Inferior Vena Cava Tumor Thrombus Research Articles

The feasibility of contrast-enhanced CT to identify the adhesive renal venous tumor thrombus of renal cell carcinoma.

To identify adhesive renal venous tumor thrombus (RVTT) of renal cell carcinoma (RCC) by contrast-enhancement CT (CECT). Our retrospective study included 53 patients who underwent preoperative CECT and pathologically confirmed RCC combined with RVTT. They were divided into two groups based on the intra-operative findings of RVTT adhesion to the venous wall, with 26 cases in the adhesive RVTT group (ARVTT) and 27 cases in the non-adhesive group (NRVTT). The location, maximum diameter (MD) and CT values of tumors, the maximum length (ML) and width (MW) of RVTT, and length of inferior vena cava tumor thrombus were compared between the two groups. The presence of renal venous wall involvement, renal venous wall inflammation, and enlarged retroperitoneal lymph node was compared between the two groups. A receiver operating characteristic curve was used to analyze the diagnostic performance. The MD of RCC and the ML and MW of the RVTT were all larger in the ARVTT group than in the NRVTT group (p = 0.042, p < 0.001, and p = 0.002). The proportion of renal vein wall involvement and renal vein wall inflammation were higher in the ARVTT group than in NRVTT groups (both p < 0.001). The multivariable model including ML and vascular wall inflammation to predict ARVTT could achieve the best diagnostic performance with the area under the curve, sensitivity, specificity, and accuracy of 0.91, 88.5%, 96.3%, and 92.5%, respectively. The multivariable model acquired by CECT images could be used to predict RVTT adhesion. For RCC patients with tumor thrombus, contrast-enhanced CT could noninvasively predict the adhesion of tumor thrombus, thus predicting the difficulty of surgery and contributing to the selection of an appropriate treatment plan. • The length and width of the tumor thrombus could be used to predict its adhesion to the vessel wall. • Adhesion of the tumor thrombus can be reflected by inflammation of the renal vein wall. • The multivariable model from CECT can well predict whether the tumor thrombus adhered to the vein wall.

35 - Surgical treatment of inferior vena cava tumor thrombus with retrograde extension

35 - Surgical treatment of inferior vena cava tumor thrombus with retrograde extension

Cardiovascular surgical experiences of IVC tumor and thrombus: Operative strategies Based on 51 consecutive patients.

The only beneficial treatment option for the management of inferior vena cava (IVC) tumor thrombus is complete tumor removal. The aim of this study was to report our experience in surgical and clinical outcomes in patients with tumor thrombosis in IVC. A retrospective chart review of patients who underwent surgical resection of IVC tumor at our institution over the past 10 years was performed. The patients were identified using a prospectively maintained database. We identified 51 patients, the mean age was 53.4 ± 16.8 years, and 25.4% were female. They were divided into three groups based on tumor thrombosis level. Twenty patients (39.2%) required sternotomy, and cardiopulmonary bypass (CPB) was used in 19 (37.2%) patients, and 2 (3.9%) cases underwent coronary artery bypass graft. The perioperative complications were severe bleeding (3 patients), pulmonary embolism (2 patients), and duodenal perforation (1 patient). Three (5.8%) in-hospital deaths occurred, and all were due to severe abdominal bleeding. After a mean follow-up time of 46.5 ± 42.0 months, 29 (56.9%) patients were alive. The mean survival time was 75.2 ± 8.4 months. In multivariate analysis, higher age (p = 0.033) and male gender (p = 0.033) proved to be independent prognostic factors. Tumor thrombus extending to the IVC is a rare and challenging event. Although using CPB may be safe and result in long-term survival with acceptable function, excessive bleeding during surgery may limit the use of this method.

V05-01 EX VIVO PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY

You have accessJournal of UrologyCME1 Apr 2023V05-01 EX VIVO PARTIAL NEPHRECTOMY IN A SOLITARY KIDNEY Martin Hofmann, Rebecca Campbell, Yi-Chia Lin, Alejandro Pita, Jesse McKenney, Mohamed Eltemamy, and Steven Campbell Martin HofmannMartin Hofmann More articles by this author , Rebecca CampbellRebecca Campbell More articles by this author , Yi-Chia LinYi-Chia Lin More articles by this author , Alejandro PitaAlejandro Pita More articles by this author , Jesse McKenneyJesse McKenney More articles by this author , Mohamed EltemamyMohamed Eltemamy More articles by this author , and Steven CampbellSteven Campbell More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003263.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Nephron-sparing surgery (NSS) is common in the management of small renal masses. In locally advanced tumors, it is typically only considered in cases of a solitary kidney. Robotic and open partial nephrectomy are standard approaches with ex vivo partial nephrectomy rarely reported. This approach was abandoned at Cleveland Clinic in 1986 due to lackluster results. Since then, however, technology has improved with better vessel sealing devices, thrombogenic materials to help pack the defect and reconstruct, and better imaging. METHODS: A 44 year old woman was found to have bilateral renal masses on imaging performed during a hypertension workup. The right renal mass was large with inferior vena cava (IVC) tumor thrombus. The left sided mass was central with renal vein thrombus. After undergoing a right radical nephrectomy and IVC tumor thrombectomy, she was treated with 8 weeks of neoadjuvant axitinib on trial to downstage the remaining left renal mass. After considering all options, an ex vivo partial nephrectomy was performed. First, a laparoscopic nephrectomy was performed in similar fashion as to donor nephrectomy. The kidney was then chilled and perfused with Collins' solution before being defatted and small vascular branches ligated. The central mass was then visualized on ultrasound and a portion of parenchyma overlying it excised to allow for hilar and tumor exposure. The renal vein was opened and tumor resected. After oversewing the parenchyma, closing open vessels, and packing the defect with Surgicel Fibrillar, the outer renorrhaphy was performed with 2-0 Chromic sutures. The autotransplantation was then performed with the kidney placed into the left iliac fossa and vascular anastomoses performed to external iliac vessels and ureteral reimplantation onto the bladder dome. RESULTS: The total time in the operating room was 6 hours with 3 hours spent on the bench preparing the kidney and resecting the mass. The estimated blood loss was 500 cc. Final pathology revealed a 7 cm pT3a grade 3 clear cell renal cell carcinoma with negative margins. She experienced acute kidney injury with peak creatinine of 5.91 on post-operative day 3 which improved to 1.54 by 6 weeks. She suffered a pulmonary embolism at that time but has done well on anticoagulation. At 6 months, her creatinine was 1.32 and surveillance imaging was negative for any recurrent disease. CONCLUSIONS: The management of bilateral locally advanced renal tumors is complex and challenging. In rare circumstances, ex vivo partial nephrectomy can be considered and performed with good result. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e424 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Martin Hofmann More articles by this author Rebecca Campbell More articles by this author Yi-Chia Lin More articles by this author Alejandro Pita More articles by this author Jesse McKenney More articles by this author Mohamed Eltemamy More articles by this author Steven Campbell More articles by this author Expand All Advertisement PDF downloadLoading ...

Application of Intraoperative Transesophageal Echocardiography in the Treatment of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

Objective To investigate the value of intraoperative transesophageal echocardiography (TEE) in the diagnosis and treatment of renal cell carcinoma with inferior vena cava tumor thrombus. Methods Ten patients of renal cell carcinoma with inferior vena cava tumor thrombus treated in the Second Hospital of Hebei Medical University from January 2017 to January 2021 were selected.TEE was employed to locate the position of the tumor thrombus,determine the occlusion point of the inferior vena cava,count the intraoperative tumor thrombus shedding rate,examine the tumor thrombus resection integrity,and measure blood loss and other indicators,on the basis of which the application value of TEE in the operation of renal cell carcinoma with inferior vena cava tumor thrombus was evaluated. Results All the 10 patients had completed the operations successfully,including 8 patients of open operation and 2 patients of laparoscopic operation.TEE showed tumor thrombi clearly,and all the tumor thrombi were completely removed.There was no tumor thrombus shedding during the operation.The blood loss varied within the range of 300-800 ml,with the mean of (520.0±193.2) ml.The grade III tumor thrombi in 2 patients and the grade I tumor thrombus in 1 patient diagnosed before operation were reduced to grade Ⅱ and upgraded to grade Ⅱ,respectively,by TEE.One patient had no floating tumor thrombus at the end of tumor thrombus before operation,and the blocking position was adjusted in time with the assistance of TEE to avoid the shedding of the floating tumor thrombus. Conclusion TEE can accurately determine and dynamically monitor the location and shape of inferior vena cava tumor thrombus,which provides an important reference and has a significant clinical value in the operation of renal cell carcinoma with inferior vena cava tumor thrombus.

Up, Up, and Above—Tumor Thrombus in RCC

AbstractIntravascular tumor thrombosis is most commonly encountered in renal cell carcinoma (RCC), which alters the staging and prognosis of malignancies, indicating an advanced stage of malignancy, which can be surgically challenging during treatment course. Imaging plays a vital role in the detection of tumor thrombus and in differentiating it from bland thrombus. The Mayo Clinic thrombus classification is widely used to describe levels of inferior vena cava tumor thrombus (IVC-TT) in patients with locally advanced RCC. In this article, we review the classification, guidelines, and recent diagnostic tools for RCC with IVC tumor thrombi, and mention about the various surgical approaches for each stage of tumor thrombi.

Хирургия опухолевых тромбов нижней полой вены.

Introduction. Venous invasion and tumor thrombus formation are rare, but life-threatening complications of renal cell carcinoma (RCC), especially in combination with metastases, are considered significant adverse prognostic factors. Aim. To systematize the existing knowledge and summarize the clinical experience of surgical treatment (open and robot-assisted surgery) of RCC with inferior vena cava (IVC) tumor thrombus. Materials and methods. A literature search in the period 2000-2022 was performed in core databases MEDLINE, Scopus, Clinicaltrials.gov, Google Scholar and Web of Science. The PICO framework (Population-Intervention-Comparison-Outcome) was used to develop a literature search strategy. The following keywords were used to search databases: «renal cell carcinoma», «venous invasion», «inferior vena cava tumor thrombus», «surgical treatment», «robot-assisted», «clinical outcomes». Results. A total of 65 publications were identified. Various classifications of tumor thrombus level are considered, their inferiority and superiority in terms of selecting optimal surgical treatment, both open or robot-assisted surgeries, are discussed. Independent predictors of severe perioperative complications are determined. Optimal surgical treatment of RCC with tumor thrombus is highlighted. Functional and oncological outcomes of patients with RCC with IVC tumor thrombus, who underwent open surgical intervention and robot-assisted ones, are presented. Conclusion. Open surgery in patients with RCC and IVC tumor thrombus above the hepatic veins is associated with prolonged surgery duration, higher intraoperative blood loss, and prolonged in-hospital stay. Prolonged in-hospital stay, the need for blood transfusion, metastasis, sarcomatoid differentiation, and Clavien-Dindo grade 3-5 postoperative complications are predictors of poor outcomes.

The Impact of Preoperative Hemoglobin Concentration and Erythropoietin Administration on Renal Tumors Patients with Inferior Vena Cava Tumor Thrombus Underwent Robot-Assisted Laparoscopic Inferior Vena Cava Thrombectomy

Introduction: The impact of preoperative hemoglobin (Hb) concentration and recombinant human erythropoietin (rh-EPO) treatment on renal tumors (RTs) patients with inferior vena cava (IVC) tumor thrombus who underwent robot-assisted laparoscopic inferior vena cava thrombectomy (RAL-IVCTE) were not well studied.

Does Renal Mass with Venous Thrombosis always Indicate Renal Cell Carcinoma? A Case Series.

Intravascular tumor extension in the major renal veins or their tributaries, as ararebut importantclinical entitythat can change the disease stage, prognosis, and approach to treatment. There is limited literature on the obstruction of renal vein and IVC by tumor thrombus in other types of renal tumors that are not of RCC type. We presented four different renal tumor cases with the presence of gross renal vein or IVC thrombosis. Although the incidence of renal vein and IVC tumor thrombus might be suggestive of (often diagnosed as) RCC, the possibility of other non-RCC renal tumors should be included in the differential diagnosis.

Minimally-Invasive Radical Nephrectomy and Left-Sided Level II Caval Thrombectomy: A New Combined Technique

To present a combined multiport robotic and open approach for left radical nephrectomy and inferior vena cava thrombectomy in patients with a primary left renal mass and level II inferior vena cava (IVC) tumor thrombus. A 69-year-old female was diagnosed with an 8.9cm left renal neoplasm with level II IVC thrombus. She was placed in the left-side-up flank position. The descending colon was mobilized and the left gonadal vein was identified. The left renal vein was identified and fully dissected. The left renal artery was dissected and stapled. The kidney was dissected and left detached with exception of the renal vein. The robot was undocked and the patient was positioned supine. Through a supra-umbilical midline incision, the ascending colon and duodenum were mobilized medially. The right renal vein and IVC were identified and dissected to the level of hepatic veins. The IVC was clamped using a Satinsky clamp. The right renal artery and vein remained patent during thrombectomy. The IVC was opened, the thrombus was evacuated, and IVC was closed. Clamps were removed and the kidney was removed. Operative time was 405 minutes. IVC clamp time was 14 minutes. Estimated blood loss was 500cc. Recovery was uncomplicated. Length of stay was 4 days. Pathology showed clear cell carcinoma with negative margins. IVC thrombectomy is challenging on left sided tumors. Combining a robotic and open technique together is feasible and allows a smaller supra-umbilical midline incision compared to standard open incision.

Crisis Averted: Clinical T1b Renal Mass with Concurrent Arteriovenous Malformation and Renal Vein Thrombus

Arteriovenous malformations (AVMs) secondary to renal-cell carcinoma (RCC) are well-described in the literature. Independently, renal vein and inferior vena cava tumor thrombi can be detected in locally-advanced RCC. A 67-year-old gentleman presented with a cT1b renal mass detected on workup for elevated creatinine. Multiphase CT imaging obtained for partial nephrectomy surgical-planning revealed an initially-missed renal cortical AVM. This drastically changed the plan for intervention, including use of an open approach with AVM embolization by interventional radiology prior and avoidance of a nephron-sparing approach. Final pathology confirmed the AVM and a subclinical renal vein thrombus masked by arterial flow on CT imaging, making this the first concurrent case described in the literature. Herein, we describe avoidance of catastrophic intraoperative hemorrhage by careful review of preoperative imaging and provide a literature review of imaging modalities for both renal surgical-planning and detection of tumor thrombi in RCC.

Management of Locally Advanced Renal Cell Carcinoma

Renal cell carcinoma (RCC) has a natural tendency to invade the venous system with formation of a venous tumor thrombus in the renal vein, which can extend proximally into the inferior vena cava (IVC) and in some cases into the right atrium. The presence of venous involvement significantly worsens prognosis. Despite recent advances in systemic therapies, surgery remains the most effective method of treatment and in the case of complete removal of all tumor, it provides satisfactory long-term survival and must be attempted whenever possible. Several surgical techniques have been proposed, but all are associated with a high rate of perioperative complications and mortality. Minimally invasive approaches are mainly applicable for less extended IVC thrombi, while open surgery remains the gold standard for this category of patients. Most IVC thrombi can be managed without use of circulatory support by using different methods of IVC control depending on the thrombus level. However, use of cardiac bypass with or without deep hypothermic cardiac arrest is indicated in some patients with bulky intraatrial tumor thombi. In select patients presenting with IVC tumor thrombus and synchronous distant metastases, cytoreductive nephrectomy with IVC tumor thrombectomy may be considered with or without neoadjuvant systemic therapy. Surgery for RCC with venous thrombus is complex and requires experienced multidisciplinary surgical, anesthesia, and critical care teams at high-volume centers to achieve the best outcomes.

Stereotactic body radiation therapy as an effective local treatment for advanced hepatocellular carcinoma patients with inferior vena cava and right atrial tumor thrombus

BackgroundThe aim of our study was to evaluate the curative effect and safety of stereotactic body radiation therapy (SBRT) in treating hepatocellular carcinoma (HCC) patients with inferior vena cava (IVCTT) and right atrial tumor thrombus (RATT).MethodsThis retrospective study included fifteen advanced HCC patients with IVCTT and RATT who were treated with SBRT between 2013 and 2020. The prescribed dose delivered to the tumor was 45–50 Gy/7–10 fx. We report their treatment responses according to survival time and toxicities.ResultsFor these patients, the median follow-up time was 15 months (2–52 months). Local tumor control rates of the treated area were 80% at the time of death or at the last follow-up. The 6-month, 12-month, 18-month and 24-month OS rates were 80.0%, 60.0%, 33.3% and 26.7%, respectively. None of these patients died from the toxicity outcomes and complications of SBRT.ConclusionSBRT is an effective option for advanced HCC patients with IVCTT and RATT.

Preliminary experience of oblique occlusion technique in robot-assisted infrahepatic inferior vena cava thrombectomy: step-by-step procedures and short term outcomes

BackgroundWe aimed to compare the oncological outcomes between the oblique occlusion technique and the traditional technique for robot-assisted radical nephrectomy (RARN) with inferior vena cava (IVC) thrombectomy, and to explore the safety and effectiveness of the oblique occlusion technique.MethodsOverall, 21 patients with renal cell carcinoma (RCC) and IVC tumor thrombus (TT) were admitted to our hospital from August 2019 to June 2020. All the patients underwent RARN with IVC thrombectomy, of which the IVC oblique occlusion technique was used in 11 patients and traditional occlusion technique was used in 10 patients. The oblique occlusion technique refers to oblique blocking from the upper corner of the right renal vein to the lower corner of the left renal vein using a vessel tourniquet or a vessel clamp (left RCC with IVCTT as an example).ResultsCompared with patients in the traditional group, those in the oblique group had lower serum creatinine at follow-up (3 month) (95 ± 21.1 vs. 131 ± 30.7 μmol/L, P = 0.03). There was no significant difference in operation time [149 (IQR 143–245) min vs. 148 (IQR 108–261) min, p = 0.86], IVC clamping time [18 (IQR 12–20) min vs. 20 (IQR 14–23) min, p = 0.41], and estimated intraoperative blood loss [300 (IQR 100–800) mL vs. 500 (IQR 175–738) mL, p = 0.51] between both groups. During a 16-month (range, 15–23 months) follow-up period, two cases progressed in the oblique group and three cases progressed in the traditional group.ConclusionsThe modified IVC oblique occlusion technique procedure is relatively safe and effective in RARN with IVC thrombectomy. The IVC oblique occlusion technique may play a role in the protection of renal function.

Mid-term results of surgical interventions of high-grade vena cava tumor thrombus.

This study aims to investigate whether the coexistence of advanced renal cell carcinoma and inferior vena cava tumor thrombus could be treated with a multidisciplinary approach and teamwork and to evaluate early and mid-term results. Between January 2017 and December 2020, a total of 33 patients (28 males, 5 females; mean age: 55.8±13.2 years; range, 27 to 76 years) who underwent radical nephrectomy and thrombectomy of the inferior vena cava were retrospectively analyzed. Demographic characteristics of the patients, types of operations, postoperative data, mortality and morbidity rates were recorded. Of the patients, 12% (n=4) had Stage 2 tumor thrombus, 60.6% (n=20) had Stage 3 tumor thrombus, and 27% (n=9) had Stage 4 tumor thrombus. A total of 55% (n=19) of the patients had right-sided renal cell carcinoma, while 45% (n=14) of them had a left-sided mass. Totally, 66% (n=22) of the patients underwent primary inferior vena cava repair. The thrombectomy procedure and a Dacron® patch was applied with patch plasty in 24% (n=8) of the patients, and Dacron® graft interposition was applied to the inferior vena cava in 9% (n=3) of the patients. The mean follow-up was 20.3±13.0 (range, 2 to 70) months. Deep vein thrombosis was detected in the follow-up of seven (21%) patients, and no pulmonary thromboembolism was observed during the postoperative follow-up period. The mean length of stay in the intensive care unit was 1.39±0.6 (range, 1 to 3) days. The 30-day mortality rate was 3%, due to the loss of one patient from massive pulmonary embolism intraoperatively. Vascular surgical procedures performed regardless of the stage of the tumor thrombus provide satisfactory mid-term results in patients with advanced renal cell cancer.

Radiotherapy with Multimodality Therapy for Hepatocellular Carcinoma with Hepatic Vein and/or Inferior Vena Cava Tumor Thrombus

<h3>Purpose/Objective(s)</h3> Liver cancer is the seventh most common malignancy and second leading cause of cancer-related death worldwide. Hepatic vein and/or inferior vena cava (IVC) tumor thrombus are less common. Improvement in techniques allowed the increasing use of radiotherapy in treating tumor thrombus in hepatocellular carcinoma (HCC). Hence, the present study evaluated the treatment response and survival outcomes of HCC with hepatic vein tumor thrombus (HVTT) and/or IVC involvement receiving radiotherapy in modern RT technique combined with other multimodality therapies. <h3>Materials/Methods</h3> HCC patients with HVTT and/or IVC tumor thrombus receiving radiotherapy were identified at our institution. All patients were treated with VMAT or IMRT technique and 4D-CT was used in simulation. All thrombus and primary tumor in liver were included in the GTV unless they were far from gross primary tumor. The prescription dose to 95% of the PTV was planned at 50-65Gy in 22-28 fractions over 5-6 weeks. After the completion of RT, chest-abdominal CT and liver MRI were performed at 1, 3, 6, 12 months and then 3 to 6 months thereafter. Treatment response was defined as the best response evaluation in 3 months after RT. Overall survival (OS), progression free survival (PFS) and in-field PFS were recorded during follow-up. <h3>Results</h3> Between April 2010 and September 2021, 30 men and 4 women with a median age of 53.5 years (range 30-71 years) were retrospectively included in the cohort. 7 (20.6%) patients had lymph node metastasis and 10 (29.4%) patients had distant metastasis before radiotherapy (RT). In addition to hepatic vein/inferior vena cava (IVC) tumor thrombus, portal vein and right atrium involvement were present in 17 (50.0%) and 6 (17.6%) patients. Half of the patients received TACE and 14 (41.2%) patients received systemic treatment including target therapy and immune therapy before radiotherapy. Most patients received target therapy concurrent with (70.6%) and/or post RT (79.4%). During follow-up (median 13.0 months), the median PFS and median in-field PFS were 4.2 months and not reached, respectively. The PFS and in-field PFS rate were 24.6% and 79.2% at 1 year, 19.7% and 72.0% at 2 years. The OS rate was 77.6% at 1 year and 36.3% at 2 years with a median OS of 15.8 months. PFS and OS were not associated with portal vein involvement, IVC involvement and distant metastasis before RT. The most common first failure site was lung (13/34 patients, 38.2%), followed by liver (7/34 patients, 20.6%). Only 5 (14.7%) patients had progression in the RT field of liver during follow-up. No patients had radiation-induced liver disease or pulmonary embolism during follow-up. <h3>Conclusion</h3> Our study proved that HCC lesions and tumor thrombus were sensitive to RT even after other local therapies. Combination of RT and systemic therapy in treating HCC patients with HVTT and IVC tumor thrombus was safe and effective.

Clinical Outcomes of Image-Guided Proton Therapy for Recurrent Hepatocellular Carcinoma after TACE and/or RFA Treatment

<h3>Purpose/Objective(s)</h3> Additional treatment options for recurrent hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) and/or radiofrequency ablation (RFA) treatment are limited. Although proton therapy provides a more focused dose distribution on the tumor compared with X-ray therapy, the efficacy and safety of proton therapy for recurrent HCC remains unclear. The aim of this study was to evaluate the efficacy and safety of image-guided proton therapy (IGPT) for recurrent HCC after TACE and/or RFA. <h3>Materials/Methods</h3> Eligibility criteria were as follows: (1) histologically-confirmed or image-diagnosed recurrent HCC after TACE and/or RFA treatment; (2) intrahepatic recurrence cases other than treatment site recurrence are not included (3) no previous radiotherapy around the lesion and other HCC; (4) age > 20 and ≤ 80 years; (5) ECOG-PS ≤ 2; (6) Child-Pugh classification A5-B9; (7) dose constraints of the organs at risk achievable; (8) no portal vein or inferior vena cava tumor thrombus; and (9) written informed consent. Overall survival (OS), local control (LC), and progression-free survival rates were estimated using the Kaplan-Meier method. Toxicities were evaluated with the Common Terminology Criteria for Adverse Events version 5.0. Quality of life (QOL) scores were evaluated with EORTC QLQ-C30 version 3.0, QLQ-HCC18, and SF-36. Prior to treatment planning, the fiducial marker was placed just adjacent to a recurrent tumor. IGPT was performed under respiratory gating. <h3>Results</h3> From June 2013 to December 2020, 80 patients were enrolled. Major underlying liver diseases were hepatitis B (n=19), hepatitis C (n=35), alcoholic hepatitis (n=9), and nonalcoholic fatty liver disease (n=17). The Child-Pugh score was A5 in 49 patients, A6 in 16, and B7-9 in 15. The number of Albumin-Bilirubin Grade 1, 2, and 3 were 40, 40, and 0, respectively. Nineteen patients had a history of hepatic resection for other HCC. Fifty-four patients with a peripherally-located tumor were given 66 GyE in 10 fractions and 26 with a central tumor received 72.6 GyE in 22 fractions. Maximum tumor diameter ranged from 10 to 174 mm (median, 31). The median follow-up period of surviving patients was 38.0 months (range: 12.0-96.0). The 3-year OS, LC and PFS were 81% (95% confidence interval: 71-90%), 92% (86-100%), and 38% (26-49%) respectively. In univariate analysis, Child classification, operability, and tumor diameter were associated with better survival, while only Child classification was associated in multivariate analysis. Clinical remission or sustained viral response were significant factors for OS in patients with HCC recurrence derived from hepatitis virus. Non-classic radiation-induced liver disease was observed in only 1 patient with decrease of Child-Pugh score (≥ 2 points). The QOL score did not change after 1 year. <h3>Conclusion</h3> IGPT is safe and effective for recurrent HCC after TACE and/or RFA treatment. IGPT may become one of standard treatments as a curative treatment for recurrent HCC.

Renal Cell Carcinoma with Inferior Vena Cava Thrombus: A Case Report

The incidence of venous extension to the inferior vena cava (IVC) of renal cell carcinoma (RCC) is markedly increased recently mostly due to the advances in diagnostic modalities. Such vascular invasion implies a heightened biologic behavior and a surgical challenge during the course of treatment. Here we discussed a case with study of the classification guidelines, recent diagnostic tools and up-to-date therapeutic modalities for RCC with IVC tumor thrombi. Also added to the discussion are the prognostic significance regarding the pathologic nature of vascular invasion, cephalad extent of thrombi and any associated distant metastasis. Cardiovasc j 2022; 15(1): 111-115

The Current Role of Stereotactic Body Radiation Therapy (SBRT) in Hepatocellular Carcinoma (HCC).

Simple SummaryThe role of stereotactic body radiotherapy (SBRT), which can deliver high radiation doses to focal tumors, has greatly increased in not only early-stage hepatocellular carcinoma (HCC), but also in portal vein or inferior vena cava thrombi, thus expanding this therapy to bridging transplantation and treating oligometastases from HCC in combination with immune checkpoint inhibitors. Major guidelines suggest that SBRT be regarded as a substitute therapy to conventional therapies, such as surgery, ablative therapies, transarterial chemoembolization, and systemic therapy. Further investigations are expected to establish the rationale for using SBRT in each situation.The role of stereotactic body radiotherapy (SBRT), which can deliver high radiation doses to focal tumors, has greatly increased in not only early-stage hepatocellular carcinoma (HCC), but also in portal vein or inferior vena cava thrombi, thus expanding this therapy to pre-transplantation and the treatment of oligometastases from HCC in combination with immune checkpoint inhibitors (ICI). In early-stage HCC, many promising prospective results of SBRT have been reported, although SBRT is not usually indicated as a first treatment potion in localized HCC according to several guidelines. In the treatment of portal vein or inferior vena cava tumor thrombi, several reports using various dose-fraction schedules have shown relatively good response rates with low toxicities and improved survival due to the rapid advancements in systemic therapy. Although SBRT is regarded as a substitute therapy when conventional bridging therapies to transplantation, such as transarterial chemoembolization (TACE) and radiofrequency ablation (RFA), are not applicable or fail in controlling tumors, SBRT may offer advantages in patients with borderline liver function who may not tolerate TACE or RFA, according to several reports. For oligometastases, the combination of SBRT with ICI could potentially induce an abscopal effect in patients with HCC, which is expected to provide the rationale for SBRT in the treatment of oligometastatic disease in the near future.

EFFECTIVE USE OF EXTRACORPOREAL MEMBRANE OXYGENATION IN SURGICAL TREATMENT OF KIDNEY CANCER PATIENT WITH TUMOR THROMBOSIS

The presented clinical case demonstrates the potential of medical technologies with organ replacement in the treatment for kidney cancer (KC) with a tumor thrombus located in the retrohepatic inferior vena cava (IVC) complicated by thromboembolism of the medium and small branches of the pulmonary artery (PATE). The treatment outcomes in such patients are usually poor due to a great number of complications and high mortality. The literature data estimates operative mortality rate of 13 %, and the frequency of early postoperative complications reaches 60 %. Standard approaches to anesthesia in case of thromboembolism and the threat of massive PATE are ineffective. In this clinical case, we chose the therapeutic tactics with extracorporeal membrane oxygenation (ECMO) in the intra- and early postoperative period in order to avoid or minimize life-threatening complications in the KC patient with a tumor thrombus in IVC and PATE. The effective use of ECMO minimized the risk of fatal complications during nephrectomy with thrombectomy for a malignant kidney tumor in the patient with pulmonary embolism and subcompensated disorders of the oxygen transport function of the lungs. The main objective of medical care for this patient involved both the radical treatment of kidney cancer and the elimination of a potential cause of thromboembolism of the pulmonary artery branches, fragments of hematogenous and tumor microthrombi. The total duration of ECMO was 30 hours. No significant complications in organs and systems were recorded during the surgery and in the early postoperative period. The development and implementation of new technologies, including devices for oxygen blood saturation and carbon dioxide elimination, undoubtedly gives a chance for a cure for cancer patients with decompensated organ and functional capabilities.