Leiomyosarcoma of the left kidney with renal vein and inferior vena cava tumor thrombus

To investigate the prognosis of surgical treatment for renal cell carcinoma with renal vein or inferior vena cava tumor thrombus. Between August 1994 and July 2004, 33 patients with renal cell carcinoma with renal vein or inferior vena cava tumor thrombus underwent radical nephrectomy and thrombectomy. The study population included 26 male and 7 female. The median age was 60 years (20 - 82). Level of tumor thrombus was renal vein in 15 patients, infrahepatic (level I) in 9, intrahepatic (level II) in 5, suprahepatic (level III) in 1, and right atrial extension (level IV) in 3. Survival analysis was made with Kaplan-Meier method. Twenty-nine patients can be followed up. Fourteen patients were lost with a mean survival time of (16.4 +/- 2.9) months (1 - 42 months). Fifteen patients were survival with a mean follow-up of (17.3 +/- 4.6) months (3 - 67 months). One patient was lost on the second postoperative day. Three patients can not be followed up. The 5-year Kaplan-Meier survival rate was 16%. The mean survival time of patients with renal vein involvement [(49.9 +/- 9.8) months] versus level I [(16.7 +/- 1.9) months] was significantly different (P < 0.05). Radical nephrectomy plus thrombectomy is a valuable method for the treatment of renal cell carcinoma with renal vein or inferior vena cava involvement. Patients with renal vein tumor thrombus appear to have better survival compared to patients with inferior vena cava tumor thrombus.

Objective To investigate the safety and feasibility radical nephrectomy and Mayo 0-Ⅳ venous thrombectomy. Methods The clinical data 52 patients with Mayo 0-Ⅳ tumor thrombus from February 2015 to January 2017 were analyzed retrospectively. Of the 52 patients, 42 were male and 10 were female. The average age was (59.8 ±13.6) years old (2.5 to 84.0 years). The renal vein tumor thrombus or inferior vena cava tumor thrombus was found in all patients, including type 0 thrombus in 12 cases, typeⅠthrombus in 11 cases, type Ⅱthrombus in 15 cases, type Ⅲthrombus in 9 cases, type Ⅳ thrombus in 5 cases (Mayo Medical Center classification). Imaging suggested the right renal tumor in 36 cases and left tumor in 16 cases. The average tumor size was (8.5±2.0) cm(2.0-21.1 cm). There were 2 cases ASA Ⅰ, 40 cases ASA Ⅱ and 10 cases ASA Ⅲ according to the American Society Anesthesiologists (ASA). In laparoscopic radical nephrectomy and Mayo 0 venous thrombectomy, we clamped the vena cava vessel wall nearby the renal vein entrance. The vena cava blood flow was blocked partially. Then we cut the vessel wall arcuately. Mayo Ⅰ tumor thrombus requires the use a non traumatic auricle clamp to control blood flow by the block vena cava above thrombus, vena cava below the renal vein level, and the contralateral renal vein. Right kidney tumors with Mayo Ⅱ could be completed by retroperitoneal surgery. At the time vascular occlusion, the distal inferior vena cava, the left renal vein and the proximal inferior vena cava were interrupted sequentially. For left renal tumors with Mayo Ⅱ, the retroperitoneal approach combined with transperitoneal approach was used. The technique of milking can shrink the tumor thrombus and reduced the difficulty the operation. For Mayo Ⅲ tumor thrombus just at the hepatic vein level, we cut off 3-5 hepatic short veins, and separated inferior vena cava long enough to provide surgical field. For Mayo Ⅲ tumor thrombus much higher than the hepatic vein level, we used open surgeries to free the liver and porta hepatis. We first blocked the distal inferior vena cava, followed by the left renal vein, the hepatic artery and portal vein, at last the proximal inferior vena cava. Mayo Ⅳ tumor thrombus often required a median incision to open the chest and establish an extracorporeal circulation. Results All the 52 surgeries were completed successfully without intraoperative and perioperative mortality. Open radical nephrectomy and inferior vena cava thrombectomy was underwent in 22 cases. Pure laparoscopic surgery was under went in 30 case. Two cases were converted to open surgery. The average surgery time was(333.7±80.1)min(136-694 min). The average blood loss volume was (1339.0±508.1)ml(20-10 000ml). During the operation, the amount suspended red blood cells transfusion was(761.5±394.8)ml(0-10 400ml). 28 cases underwent regional lymph node dissection, and postoperative pathological diagnosis showed lymph metastasis in 4 cases. 24 cases underwent ipsilateral adrenalectomy, and 2 cases showed tumor invasion adrenal gland. 7 cases with right tumors underwent inferior vena cava wall resection because invasion by tumor thrombus. The average postoperative hospitalization all 52 cases was (9.7±4.7) d. Among 27 patients, early postoperative complications occurred in 18 cases (34.6%). There were 1 case Clavien Ⅰ, 12 cases Clavien Ⅱ, 1 case Clavien Ⅲa, 2 cases Clavien Ⅳa and 2 cases Clavien Ⅴ according to modified Clavien classifications.44 cases(84.6%) were followed up for 1 to 22 months with a median 8 months. Postoperative recurrence occurred in 3 cases, and distant metastasis occurred in 9 cases. 9 cases (20.5%) had tumor specific death. Conclusions Our initial clinical results show that radical nephrectomy and inferior vena cava thrombectomy is safe and effective for patients with Mayo 0-Ⅳtumor thrombus, but the wide extension vein tumor thrombus leads to the difficulty operation technique. Sufficient preoperative preparation, rich operative experience and skills can improve the safety operation. Key words: Renal carcinoma; Tumor thrombus; Inferior vena cava

BackgroundUrothelial carcinoma (UC) of the renal pelvis with renal vein and inferior vena cava (IVC) tumor thrombus (TT) was extremely rare. We aimed to explore the clinical and pathological characteristics, diagnosis and treatment of renal pelvis UC with renal vein and IVC TT.MethodsFrom March 2016 to January 2019, eight patients of renal pelvis UC with renal vein and IVC TT were diagnosed and underwent operation in our hospital. Clinical features, operative details, pathological outcomes, and prognosis data were reviewed and collected.ResultsThere were five males and three females (52–84 years old). Their main symptoms were flank pain and hematuria. According to the Mayo classification, the TT was 4 level-0 (1 left and 3 right), 2 level-I (right), and 2 level-II (right). Half the patients underwent retroperitoneal laparoscopic radical nephroureterectomy with thrombectomy, and the other underwent open procedures. The mean operative time was 298.9 minutes. Pathological outcomes revealed high-grade UC, with positive lymph nodes in 6 cases. Four patients received adjuvant chemotherapy, one target therapy and one adjuvant chemotherapy combined with immunotherapy after surgery. The mean follow-up time was 11.1 months. Three patients are alive, and two of them developed recurrence and lung metastasis.ConclusionsPreoperative differentiation between renal pelvis UC and renal cell carcinoma with venous TT was very important for the management. Radical nephroureterectomy with thrombectomy might be a reasonable method for renal pelvis UC with venous TT. The prognosis of such cases was poor even if adjuvant therapy was scheduled.

Renal Cell Carcinoma with Thrombus Extension into the Inferior Vena Cava and the Right Atrium: A Case Report

Objectives: To compare the perioperative hemodynamic consequences and oncology outcomes of robotic retroperitoneal vs transperitoneal inferior vena cava (IVC) thrombectomy (IVCT) for right renal cell carcinoma (RCC) with IVC tumor thrombus (IVCTT) that located below the first porta hepatis. Patients and Methods: Between January 2018 and June 2019, 35 patients of right RCC with IVCTT that located below the first porta hepatis underwent robotic retroperitoneal IVCT (16 patients) or transperitoneal IVCT (19 patients). We have described the procedures of transperitoneal IVCT earlier. The main procedure of robotic retroperitoneal IVCT include circumferential dissection of the IVC, sequentially clamping subhepatic IVC, the left renal vein and the caudal IVC with vessel loops, IVCT, IVC repair, and radical nephrectomy (RN). The following parameters were compared between the two groups: baselines characteristic, perioperative consequences, and hemodynamic changes. Results: Retroperitoneal and transperitoneal cohorts were comparable in terms of IVC thrombus length (3.2 vs 4.0 cm), IVC block time (18 vs 16 minutes, p = 0.64), postoperative hospital stay (6 vs 6 days, p = 0.67), postoperative complications (0 vs 0), and recurrence or metastasis rate (0 vs 0) for patients with similar baseline characteristic. The retroperitoneal cohort tended to less blood loss (160 vs 240 mL, p = 0.024), shorter operative time (130 vs 145 minutes, p = 0.003), lower central venous pressure (p < 0.05), and smaller diameter of IVC (p < 0.05). Conclusions: Robotic retroperitoneal RN and IVCT is feasible for patients of right RCC with IVCTT located below the first porta hepatis and is superior to transperitoneal IVCT in terms of bleeding control and operation time for skilled surgeons.

BackgroundTransitional cell carcinoma (TCC) originating from the renal pelvis with a venous tumor thrombus is a rare entity. However, clinicians should be aware of it because of its high malignancy and poor prognosis.Case presentationHere, we report three cases of pathologically confirmed TCC originating from the renal pelvis with extension into the renal vein or inferior vena cava (IVC). Of these patients, two are males and one is female (58~73 years old). Their main symptom is flank pain; besides, gross hematuria and weight loss is observed in one of the patients. Computed tomography (CT) scan of the first patient revealed multiple space-occupying lesions in the left renal pelvis and left medium and lower ureter with a tumor thrombus in the left renal vein. CT scan of the second patient revealed a right renal mass and extension into the IVC. Abdominal magnetic resonance imaging (MRI) of the third patient showed a soft tissue mass in the region of the left renal sinus, and the signal of the soft tissue was observed in the left renal vein. The preoperative diagnoses of the first and third patient were TCC, while the second patient was renal cell carcinoma (RCC). Two patients with the preoperative diagnosis of TCC underwent laparoscopic radical nephroureterectomy with thrombectomy, and the other patient underwent radical nephrectomy with thrombectomy. The surgeries were successful. Although two of our patients underwent chemotherapy and radiotherapy, they died 2 and 19 months after the surgery, respectively. The other patient refused any adjuvant therapy and died 3 months after the operation.ConclusionsCompared to the extension of RCC to the renal vein or IVC, extension of TCC to the renal vein or IVC is rare. TCC with a venous tumor thrombus is often misdiagnosed as RCC. However, a correct preoperative or intraoperative diagnosis is of great importance to decide surgical strategy. Laparoscopic radical nephroureterectomy with thrombectomy may be a safe and feasible operative method in treatment of TCC with a renal vein thrombus. The prognosis of such cases is poor even if chemotherapy and radiotherapy are scheduled.

Renal Cell Carcinoma With Tumor Thrombus Extension: Biology, Role of Nephrectomy and Response to Immunotherapy

Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus.

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The Accuracy of Multidetector Computerized Tomography for Evaluating Tumor Thrombus in Patients With Renal Cell Carcinoma

Introduction Renal cell carcinoma (RCC) has a unique tendency toward intravascular growth into the renal vein (RV), inferior vena cava (IVC), or even into the heart. To determine the operative approach and degree of surgical resection required, an accurate preoperative assessment of the extent of the tumor thrombus (TT) is mandatory. The purpose of this report is to describe the presentation of TT with color duplex ultrasound (CDU) and to report our initial experience in mapping the extent of vascular invasion in five patients. Methods Between January and November 2004, 5 patients with suspected RCC underwent a renal CDU examination. The presence and extent of TT by CDU was correlated with contrast enhanced computerized tomography (CT), magnetic resonance imaging (MRI) or surgical findings. Results Three men and two women were found to have a unilateral renal mass. The arterial supply to each tumor was conspicuous and consisted of prominent feeding arteries by color or power Doppler that circumscribed and penetrated the mass. TT was localized to the RV in one case and involved the RV and IVC in four. For two patients, the growth of TT into the IVC was limited and nonocclusive whereas in two others it was extensive and occlusive. In one case, TT invaded the IVC and the contralateral RV. By gray-scale imaging, TT appeared as an echogenic, heterogeneous mass that caused focal dilatation of the vein followed by rapid tapering. Interestingly, in three patients, low-resistance pulsatile flow could be recorded within the TT tissue itself. When compared with computed tomography, magnetic resonance imaging, or the operative findings, CDU agreed with the location and extent of TT in all 5 cases. Conclusion CDU appears to be an accurate technique for mapping the extent of TT in patients with RCC. Although this series is small, the unique gray scale and spectral Doppler characteristics of TT noted on CDU may be beneficial in distinguishing bland thrombus from TT.

Objective To explore the clinical characteristics of renal angiomyolipoma (AML) with inferior vena cava (IVC) tumor thrombus and to improve the diagnosis and treatment of the disease. Methods The clinical data of 3 patients with renal AML and inferior vena cava tumor thrombus was retrospectively reviewed. The patients were all female, aged 19 to 70 years. Among them, 2 patients presented with lumbago on the right side, and the other one was diagnosed by physical examination. The body mass index ranged from 18.4 to 24.6 kg/m2, with a median value of 20.4 kg/m2. According to the American Society of Anesthesiologists (ASA), they were classified as grade Ⅱ. Color doppler ultrasound examination of the kidney and IVC was performed in all the 3 patients, all of which showed hyperechoic solid mass in the right kidney. Color doppler ultrasound of IVC showed hyperechoic band in the IVC, indicating blood flow signals and the tumor thrombus. All the 3 cases showed irregular fat density or mixed density in the right kidney and multiple irregular fat density were observed in the right renal vein and inferior vena cava on CT. Two of them received MRI examination of IVC, which showed irregular lesions in the right kidney, short T1 and long T2 signals, low lipids, and no definite limited diffusion on DWI. Irregular fat signal were seen in the right renal vein and inferior vena cava. All 3 patients were diagnosed with right renal mass with IVC tumor thrombus, with 1 patient of Mayo grade Ⅲ tumor thrombus and the other 2 of Mayo gradeⅡtumor thrombus. One underwent laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy, another one underwent open right partial nephrectomy and tumor thrombectomy, and the third one suffered preoperative AML rupture, undergoing open radical nephrectomy and tumor thrombectomy. Results The operation time was 168 to 659 min, with median of 220 min. Intraoperative blood loss ranged from 50 to 300 ml, with the median of 50 ml. Postoperative indwelling time of drainage tube was 5 to 11 days, with the median of 6 days. Postoperative hospital stay ranged from 7 to 14 days, with a median of 8 days. Postoperative follow-up ranged from 12 to 16 months, with a median follow-up of 13 months. All the three patients underwent operation without postoperative complications. Postoperative pathology proved to be right renal angiomyolipoma. After 3 months of follow-up, the patients showed no tumor recurrence or metastasis. Conclusions Renal AML is a benign lesion, which is rarely concurrent with inferior vena cava cancer thrombus. Enhanced CT examination is the main diagnostic method, surgical resection of the lesion is the preferred treatment, partial nephrectomy combined with thrombectomy can be performed in patients with AML, if permitted, and postoperative prognosis turns out to be propitious. Key words: Inferior vena cava; Renal angiomyolipoma; Tumor thrombus

Renal cell carcinoma has a propensity to extend as tumor thrombus into the renal vein and inferior vena cava (IVC). The preoperative assessment for the presence and extent of renal vein and IVC tumor thrombus is important for planning appropriate surgical resection. Imaging procedures [CT, ultrasound (US), MR, venacavography] were correlated with surgical findings and pathology in 431 consecutive patients who had a radical nephrectomy for renal cell carcinoma. Ninety-nine (23%) patients had tumor thrombus extending at least into the main renal vein. Of these, 29 had tumor thrombus extending within the IVC. Patients were classified into two groups based on the surgical extent of tumor thrombus. Group A patients had no tumor thrombus or had tumor thrombus only in the renal vein proximal to the site of surgical ligation. Group B patients had tumor thrombus that extended to or beyond the distal renal vein at the site of surgical ligation. Forty-one patients had Group B tumor thrombus. Group B tumor thrombus was not seen in a renal cell carcinoma that was smaller than 4.5 cm. The sensitivity of CT for detecting Group B tumor thrombus was 79% and that of US was 68%. However, a much higher percentage of US examinations were technically indeterminate. In the patients who had either MR or venacavography, both imaging procedures were 100% sensitive for detecting group B tumor thrombus. Magnetic resonance imaging and venacavography appear to be the most sensitive means of identifying tumor thrombus.

Haemodynamic changes during radical nephrectomy with inferior vena cava thrombectomy: A pilot study.

Facing the 0.7-22% incidence rate of hepatocellular carcinoma (HCC) with inferior vena cava tumor thrombus (IVCTT), there are usually no obvious symptoms and signs when the tumor thrombus completely blocks the IVCTT in the early stage.1.J Gastroenterol. 29:41-46;2.Hepatogastroenterology. 41:154-157;3.Clin Cardiol. 19:211-213; Once diagnosed, it is the end-stage manifestation without unified treatment for HCC with IVCTT, bringing poor prognosis. Without active treatment, the median survival time is only 3 months. Previous scholars believed that patients with IVCTT should not adopt active surgical treatment. With the advance of technology, active surgical treatment has significantly lengthened the survival time with IVCTT.4.Ann Surg Oncol. 20:914-22;5.World J Surg Oncol. 11:259;6.Hepatogastroenterology. 58:1694-1699; However, for patients with HCC and IVCTT, open surgery was always selected in the past by opening the diaphragm through the combined thoracoabdominal incision to block the superior and subhepatic vena cava, leading long incision and huge trauma. With the development of minimally invasive techniques, laparoscopy thoracoscopy has showed great advantages in the treatment of HCC with IVCTT. A patient underwent laparoscopic with thoracoscopic resection of tumor and cancer thrombectomy after neoadjuvant therapy and then survived after follow-up.7.Ann Surg Oncol. 29:5548-5549 Therefore, it used as a first reported case of robot-assisted laparoscopic with thoracoscopic treatment of HCC complicated inferior vena cava cancer thrombectomy. A 41-year-old man had a liver space-occupying lesion discovered during his medical examination 2 months ago. The diagnosis of HCC with IVCTT was confirmed by enhanced CT and biopsy specimen in the first hospitalization. A combination of TACE, targeted therapy, and immunotherapy plan was applied for the patient after multidisciplinary treatment (MDT). Specifically, Lenvatinib was taken orally 8 mg daily and 160 mg of toripalimab was given intravenously every 3 weeks. His reexamination CT showed that the tumor was more advanced after 2 months of treatment. The surgical operation was performed based oncomprehensiveconsideration. The patient was placed in the left lateral decubitus position, and a thoracoscopic prefabricated the inferior vena cava above diaphragm blocking device was pulled out of the incision. The patient was switched to a supine position with the head of the bed raised 30 degrees. The gallbladder was removed first after entering the abdominal cavity, then prefabricated first hilar blocking band. Sterile rubber glove edges and hemo-lock were used to fabricate the blocking device. The novel hepatic inflow occlusion device is a safe, reliable, and convenient technique that is associated with favorable perioperative outcomes and low risk of conversion.8.Surg Endosc. 34:2807-2813 The liver along the middle hepatic vein was cut to expose the anterior wall of the inferior vena cava, then prefabricated posterior inferior vena cava blocking belt and right hepatic vein blocking belt. Finally, the first portal of liver, right hepatic vein, retrohepatic inferior vena cava, and inferior vena cava above diaphragm were blocked in sequence, so that accomplishing tumor resection and thrombectomy of inferior vena cava. It should be emphasized that before the inferior vena cava is completely sutured, the retrohepatic inferior vena cava blocking device should be released to allow blood flow to flush the inferior vena cava. Moreover, transesophageal ultrasound is required to real-time monitor inferior vena cava blood flow and IVCTT. Some images of the operation are shown in Fig. 1. Fig. 1 (a) Layout of the trocar. ①Make a 3cm small incision between the right anterior axillary line and the midaxillary line, parallel to the fourth and fifth intercostal spaces; a puncture hole in the next intercostal space for endoscope; ②2cm above the intersection of umbilicus horizontal line and axillary front line; ③Intersection of right clavicular midline and umbilical horizontal line; ④Superior margin of umbilicus; ⑤The midpoint of '④ & ⑥'; ⑥2cm below the intersection of left clavicular midline and left costal margin. (b) Prefabricated the inferior vena cava blocking device above diaphragm by thoracoscopic. (c) The smooth tumor thrombus protruding into the inferior vena cava RESULTS: It took 475 min to finish the operation, and the loss of blood was estimated as 300 ml. The patient was discharged from hospital 8 days after the operation without postoperative complication. HCC was confirmed by postoperative pathology. Robot surgical system reduces the limitations of laparoscopic surgery by offering a stable three-dimensional view, 10-times-enlarged image, restored eye-hand axis, and excellent dexterity with the endowristed instruments, which has several advantages over open operation such as diminished blood loss, reduced morbidity, and shorter hospital stay.9.Chirurg. 88:7-11;10.BMC Surg. 11:2;11.Minerva Chir. 64:135-146; Furthermore, it could favor the operative feasibility of difficult resections reducing the conversion rate and playing a role to extend the indications of liver resection to minimally invasive approaches. It may provide new curative options in patients deemed inoperable with conventional surgery, such as HCC with IVCTT.12.Biosci Trends. 16:178-188;13.J Hepatobiliary Pancreat Sci. 29:1108-1123.