation. Some centers, such as ours, have gone to great lengths to avoid CPB altogether, using innovative technical maneuvers [3Ciancio G. Gonzalez J. Shirodkar S.P. Angulo J.C. Soloway M.S. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description.Eur Urol. 2010; 59: 401-406Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 4Ciancio 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: 505-510Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. The best approach for such patients would be to refer them to centers with extensive experience with these complex operations, where the operation can be tailored to the specific location of the tumor, with use of a multidisciplinary surgical team that includes a urologic oncologist, a cardiothoracic surgeon, and an anesthesiologist with expertise in transesophageal echocardiography. It is important to determine the exact extension of the tumor thrombus and involvement of the IVC wall with imaging technology. This helps the surgeons to individualize the approach, the extent of expected surgical procedure, and the need for CPB. These tumors with vascular invasion into the IVC continue to be a challenge to the surgical team. It is clear that complete excision of the tumor, including removal of involved IVC, with negative margins, as described by the authors, allows the best chance for patient survival. Deep Hypothermia and Low Flow for Surgery for Abdominal or Extraperitoneal Tumors With Cavoatrial ExtensionThe Annals of Thoracic SurgeryVol. 95Issue 6PreviewSurgical treatment of retroperitoneal tumors with cavoatrial involvement can be challenging. Completeness of resection of the cava tumor extension is crucial for the patient's survival. We report a monocentric experience with the use of cardiopulmonary bypass and deep hypothermic low flow for the surgical resection of caval and atrial involvement of retroperitoneal tumors. Full-Text PDF