Surgical treatment of hepatocellular carcinoma combined with tumor thrombus in right atrium and inferior vena cava

Abstract

Objective To explore the clinical effect of embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart + partial hepatectomy for hepatocellular carcinoma (HCC) combined with tumor thrombus in right atrium and inferior vena cava. Methods The retrospective and descriptive study was conducted. The clinical data of 1 patient with HCC combined with tumor thrombus in right atrium and inferior vena cava who were admitted to the Peking University People′s Hospital in December 2014 were collected. The patient underwent embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart+ partial hepatectomy. Observation indicators: (1) intra- and post-operative situations: intraoperative findings, operation time, cardiopulmonary bypass time, volume of intraoperative blood loss, intraoperative blood transfusion, postoperative complication and duration of hospital stay; (2) postoperative pathological examination; (3) follow-up situation: survival of patient and tumor recurrence or metastasis. Follow-up using outpatient examination was performed to detect survival of patient and tumor recurrence or metastasis up to September 2016. Results (1) Intra- and post-operative situations: size of tumor thrombus in right atrium, operation time, cardiopulmonary bypass time, volume of intraoperative blood loss, volumes of intraoperative red blood cell and blood plasma transfusions were 3.0 cm×4.0 cm, 630 minutes, 85 minutes, 4 000 mL, 1 820 mL and 2 200 mL, respectively. The abnormal and transient liver and renal functions in early stage after surgery recovered quickly to the normal level. Patient with pleural effusion and pulmonary infection received active treatment, and then ventilator treatment was stopped at 5 days postoperatively and closed thoracic drainage-tube was removed at 15 days postoperatively. There was no occurrence of hemorrhage, bile leakage and wound infection. Patient was discharged from hospital at 25 days postoperatively. (2) Postoperative pathological examination: tumor with unclear boundary and gray-white section located in the right posterior lobe of the liver. Tumor thrombus in right atrium and inferior vena cava was gray-white, with a rough texture and size of 4.0 cm×4.0 cm×2.0 cm. Immunohistochemical staining dectection showed that liver cells, glypican 3 and CD34 were positive and alpha-fetoprotein was negative, with a positive index of Ki-67 of 15%. The moderate-differentiated HCC was confirmed by pathologic examination. (3) Follow-up situation: patient had a smooth recovery after discharge, without obvious discomfort. Hepatic arterial-venous fistula was confirmed at 45 days postoperatively by hepatic arterial angiography. Patient underwent preventive infusion chemotherapy with oxaliplatin and gemcitabine, and right hepatic arterial embolization with gelatin sponge. During the follow-up, patient received regular reexaminations of abdominal computed tomography and chest X-ray, without tumor thrombus in inferior vena cava and tumor recurrence. Conclusion Embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart and partial hepatectomy are safe and feasible for patient with HCC combined with tumor thrombus in right atrium and inferior vena cava. Key words: Hepatic neoplasms; Venous tumor thrombus; Surgical procedures, operative; Cardiopulmonary bypass