The Increasing Use of Liver Transplantation Surgical Techniques in the Management of Renal and Nonrenal Cancer With or Without Inferior Vena Cava Tumor Thrombus

Abstract

We congratulate Facciuto et al. [1] for their report on their surgical experience with retroperitoneal tumors, mainly renal cell carcinoma (RCC) with tumor thrombus extending into the inferior vena cava (IVC). There outcomes were very good, and they had no intraoperative or postoperative mortality. We are very pleased that other centers are now using liver mobilization and liver transplantion techniques for these large retroperitoneal tumors as we have previously emphasized how useful this approach is for managing these complex tumors. I would like to clarify and expand on a few points that address some additional complex situations, but the consonance between our two series is startling. During the past 13 years at the University of Miami Miller School of Medicine and Jackson Memorial Hospital, we have used liver transplantation techniques (conventional or piggyback style mobilization) [2–9] to gain adequate exposure of the upper abdomen when dealing with urological tumors involving the IVC [2–4]. These techniques have been described in detail previously [3–5]. Frequently, we also have been able to control the intrapericardial IVC transabdominally [2–9] and have described the surgical approach for managing tumor thrombus of the retrohepatic and suprahepatic portions of the inferior vena cava: level III in our new classification [4]. In our paper, 23 patients with level III tumors underwent surgical resection using liver transplant techniques for mobilization of the liver off the IVC (piggyback mobilization). None of the patients required a thoracoabominal approach, cardiopulmonary or veno-venous bypass. In three patients, the intrapericardial IVC was controlled without the use of a sternotomy [4]. Our experience now extends to 52 patients with level III tumors, and we have described how to avoid veno-venous bypass [6] and how to deal with RCC with IVC thrombus causing Budd-Chairi syndrome [5]. This approach can be applied to even more complex situations, including removing adherent [2] and nonadherent [7] level IV (intra-atrial thrombus) tumor thrombus without a thoracoabdominal approach, median sternotomy, and/or cardiopulmonary bypass (CPB). These liver transplantation techniques also can be invaluable when dealing with adrenal tumors that have IVC tumor thrombus extending above the diaphragm [10–12]. The extensive experience accumulated at the University of Miami Miller School of Medicine/Jackson Memorial Hospital demonstrates that these difficult tumors can almost always be managed transabdominally without CPB even if the thrombus extends into the atrium. We are delighted that other centers are now embracing the techniques that we have described.