Tumor Thrombus Extension Research Articles

Renal tumor with tumor thrombus in inferior vena cava and right atrium: the report of five cases with long-term follow-up

To evaluate early and long-term results of radical surgical removal of renal cell cancer (RCC) with tumor thrombus (TT) in the inferior vena cava (IVC) and right atrium (RA). The study included five patients with RCC with TT in IVC and right atrium, operated from January 2004 to September 2009 in the Institute for Cardiovascular disease "Dedinje", Belgrade, Serbia. All patients underwent atrial and caval thrombectomy with the use of normothermic cardiopulmonary bypass (CPB) and the radical nephrectomy, by a joint cardiovascular and urological team. After the surgery, patients were evaluated every 3 months for the first year, every 6 months for the next 2 years, and yearly thereafter. The mean follow-up was 32.6 months (range: 7-67 months). There were no per-operative embolism and no in-hospital deaths. Two patients developed tumor recurrence during a mean time of 5 months and died within 1 year after the surgery. The three remaining patients are alive (mean follow-up: 48 months) and without the evidence of tumor recurrence or metastases. No patients received adjuvant therapy. Patients with RCC and the extension of TT in IVC and right atrium need a multidisciplinary surgical strategy. Atrial and caval tumor thrombectomy can be performed safely and effectively, with a low complication rate, using normothermic CPB. Long-term results are promising; however, larger prospective multicentre studies are necessary.

Resection of advanced stage malignant retroperitoneal neoplasms with tumor thrombus extending into the right atrium: Report of four cases

Surgery for retroperitoneal neoplasms with a tumor thrombus extension into the right atrium is challenging. This study reviewed four surgical cases of advanced stage malignant neoplasms with the tumor thrombus extending into the right atrium. The malignant neoplasms involved the kidney in two patients, and the liver and adrenal gland in one each. The tumor thrombus was removed through a longitudinal cavotomy and right atriotomy in all cases. The inferior vena cava reconstruction was performed by directly closing it in one patient and by pericardial patch suturing in another. Cardiopulmonary bypass was used for all procedures and a Pringle maneuver was used to reduce bleeding from the liver in three. There was no perioperative or hospital death. Two of the four with renal cell carcinoma were alive 7 and 13 months after the surgery. One with hepatocellular carcinoma died of recurrent malignancy after 4 months, while the patient with an adrenal carcinoma remained disease free after surgery. These cases indicate the safety of the present procedure. Although the long-term results are still unknown, there were favorable early results and a lack of perioperative complications. Surgical challenges in resecting an intracardiac extension of retroperitoneal malignancy require close cooperation among the attending urologist, and both gastrointestinal and cardiovascular surgeons.

Extensive tumor thrombus in a case of carcinoma lung detected by F18-FDG-PET/CT

Tumor thrombus is a rare complication of solid cancers, mainly seen in cases of renal cell carcinoma, wilm's tumor, testicular carcinoma, adrenal cortical carcinoma and hepatocellular carcinoma.[1] Tumor thrombus in inferior vena cava is a rare complication of primary carcinoma lung. It should be identified so as to rule out venous thromboembolism and avoiding unnecessary anticoagulant therapy. We describe a case where F18-Fluorodeoxyglucose (FDG) positron emission tomography - computed tomography (PET/CT) helped to identify extensive tumor thrombus.

Prognostic Impact of the 2009 UICC/AJCC TNM Staging System for Renal Cell Carcinoma with Venous Extension

BackgroundThe prognostic significance of venous involvement and tumour thrombus level in renal cell carcinoma (RCC) remains highly controversial. In 2010, the American Joint Committee on Cancer (AJCC) and the Union International Centre le Cancer (UICC) revised the RCC staging system (7th edition) based on tumour thrombus level, differentiating the T stage of tumours limited to renal-vein-only involvement. ObjectiveWe aimed to evaluate the impact of tumour thrombus extension in a multi-institutional cohort of patients. Design, setting, and participantsAn international consortium of 11 institutions was established to retrospectively review a combined cohort of 1215 patients undergoing radical nephrectomy and tumour thrombectomy for RCC, including 585 patients with inferior vena cava (IVC) involvement or higher. MeasurementsPredictive factors of survival, including histology, tumour thrombus level, nodal status, Fuhrman grade, and tumour size, were analysed. Results and limitationsA total of 1122 patients with complete data were reviewed. The median follow-up for all patients was 24.7 mo, with a median survival of 33.8 mo. The 5-yr survival was 43.2% (renal vein involvement), 37% (IVC below the diaphragm), and 22% with caval involvement above the diaphragm. On multivariate analysis, tumour size (hazard ratio [HR]: 1.64 [range: 1.03–2.59]; p=0.036), Fuhrman grade (HR: 2.26 [range: 1.65–3.1]; p=0.000), nodal metastasis (HR: 1.32 [range: 1.09–1.67]; p=0.005), and tumour thrombus level (HR: 2.10 [range: 1.53–3.0]; p=0.00) correlated independently with survival. ConclusionsBased on analysis of the largest known cohort of patients with RCC along with IVC and atrial thrombus involvement, tumour thrombus level is an independent predictor of survival. Our findings support the changes to the latest AJCC/UICC staging system.

Vena Cava Thrombectomy and Primary Repair After Radical Nephrectomy for Renal Cell Carcinoma: Single-Center Experience

Inferior vena cava (IVC) reconstruction for locally advanced renal cell carcinoma (RCC) includes resection with and without interposition grafting, patch graft, or primary repair. The proposed benefits of lateral venorrhaphy and primary repair are avoidance of foreign material, a more expeditious repair, and preservation of lower extremity venous outflow. A single-center retrospective review of 22 patients with RCC and IVC tumor thrombus treated with radical nephrectomy, lateral venorrhaphy, thrombectomy, and primary vena cava repair between July 2002 and June 2009 was carried out. Demographic data, diagnostic information, radiographic cross-sectional imaging, and procedural outcomes were examined. Among the 13 men and nine women, the mean age was 62.1 years (42-83); mean tumor size was 9.8 cm (3-17 cm), and 90% (n = 18) of the cases with RCC were identified pathologically as clear cell adenocarcinoma; on the basis of the classification system adopted by Neves, level I was for 50% (n = 11), level II for 32% (n = 7), level III for 9% (n = 2), and level IV for 9% (n = 2) of the patients. All patients underwent en bloc radical nephrectomy with tumor thrombus removal and primary IVC repair. Mean total operative time was 547.9 ± 138.5 minutes, whereas mean IVC cross-clamp time was 10.8 minutes (6-29 minutes). There were no intraoperative deaths or pulmonary embolism and all IVC margins were found to be pathologically negative. Postoperative complications included one pulmonary embolism, one exacerbation of chronic lymphedema, and two cases of new onset erectile dysfunction. Mean follow-up was 36.4 ± 23.2 months (6-92 months). There were no radiographic or clinically significant changes in mean IVC diameter during follow-up. Five late deaths (23%) occurred as a result of metastatic RCC over a mean period of 24 months (range, 12-48), but without any local recurrences. For advanced RCC with tumor thrombus extension into the IVC, lateral venorrhaphy and primary IVC repair avoids complicated caval reconstructions and results in high patency rates with a low local tumor recurrence rate.

Hepatocellular Carcinoma with IVC and Right Atrium Extension

Purpose: Hepatocellular carcinoma (HCC) is the fifth most common malignancy of the world. Most cases are diagnosed at an advanced stage, with metastasis to the lungs, peritoneum, adrenal glands and bones. Tumor extension to the heart via Inferior vena cava is most frequently implicated in primaries from renal cell, thyroid and testicular carcinomas and rarely in HCC. This report describes an unusual case of HCC with tumor thrombus extension to right atrium. Case Report: 64-year-old man with history of alcoholism, chronic hepatitis C presented with 2 week history of abdominal distention, leg swelling and decrease in exercise tolerance. Examination was significant for cachexia with bilateral leg, scrotal edema and ascites. Labs were significant for AST 279, ALT 62, ALP 146 and total bilirubin of 3.5 with Albumin of 1.6 and protein 8.9. Alpha feto protein was elevated to 19,282. Magnetic resonance imaging showed confluent tumor involving right hepatic lobe consistent with HCC with tumor thrombus extending into the right hepatic vein, inferior vena cava and right atrium. Discussion: Extra hepatic spread at the time of diagnosis of HCC is found in 10% cases. The most common sites being lung, intraabdominal lymph nodes, bone and adrenals. Few cases with tumor extension to the heart have been reported. These patients usually die because of pulmonary embolism, heart failure or cancer progression. Diagnosis of tumor thrombus extension should be considered in patients with HCC presenting with symptoms suggestive of CHF or pulmonary embolism. Different treatment modalities like surgical resection, transarterial chemo embolization or resection and external beam radiation therapy (EBRT) are being used with varied success and should be considered.Figure: MRI scan (contrast enhanced T1-weighted, coronal view).Figure: MRI scan (T2-weighted, axial view) IVC tumor thrombus.

Editorial Comment

This small series demonstrates that a patient with an incidental, small renal vein branch thrombus will often have localized disease that can be cured with nephron-sparing surgery alone. When pT3b disease is confined to the renal vein, long-term outcomes after nephrectomy are quite good in clinically localized patients, as Moinzadeh et al 1 Moinzadeh A. Libertino J.A. Prognostic significance of tumor thrombus level in patients with renal cell carcinoma and venous tumor thrombus extension. Is all T3b the same?. J Urol. 2004; 171: 598-601 Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar showed with a 66% 10-year survival in the series of the Lahey Clinic. Given the growing body of evidence that overall morbidity and mortality are reduced when nephron-sparing surgery is used for small renal masses, 2 Huang W.C. Elkin E.B. Levey A.S. et al. Partial nephrectomy versus radical nephrectomy in patients with small renal tumors—is there a difference in mortality and cardiovascular outcomes?. J Urol. 2009; 181 (discussion 61-62): 55-61 Abstract Full Text Full Text PDF PubMed Scopus (680) Google Scholar planned partial nephrectomy, when feasible, for small masses with a branch thrombus seems reasonable even in the elective setting. This does need to be supported by larger series with longer follow-up, as the presented series has only 8 patients with a median follow-up of 19.8 months. Single Institutional Experience with Nephron-sparing Surgery for Pathologic Stage T3bNxM0 Renal Cell Carcinoma Confined to the Renal VeinUrologyVol. 76Issue 3PreviewTo assess our institution's experience with the management of pathologic stage T3bNxM0 renal cell carcinoma with tumor thrombus confined to the renal vein treated with nephron-sparing surgery (NSS). Full-Text PDF ReplyUrologyVol. 76Issue 3PreviewThe authors agree with the editorial comments and caution that the usage of elective nephron-sparing surgery in the setting of T3bN0M0 renal cortical tumors should be approached with caution. The complexity of venous control and reconstruction for large segmental branch thrombi may preclude the widespread usage of this practice. However, in nonelective settings when radical nephrectomy would result in imminent short-term morbidity due to renal insufficiency, we feel the data presented support the conclusion that nephron-sparing surgery is feasible at a tertiary care referral center. Full-Text PDF

Imaging of advanced renal cell carcinoma

To describe current radiological cross-sectional imaging in the detection and staging of advanced renal cell carcinoma (RCC), defined here as RCC reaching beyond the renal capsule, whether by immediate extension or by metastasis. Review and summary of current radiological and urological literature, including original articles and reviews, retrieved from the medical data base "PubMed". Multi-detector-row computed tomography (MDCT) shows a sensitivity of up to 100% and specificity of about 90% for retroperitoneal disease, venous tumour thrombus, and metastasis, but limited accuracy for lymphadenopathy in RCC. Magnetic resonance imaging (MRI) is applied as a problem-solving modality, with particular strength in imaging metastasis to brain and bone. However, dynamic, contrast-enhanced- (DCE-) and arterial-spin-labelling (ASL-) MRI may help to monitor early response to angiogenesis inhibitor drugs. Ultrasonography (US) shows limited capability of identifying retroperitoneal disease, venous tumour thrombus extension, and metastasis. Positron Emission Tomography with 18-fluoro-desoxy-glucose (FDG-PET) demonstrates modest accuracy for metastasis of RCC, with positive studies being suspicious, while negative studies cannot reliably exclude disease. MDCT represents the diagnostic mainstay for the detection and staging of RCC. In the wake of new systemic therapies for advanced RCC, including angiogenesis inhibitor drugs, monitoring treatment response may become a new task for cross-sectional imaging.

Cardiac myxoma mimicking extension of renal cell carcinoma

Cardiac myxomas are the commonest benign tumour of the heart. We are describing a rare presentation of a myxoma in a patient with renal cell carcinoma (RCC). Since there was no single reported case of myxoma with RCC, a presumptive diagnosis of RCC with right atrial extension of tumour thrombus was made. Both the tumours were resected in the same operation by radical nephrectomy with open heart surgery.

Cavo-atrial thrombectomy combined with left hemi-hepatectomy for vascular invasion from hepatocellular carcinoma on diseased liver under hypothermic cardio-circulatory arrest☆

Vascular invasion of supra-hepatic veins (SHV) is a major complication of primary liver tumours. The tumorous thrombus, when extended to the vena cava and right atrium, may produce occlusion of the tricuspid valve or pulmonary embolism with sudden cardiac death. The presence of macroscopic vascular infiltration represents an advanced stage of the tumour contraindicating liver transplantation, thus liver resection with thrombectomy is the only therapeutic option in this setting despite the concerns of postoperative liver failure and the dismal results at distance. A 45-year-old male with chronic active hepatitis/cirrhosis was referred to our department for a tumour in the left hemi-liver with infiltration of the left-middle hepatic veins and a tumour thrombus extension to the right atrium. We reported a successful cavo-atrial thrombectomy, along with left hemi-hepatectomy, under hypothermic cardio-circulatory arrest (HCA). To our knowledge, this technique has been used only once for primary liver cancer on chronic liver disease, this being the second case reported in literature. We conclude that this technique should be considered for atrial thrombi removal in patients affected by liver tumours in the presence of a healthy liver or of a well compensated liver cirrhosis in order to prolong the patient's life span.

Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary Bypass

Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA. Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy. In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA.

Invited Commentary

During a 12-year period, the authors have treated 102 patients with renal cell carcinoma [1Ciancio 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: 505-511Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar]. The tumor thrombus in 12 patients extended into the supradiaphragmatic inferior vena cava and the right atrium (level 4 tumor). By combining the skill sets of liver transplantation, urologic oncology, cardiac surgery, and anesthesiology familiar with transesophageal echocardiography, these tumors were treated without sternotomy, cardiopulmonary bypass, or deep hypothermic circulatory arrest. An extended abdominal chevron incision was used. The inferior vena cava, liver, kidney, and right atrium were thoroughly mobilized to facilitate sequential clamping and tumor extraction. The surgical strategy is illustrated well in the figures. It is not surprising that the operations were time consuming (8 hours), with nearly 3 liters of blood loss and 9 units of transfusion per patient, despite use of a cell-saving device in 8 of the 12 patients. Obstruction of the hepatic veins with Budd-Chiari syndrome intensified bleeding problems. The postoperative intensive care unit stay was 7 days. There were 2 deaths: an 80-year-old patient died of a cardiac arrhythmia and another death was attributed to acute respiratory distress syndrome and multiple organ failure. Pulmonary metastases developed in 2 patients at 1 and 3 years after their operations, and local recurrence in the renal fossa was noted in 1 patient. These complications and deaths underscore the seriousness of the condition. The authors note a sobering 32% to 69% survival at 5 years in patients with tumor invading the inferior vena cava. This approach is novel, and some precautions seem warranted:1This technique will need intense preoperative planning based on imaging studies and pooling the skills of four physician teams involved in the procedure.2Findings during the assessment may suggest that cardiopulmonary bypass with hypothermia may be safer in view of caval or right atrial involvement.3If this technique is used, cell-saving devices and rapid infusion of shed blood will minimize blood requirements.4Great care is required in clamping the right atrium/inferior vena cava so that no tumor is left behind. Hand-held right atrial echocardiography scanning may be a useful adjunct and will, in addition, identify coronary sinus location.5Selective use of this new technique may be warranted in patients at high risk for cardiopulmonary bypass and possible hypothermic arrest. Renal Carcinoma With Supradiaphragmatic Tumor Thrombus: Avoiding Sternotomy and Cardiopulmonary BypassThe Annals of Thoracic SurgeryVol. 89Issue 2PreviewRenal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported. Full-Text PDF

Techniques for Avoidance of Sternotomy and Cardiopulmonary Bypass During Resection of Extensive Renal Cell Carcinoma with Vena Caval Tumor Thrombus Extension Above the Diaphragm

Renal cell carcinoma (RCC) is a commonly encountered malignancy in urology. Extensive RCC may frequently invade the renal vein and the inferior vena cava (IVC). In advanced cases, this tumor thrombus may grow cephalad up to the level of the right atrium. The mainstay of surgical treatment for such lesions remains resection of all possible tumor burden. Current techniques for resection of supradiaphragmatic RCC tumor thrombus in the IVC incorporate cardiopulmonary bypass (CBP) with deep hypothermic circulatory arrest, especially in cases where the thrombus reaches the right atrium. We report a safe technique using a transabdominal approach to such lesions that allows exposure to the level of the intrapericardial IVC and right atrium permitting safe resection of the tumor thrombus without median sternotomy, CBP, or deep hypothermic circulatory arrest.

Renal cell carcinoma with inferior vena caval extention: impact of tumour extent on surgical outcome

To evaluate our experience with surgical resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) involvement and examine the relationship between prognosis and tumour extent. A retrospective review of nephrectomy performed between 1985 and 2005 identified 50 patients presenting with tumour thrombus extension into the IVC. Clinical characteristics and outcome were evaluated. Of the 50 patients evaluated, 7, 26, 10 and 7 presented with level I, II, III and IV thrombus, respectively. Major postoperative complications occurred in 16% of patients. Local or distant failure occurred in 25 (64%) patients. The mean time to recurrence was 10 months. Only supra-diaphragmatic extension of the tumour thrombus was predictive of disease recurrence. Locally advanced RCC with IVC thrombus remains associated with significant local and distant failure rate. The level of thrombus extension is significantly associated with disease recurrence. Effective adjuvant therapy is needed to improve outcome in this patient population.

Circumferential Resection of the Inferior Vena Cava for Primary and Recurrent Malignant Tumors

Circumferential vena caval resection is occasionally performed in patients with advanced malignancy. We explored the oncological effectiveness of inferior vena caval resection, as determined by margin status, cancer recurrence and survival. Also, we addressed the morbidity associated with inferior vena caval obstruction and resection, and determined indications for inferior vena caval reconstruction. A total of 18 patients underwent attempted inferior vena caval resection from 1999 to 2008. Primary tumor type was renal cell carcinoma in 7 patients, metastatic testicular cancer in 5, leiomyosarcoma in 3, and adrenal cortical carcinoma, primary retroperitoneal germ cell tumor and upper tract transitional cell carcinoma in 1 each. Data reviewed included preoperative and postoperative sequelae of inferior vena caval obstruction, postoperative complications, pathological results, cancer recurrence, graft requirements and functional outcomes. Mean followup in the entire patient cohort was 24 months. Inferior vena caval resection was completed in 15 of 18 patients, of whom 12 (80%) had negative surgical margins. Of the patients 50% presented with symptoms of venous hypertension, including lower extremity edema with or without venous thrombosis, or abdominal wall varicosity. After inferior vena caval resection symptoms resolved in half of them, likely due to the ongoing formation of collateral vessels. Five asymptomatic patients with incomplete inferior vena caval occlusion underwent reconstruction with inferior vena caval vascular grafts of polytetrafluoroethylene (4) or Dacron (1). The polytetrafluoroethylene grafts remained patent. A total of 12 patients underwent simultaneous nephrectomy and/or left renal vein ligation in the same setting with acceptable alterations in postoperative renal function and no need for permanent dialysis. Cancer recurred locally in 4 of 15 patients who underwent resection. Five of 15 patients in the resection group died of disease or were lost to followup compared to all 3 in whom resection was aborted or macroscopically incomplete (mean followup 19.2 vs 4.3 months). Local cancer control and potentially increased cancer specific survival can be achieved with successful complete circumferential resection of the inferior vena cava as a component of multimodality care in select patients with locally advanced malignancy. Polytetrafluoroethylene is the preferred prosthetic material when inferior vena caval replacement is indicated. The most common postoperative complications are renal insufficiency and lower extremity edema, which are generally transient.

Long-term Survival in Patients Undergoing Radical Nephrectomy and Inferior Vena Cava Thrombectomy: Single-Center Experience

BackgroundRenal cell carcinoma (RCC) with a tumor thrombus extension into the inferior vena cava (IVC) demands aggressive surgical management. ObjectiveTo evaluate the long-term survival in patients undergoing radical nephrectomy and IVC thrombectomy. Design, setting, and participantsWe performed a retrospective analysis of 87 patients undergoing surgery between 1997 and 2008. The patients were grouped according to the extent of tumor thrombus, with level I involving the IVC at the level of the renal vein, level II being infrahepatic IVC, level III being intrahepatic IVC, and level IV being suprahepatic IVC or right atrium. Relevant clinical and pathologic data were analyzed. MeasurementsDisease-free survival (DFS) and disease-specific survival (DSS) were studied. Results and limitationsThe median follow-up was 22 mo, and 19, 14, 40, and 14 patients had level I, II, III, and IV IVC thrombus, respectively. Among patients with M0 disease, 22 developed metastases. The 5-yr DFS was 64% for all levels and 74%, 69.5%, 59.5%, and 58% for levels I, II, III, and IV, respectively. Of the level I group, 16% of patients died of disease compared to 57% of the level IV group. The 5-yr DSS for all levels was 46% and 71%, 48%, 40%, and 35% for levels I, II, III, and IV, respectively. Patients with level IV thrombus had a significantly lower 5-yr DSS compared to level I (p=0.03). However, when analyzed in two groups—supradiaphragmatic and infradiaphragmatic—there was no significant difference in DSS (P=0.14). On univariate analysis, metastasis at presentation, non–clear-cell histology, lymph node metastases, and higher nuclear grade were statistically significant prognostic factors influencing DSS. Only higher nuclear grade (p=0.03), metastasis at presentation (p<0.01), and non–clear-cell histology (p=0.03) were independent prognostic factors on multivariate analysis. ConclusionsRadical nephrectomy and IVC thrombectomy offer reasonable long-term survival. The level of tumor thrombus is not an independent prognostic factor. Distant metastasis at presentation, higher nuclear grade, and non–clear-clear cell histology are significant prognostic factors influencing DSS.

Primary Small Cell Carcinoma of the Kidney with Tumour Thrombus Extension into the Inferior Vena Cava and Pulmonary Artery: A Case Report and Review of the Literature

Renal small cell carcinoma is a rarely seen malignant neoplasm with high propensity for distant metastasis and aggressive behaviour showing combined characteristics of neuroendocrine and epithelial neoplasia in terms of immunohistochemistry and ultrastructure. To the best of our knowledge this is the first report of primary small cell carcinoma of the left kidney with tumour thrombus extending to the inferior vena cava and pulmonary artery to undergo left radical nephrectomy and tumour thrombectomy under extracorporeal circulation and deep hypothermic circulatory arrest. The patient was a 33-year old male. He was discharged from hospital 10 days following the procedures and remained alive at the time of writing, over 7 months after discharge. Light microscopy, immunohistochemistry and the survival outcome of this case are presented and these are discussed in the context of a review of similar cases in the current literature. This case demonstrated that, in the absence of distant metastases, renal small cell carcinoma with tumour thrombus does not contraindicate surgery.

Temporary Balloon Occlusion of Inferior Vena Cava in Resection of Renal Tumor With Vena Cava Thrombus Extension

To investigate a novel and effective method to occlude the inferior vena cava (IVC) during surgical management of a renal tumor with a tumor thrombus extension into the IVC. We retrospectively reviewed the records of 10 patients with renal cell carcinoma or renal angiomyolipoma with tumor thrombus extending into the IVC who had undergone surgical intervention at our institute from May 2005 to May 2006. The balloon occlusion of the IVC was performed during surgery to decrease the risk of pulmonary embolism. One patient could not tolerate the test occlusion of the IVC and the procedure was converted to IVC-right atrium bypass. The remaining 9 patients successfully underwent nephrectomy and thrombectomy with the help of temporary balloon obstruction of the IVC without perioperative mortality or morbidity. The blood pressure and circulatory status were stably maintained during occlusion of the IVC. Temporary balloon occlusion of the IVC is a simple and reliable technique that decreases the risk of pulmonary embolism and facilitates the resection of renal tumor with levels II and III IVC thrombus.

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

New advances in computerized tomography, including multidetector computerized tomography with 3-dimensional reformatting has recently called into question the absolute need for magnetic resonance imaging for evaluating renal cell carcinoma with suspected venous involvement. We assessed the accuracy of multidetector computerized tomography for predicting tumor thrombus and the level of venous involvement in patients with renal cell carcinoma. We retrospectively reviewed clinical and pathological features in 41 patients with renal cell carcinoma who underwent staging multidetector computerized tomography before surgery. Multidetector computerized tomography findings regarding the presence and level of tumor thrombus were compared to findings at surgery and at final pathological evaluation. All multidetector computerized tomography studies were read by a single radiologist (EKF) before surgery. When excluding patients with segmental venous involvement only, the concordance rate between multidetector computerized tomography and pathological findings was 84%. Multidetector computerized tomography accurately predicted the level of tumor thrombus in 26 of 27 patients (96%). Four cases of negative multidetector computerized tomography findings were up staged to renal vein involvement based on pathological findings. All 4 patients had early distal thrombi that did not change operative management. Multidetector computerized tomography with 3-dimensional mapping is an effective imaging modality for accurately characterizing the level of venous thrombus in patients with renal cell carcinoma. This modality effectively identified patients with clinically significant venous thrombus. Patients with renal cell carcinoma in whom multidetector computerized tomography fails to detect tumor thrombus are unlikely to have a tumor thrombus found at surgery that would change the surgical approach.

A case of acinar cell carcinoma of the pancreas that formed extensive tumor thrombus of the portal vein.

A 58-year-old man was admitted to our hospital because of anorexia and back pain. He had been previously diagnosed with chronic pancreatitis with blood thrombus of the splenic vein at another hospital. Abdominal ultrasonography and computed tomography revealed a large mass in the body and tail of the pancreas, which directly invaded the stomach and the spleen. Small nodular metastases in both lungs were also detected. Furthermore, tumor thrombus continuously involved the splenic and proximal superior mesenteric vein, main portal vein, and its right intrahepatic branch. A metastatic mass was disclosed in the adjacent liver. The specimens obtained from portal tumor thrombus were histologically compatible with acinar cell carcinoma. Portal tumor thrombus is a rare condition in pancreatic tumors; however, it seems to be important to differentiate tumor thrombus from blood thrombus of the portal vein in order to know the true clinical stage and provide a suitable treatment.