Xanthogranulomatous Pyelonephritis Presenting with Inferior Vena Cava Thrombus Mimicking Renal Cell Carcinoma: A Case Report

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

Endovascular treatment of obliterative hepatocavopathy with inferior vena cava occlusion and renal vein thrombosis

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

Nutcracker syndrome due to left-sided inferior vena cava compression and treated with superior mesenteric artery transposition

Renal Vein Ostium Wall Invasion of Renal Cell Carcinoma With an Inferior Vena Cava Tumor Thrombus: Prediction by Renal and Vena Caval Vein Diameters and Prognostic Significance

We describe a case that involved surgery and anesthesia for removal of a renal cell carcinoma invading right kidney, inferior vena cava (IVC) and right atrium. Since such cases are usually performed only in major hospitals we think it is worth while to report this procedure and to include a variety of images. The perioperative use of transesophageal echocardiography (TEE) in these cases is highly encouraged. INTRODUCTION A 70 year-old man presents with a history of gross hematuria, gross passage of clots, abdominal distention and right flank pain. He has a history of coronary artery disease with a myocardial infarction about 20 years ago. He does not currently suffer from any chest pain during physical activity. He has a history of hypertension for 20 years and is treated with calcium channel blockers. All other systems are without problems. WORKUP Urology workup reveals a right renal mass extending into the right renal vein, inferior vena cava and right atrium. Figure 1 Image 1: MRI demonstrating the right renal mass extending into right renal vein and IVC Figure 2 Image 2: CT Scan with tumor in IVC Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 2 of 7 Figure 3 Image 3: Angiogram showing the vascularization of the renal mass Figure 4 Image 4: Intraoperative transesophageal echocardiography showing a mass in the right atrium Bone scan, CT scan of the brain, CT scan of the chest, and chest X-ray demonstrated no evidence of metastasis. Preoperative transthoracic echocardiography showed an ejection fraction (EF) of 60% with normal systolic and diastolic function. The intra-atrial mass was noted. No valvular problems could be diagnosed. All laboratory values were within normal limits. The electrocardiogram (EKG) showed normal sinus rhythm with an old inferior myocardial infarction. The past surgical history was insignificant. DIAGNOSIS Right renal mass (most likely a renal cell carcinoma) extending into the right renal vein, inferior vena cava and right atrium. Clinical stage T3, NX, M0. PLAN AND OPERATIVE PROCEDURE The patient was scheduled for a right radical nephrectomy with removal of the tumor mass from the IVC and heart. In addition, he was scheduled to undergo embolization of his right kidney by vascular radiology 2 days prior to his nephrectomy. Anesthesia was induced with midazolam 2 mg, sufentanyl 20 mcg, oxygen, etomidate 20 mg, and 60 mg rocuronium bromide. The patient was intubated with a regular # 8 endotracheal tube. Anesthesia was maintained with oxygen/air 2/2 liters/min, isoforane, sufentanyl drip at 0.2 mcg/kg/hr, and rocuronium bromide at 4 mcg/kg/min. Both, an 8.5 french intoducer and a 12 french 3-lumen central venous catheter (CVC) were inserted via the right jugular vein. The CVC’s were not inserted too far in order to avoid rupture and displacement of the right atrial tumor mass. Such displacement could easily result in a massive pulmonary embolism. Blood pressure was recorded via an radial arterial catheter. Transesophageal echocardiography confirmed the right atrial mass. One of the CVC tips could be seen well above the superior vena cava (SVC) atrial junction. Surgery was simultaneously performed on chest and abdomen. The large vessels (aorta, superior vena cava, and femoral vein) were cannulated prior to the nephrectomy. The right kidney was removed. The patient was then put on cardiopulmonary bypass and the right atrium opened. The right atrial mass was removed in one piece. The IVC was then clamped at the tumor free distal segment and the heart was closed again. The remaining tumor mass was then removed from the IVC while the patient was rewarmed. The patient was separated from cardiopulmonary bypass without problems and the incisions were closed. After surgery, the patient was transferred to the ICU in stable condition. He was extubated the following day and transferred to the regular floor after 5 days. Total cardiopulmonary bypass time was 51 minutes with an aortic clamp time of 21 minutes. Pringle time (ischemic time to the intraabdominal organs) was 25 minutes. Estimated blood loss was 3 liters. The patient received 5 units of red blood cells, 2 units of fresh frozen plasma, and 10,4 liters of cristalloids. Total anesthesia time was 8 hours and 25 minutes. Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 3 of 7 Figure 5 Image 5: Surgical teams at work Figure 6 Image 6: Cannulation of the large vessels Figure 7 Image 7: All cannulas for cardiopulmonary bypass in place Figure 8 Image 8: Intraoperative TEE image of the right atrium after cannulation (cannulation was guided by TEE) Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 4 of 7 Figure 9 Image 9: Right kidney with renal cell carcinoma Figure 10 Image 10: Removal of the intracardiac tumor mass Figure 11 Image 11: Intracardial mass removed from the right atrium Figure 12 Image 12: Removal of remaining tumor mass from IVC Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 5 of 7 Figure 13 Image 13: Tumor mass removed from IVC Figure 14 Image 14: Tumor mass removed from IVC Figure 15 Image 15: Transesophageal echocardiography with no tumor mass left in right atrium SUMMARY AND CONCLUSION We report a case of a renal cell carcinoma extending from the right kidney into the inferior vena cava and the right atrium. Surgery, anesthesia, intensive care and nursing went uneventful. The surgical procedure for such cases requires cardiopulmonary bypass. The general surgical and anesthesiologic community does not see this kind of surgery very often. This is the reason for adding such a case to our series describing unusual, rare, or interesting procedures. We would like to point out certain details: 1. Good preoperative evaluation is essential. 2. Renal cell carcinoma patients may bleed more than others. Assure adequate vascular access including large peripheral iv and central venous catheter. Make sure to have an adequate supply on blood products available. 3. Don’t advance guidewires and central venous catheters below the superior vena cava atrial junction. There is a high risk for tumor embolism with potentially fatal pulmonary embolism. 4. Do not float a pulmonary artery catheter through the right heart containing tumor masses. There is a high risk for tumor embolism with potentially fatal pulmonary embolism. Use an alternative technique if measurements of preload/afterload/cardiac output are required (i.e. TEE, esophageal Doppler probes or endtidal CO2 loops) 5. Plan to use perioperative transesophageal echocardiography. The TEE allows monitoring the intracardiac mass, facilitates the confirmation of the position of the CVC tip(s), and provides guidance for the insertion of Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 6 of 7 the cannulas for cardiopulmonary bypass. 6. Some of the advantages of using intraoperative TEE are 7. Be prepared to initiate cardiopulmonary bypass for pulmonary embolectomy at any time when manipulating the tumor mass in the IVC. 8. Good perioperative teamwork and communication between urology, cardiothoracic surgery, perfusionists, nursing, interventional radiology, blood bank and anesthesiology is essential for success. References Interesting Cases A Case Report: Renal Cell Carcinoma With Tumor Mass In IVC And Heart 7 of 7 Author Information Olivier Wenker, MD Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center Lora Chaloupka, CRNA Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center Renea Joswiak, CRNA Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center Dilip Thakar, MD Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center Christopher Wood, MD Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center Garrett Walsh, MD Departments of Anesthesiology, Urology, and Thoracic Surgery, The University of Texas MD Anderson Cancer Center

Objectives: The prognostic value of tumor extension into the renal vein or vena cava is still a controversial issue. The aim of this study is to report our experience with radical surgery in patients with renal cell carcinoma (RCC) extending into the renal vein or subdiaphragmatic vena cava. Methods: We evaluated 142 patients with RCC involving the renal vein or inferior subdiaphragmatic vena cava. RCC had extended into the renal vein in 118 patients and into the inferior vena cava in the remaining 24. Radical nephrectomy was performed in all cases with renal vein invasion. Radical nephrectomy with cavotomy and tumor thrombus removal was carried out in all cases with inferior subdiaphragmatic vena caval invasion. Cause-specific survival was calculated by means of the Kaplan-Meier method. The log rank test was used for survival comparisons and univariate analysis. Results: The 5- and 10-year cause-specific survival rates were 51.5 and 39%, respectively, in the group of patients with tumor extension into the renal vein and 33.4% in those with inferior vena caval involvement. In 52 patients (44%), RCC extended only into the renal vein. In the remaining 66 patients, renal vein invasion was associated with other adverse prognostic factors. Life expectancy was lower for patients with other concurrent adverse prognostic factors than for those affected by renal vein involvement alone (p < 0.0001). In the latter group, survival expectancy was similar to those with stage T2N0M0 tumor. In 7 cases (29%), inferior vena caval invasion was not associated with other adverse prognostic factors. In the remaining 15 patients (71%), vena caval involvement was associated with other adverse prognostic factors. Concurrence of other adverse prognostic factors with vena caval invasion significantly decreased the disease-specific survival expectancy in comparison with the patients in whom vena caval involvement was the main prognostic factor (p = 0.008). In these patients, disease-specific survival was similar to those with stage T2N0M0 tumor. Conclusion: Renal vein or inferior subdiaphragmatic vena caval involvement does not significantly affect prognosis in patients with RCC.

Massive Renal Replacement Lipomatosis With Foci of Xanthogranulomatous Pyelonephritis in a Horseshoe Kidney

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

Multiplane Transesophageal Echocardiographic Guidance During Resection of Renal Cell Carcinoma Extending into the Inferior Vena Cava

Anaesthesia for nephrectomy

Xanthogranulomatous Pyelonephritis: Segmental or Generalized Disease?

Pyélonéphrite xanthogranulomateuse diffuse du nourrisson

A retrospective evaluation of the computed tomography (CT) findings in 50 patients with the nephrotic syndrome was undertaken. In four patients with clinical manifestations of acute renal vein thrombosis (RVT) on initial examination, the diagnosis was confirmed by CT findings. Three patients had left RVT, one had right RVT, and all four had thrombus in the inferior vena cava (IVC) at the level of the renal veins. Of the remaining 46, otherwise asymptomatic patients, one had bilateral RVT, two had left RVT, and five had isolated IVC thrombus. The abnormalities noted on CT scans were widened renal vein(s) containing thrombus, thrombus in the IVC, renal enlargement, thickened Gerota fascia and formation of pericapsular venous collaterals, and an abnormal renal parenchymal enhancement pattern consisting of prolonged corticomedullary discrimination, delayed and/or persistent paraenchymal opacification, and delayed or absent pyelocalyceal visualization.

BackgroundWe present a case of Xanthogranulomatous pyelonephritis (XGPN) in a male child with renal vein thrombus extending into the inferior vena cava. This is a rare presentation. XGPN is a rare type of renal infection characterised by granulomatous inflammation with giant cells and foamy histiocytes. The peak incidence is in the sixth to seventh decade with a female predominance. XGPN is rare in children.Case presentationAn 11 year old male child presented with a history of high grade fever and chills, right flank pain and progressive pyuria for two months. He had a history of vesical calculus for which he was operated four years back. In our case, a subcapsular right nephrectomy was performed. The surgical specimens were formalin fixed and paraffin embedded. The sections were stained with routine Hematoxylin & Eosin stain. Grossly; the kidney was enlarged with adherent capsule and thickening of the perinephric tissue. The pelvicalyceal system was dilated and was filled with a cast of pus. Histological evaluation revealed diffuse necrosis of the renal parenchyma and perinephric fat. Neutrophils, plasma cells, sheets of foamy macrophages and occasional multinucleate giant cells were seen. The renal vein was partially occluded by an inflammatory thrombus with fibrin, platelets and mixed inflammatory cells. The thrombus was focally adherent to the vein wall with organization.ConclusionsThe clinical presentation and the macroscopic aspect, together with the histological pattern, the cytological characteristics addressed the diagnosis towards XGPN with a vena caval thrombus. Our case illustrates that the diagnosis of XGPN should be considered even in paediatric age group when renal vein and vena caval thrombi are present.