Inferior Vena Cava Tumor Research Articles

Surgical treatment of hepatocellular carcinoma combined with inferior vena cava tumor thrombosis

Hepatocellular carcinoma (HCC) combined with inferior vena cava (IVC) tumor thrombosis is regarded unresectable.Most of the patients received non-surgical treatment or gave up treatment,and the prognosis of these patients is poor.As the development of surgical treatment,the success rate of surgical treatment for HCC combined with IVC tumor thrombosis is increasing yearly.In May of 2012,one patient with HCC combined with IVC tumor thrombosis received hepatic Ⅴ,Ⅶ and Ⅷ segmentectomy + tumor thrombosis removal from the IVC at the Second Affiliated Hospital of Harbin Medical University.Preoperative computed tomography showed space-occupying lesions in the segments Ⅴ,Ⅶ and Ⅷ,and the IVC was filled with tumor thrombi.The volume of the left liver was 489 cm3,which was under the limit for survival.In order to preserve the remnant liver,right hepatectomy with reservation of hepatic segment Ⅵ,and the tumor thrombi in the IVC were removed with total hepatic vascular exclusion.The patient was recovered with no tumor recurrence or metastasis at postoperative month 18. Key words: Liver neoplasms; Inferior vena cava tumor thrombosis ; Liver resection; Surgical technique

Outcomes after inferior vena cava thrombectomy and reconstruction for advanced renal cell carcinoma with tumor thrombus.

This report details the experience of a multidisciplinary surgical team in the management of stage III and stage IV renal cell carcinoma (RCC) with concomitant inferior vena cava (IVC) tumor thrombus. A retrospective inquiry of our vascular database from 2003 to 2012 identified 55 surgical cases of stage III (n= 40) and stage IV (n= 15) RCC presenting with IVC tumor thrombus. Tumor characteristics and IVC tumor thrombus were evaluated by clinical staging and postoperative pathology staging. Patient demographics and surgical reconstruction are detailed. Cancer-specific outcomes consisted of oncologic surveillance with computed tomography or magnetic resonance imaging. A Clavien-Dindo classification of early (<30days) complications and mortality was recorded, including a review of secondary surgical interventions. According to the Novick classification of IVC tumor thrombus, there were 10 supradiaphragmatic (level IV), 20 intrahepatic (level III), and 25 infrahepatic (level II or I) tumor thrombi. Vena cava reconstruction was completed in 54 patients (98%), with one patient deemed unresectable. Vena cava control required cardiac bypass (n= 10), venovenous bypass (n= 4), or infrahepatic IVC control (n= 40). Reconstruction of the IVC was completed with two prosthetic interposition grafts for one stage IV thrombus and one stage III thrombus; two patch repairs were done for stage III thrombus, and there were 50 primary IVC repairs. All other IVC reconstructions were patent at a mean follow-up of 23months. A single asymptomatic patient with primary IVC repair had estimated 30% IVC narrowing but no other measurable stenosis as detected by postoperative imaging. Three patients required reoperation (two for surgical site bleeding, one for small bowel fistula). Early surgical complications included Clavien-Dindo grades I (n= 3), II (n= 6), IIIa (n= 2), IIIb (n= 3), and V (n= 2). Regional retroperitoneal or distant recurrent RCC occurred in 26 patients (48%); a single patient demonstrating recurrent IVC tumor thrombus at 8months required secondary IVC thrombectomy. All patients with tumor invasion of the IVC wall developed recurrent RCC, and no patient survived beyond 5years. Early mortality was 3.6% (n= 2), with 27 patients (49%) dying within 24months, resulting in an overall mortality for the cohort of 80% (n= 44) as established on routine regular postoperative surveillance. A multidisciplinary approach for the management of advanced RCC and IVC tumor thrombus helps optimize outcomes. Primary IVC repairs are possible in most patients, and IVC patency is good. Recurrent tumor thrombus rates are low; however, RCC tumor recurrence and mortality are high, especially among patients with advanced cancer with IVC wall invasion.

Clinical analysis of modified radical nephrectomy and inferior vena cava thrombectomy with deep hypothermic circulatory arrest

Objective To evaluate the safety and efficacy of modified radical nephrectomy and high level inferior vena cava thrombectomy with deep hypothermic circulatory arrest.Methods From March 1997 to February 2013,36 patients,diagnosed as renal cell carcinoma (RCC) associated with level Ⅲ-Ⅳ inferior vena cava (IVC) tumor thrombi,were accepted radical nephrectomy and IVC thrombectomy using cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA).Among them,24 patients were male and 12 patients were female.Their age ranged from 19 to 72 years old (mean 53.8± 13.1 years old).Level Ⅲ IVC tumor thrombi was found in 29 cases and level Ⅳ IVC tumor thrombi was found in 7 cases.Eight radical nephrectomies with IVC thrombectomies were performed according to the classic surgical procedures,including 7 cases with level Ⅲ IVC tumor thrombi and one case with level ⅣV IVC tumor thrombus.Twenty-eight radical nephrectomies with IVC thrombectomies were performed using modified techniques,including 22 cases with level Ⅲ IVC tumor thrombi and 6 cases with level Ⅳ IVC tumor thrombi.The mean size of tumor was 10.2±4.3 cm.There were no significant differences in patient and pathological characteristics,including age,sex gender,body mass index (BMI),Eastern Cooperative Oncology Group (ECOG) performance status,tumor size and thrombus levels (P＞0.05).The main modifications techniques included as follow:①Taking the 4th right intercostal incision and right inguinal incision to establish CPB in order to avoid the need of median sternotomy.Meanwhile,the right subcostal and lateral rectus incision was considered as the approach for nephrectomy; ②Applying the laparoscopic ultrasound probe to monitoring the thrombus level during the procedures ; ③Delaying the maximal mobilization of kidney tumor after thrombectomy.The operation time,CPB time,circulatory arrest time,estimated blood loss,intraoperative blood transfusions,postoperative hospital stays,perioperative complications and mortality were compared between the two groups.Results The mean operation time (580.0± 31.0 min vs.438.2 ± 87.1 min),CPB time (190.0±11.4 min vs.160.4±30.2 min),postoperative ICU stays (74.0±11.8 h vs.38.7±17.2 h) and postoperative hospital stays (12.9± 1.6 d vs.9.6± 1.9 d) were siguificantly shorter in the technique modified group than those in the traditional group (P＜0.05).At the same time,the estimated blood loss (4 166.7± 871.0 ml vs.2 547.1 ± 1 363.4 ml),intraoperative blood transfusions (3 133.3±575.0 ml vs.1 894.1±956.9 ml) and perioperative mortality (2/8 vs.0,i.e 25.0％ vs.0) were also significantly lower in the technique modified group than those in the traditional group (P＜0.05).The circulatory arrest duration (27.3±5.9 min vs.24.4±8.2 min),resuscitation time (4.6±0.9 h vs.3.8± 1.7 h) and perioperative complication rates (2/ 8 vs.4/28,i.e 25.0％ vs.14.3％)didn't show significantly different between the two group (P＞0.05).Conclusions Radical nephrectomy and level Ⅲ-Ⅳ tumour thrombectomy using CPB combined with DHCA is relatively safe and with low morbidity and mortality rate.The technical modifications may facilitate the operation,help minimize surgical trauma and improve perioperative outcomes. Key words: Renal cell carcinoma; IVC thrombus; Deep hypothermic circulatory arrest; Technical modifications

Aggressive renal angiomyolipoma with vena cava extension: A case report and literature review.

Renal angiomyolipoma (AML) is the most common type of benign mesenchymal tumor of the kidney. AMLs typically present as benign lesions without local invasion. However, the tumor may exhibit aggressive behavior. Intravascular extension into the inferior vena cava (IVC) and hemorrhagic aneurysm formation associated with AML has rarely been reported in the past. In the current study, the novel case of a 77-year-old female is described who presented with a tumor thrombus extending to the IVC. The patient subsequently underwent a radical nephrectomy and an IVC tumor thrombectomy. In addition, the available literature regarding this unusual complication of a common renal neoplasm has been reviewed. It is essential for radiologists and clinicians to be aware that AMLs may exhibit these types of aggressive behaviors.

A Rare Case of Leiomyosarcoma of Inferior Vena Cava Managed with Curative Resection and PTFE Vascular Graft Reconstruction: A case report with review of literature

Primary vascular leiomyosarcoma is rare tumour arising most frequently from inferior vena cava. In lit erature only case reports or small case series are available. The pre sentation and surgical management depends on origin of the tumour in relation to the hepatic and renal veins, tumour gro wth (extra luminal or intra luminal) and involvemen t of surrounding structures. Leiomyosarcoma of inferior vena cava tu mour poses a challenge with respect to resectabilit y, reconstruction, potential for massive haemorrhage, requirement of c ardiopulmonary bypass and possibility of tumour thr omboemboli. Our experience with successful management of rare case and with thorough literature review suggest surgica l resection of leiomyosarcoma of the IVC with P olytetrafluoroethylene vascular graft reconstruction provides good surgic al and oncological outcome.

Anesthesia management for surgical resection of inferior vena caval tumor thrombus extending into right cardiac cavities.

Inferior vena caval (IVC) tumor thrombus, majorly originated from intravenous leiomyomatosis (IVL) and renal or hepatic carcinoma, can extend into right cardiac cavities. Complete tumor resection, supported by cardiopulmonary bypass (CPB), has been proved to be the most effective treatment but also to be dramatically challenging. Randomized clinical trials of the surgical treatment for IVC tumor with cardiac extension are very limited due to the disease rarity, whereas publications on IVC tumor surgery are predominately confined to case report. So far, no clinical research or review, focused on intraoperative anesthesia management for surgical resection of IVC tumor with cardiac extension, has been identified; even anesthesia-targeted case report can not be found. In this article, we briefly introduce the disease characteristic and related surgical procedure and offer some suggestions upon the anesthesia management based on our own clinical experiences.

Unusual case of chronic heart failure acutisation

E-mail: tatjana.zekic@ri.t-com.hr Introduction: Chronic heart failure (CHF) is a result of many different causes, but rarely occurs due to intraatrial masses. Most commonly seen are thrombi related to atrial fibrillation (AF), valvular vegetations and cardiac tumors (mixomas), but the dignosis of extensive mass reaching from the inferior vena cava (IVC) to the right atrium of the heart is an extreme rare finding. The literature reported tumor spread in 1-4% cases of hepatocellular carcinoma (HCC). We report a similar case causing the acutisation of CHF. Case report: A 83-year-old man reported to the emergency department (ER) for several times in four months due to progressive dyspnea and leg swelling. His medical history included alcoholic liver cirrhosis with hepatocellular carcinoma (HCC) treated by chemoembolisation four years ago, CHF, valvular heart disease, chronic renal disease 3b, AF. He was treated with warfarin therapy for a few months due to the patient noncompliance and also with beta-blocker, digitalis and loop diuretic, whose dose was repeatedly increased after each subsequent visit to the ER. MSCT pulmonary angiography excluded pulmonary embolism. Abdominal ultrasound showed compensated liver chirrosis with solitary HCC. At the time of our examination he had signs of heart failure along with liver decompansation. The abdominal ultrasound noted a mass extending from inferior hepatic vein through IVC all the way to the right atrium which was sized 2.7 cm. Given the extent of malignant disease and the complications, the patient was treated with low molecular weight heparin with gradual impairment of heart and kidney parameters. He died shortly after the admission of bleeding from the upper gastrointestinal tract. Discussion: The literature suggests that right atrial thrombus may not cause any symptoms, but can sometimes lead to shock from ball valve obstruction of the tricuspid valve, right heart failure, pulmonary emboli and sudden death. This patient had many comorbidities that contribute to the thrombus development and also to heart failure, but HCC is known for its ability to progress through veins. Very high mortality rates are observed for advanced HCC with IVC and intraatrial tumor thrombus extension. Mean survival time is around three months. Pharmacotherapeutic and surgical treatments is equally poor. Conclusion: The patients with progressive heart failure and liver cirrhosis with HCC should be suspected of having masses of IVC or right atrium that is easily detected by echocardiography or abdominal ultrasound. In our case it was probably spreading of tumor itself.

The Choi response criteria for inferior vena cava tumor thrombus in renal cell carcinoma treated with targeted therapy.

To evaluate the prognostic significance of the Choi criteria for assessing the responses of a renal mass and inferior vena cava (IVC) tumor thrombus in patients with renal cell carcinoma (RCC) receiving targeted therapy. We reviewed the medical records of 22 patients diagnosed with RCC and IVC thrombus between 2005 and 2012. The efficacy of targeted therapy in renal mass and IVC tumor thrombus was evaluated using response evaluation criteria in solid tumors (RECIST) and Choi criteria, respectively. Overall survival was estimated, and the prognostic significance of each variable was estimated using Cox proportional-hazards regression modeling. There were no significant differences in overall survival between patients with partial response (PR) and nonresponse according to RECIST criteria (19.3 vs 43 months; p = 0.212) or Choi criteria (9.0 vs 23.3 months; p = 0.109) in primary tumor. Regarding the response of IVC tumor thrombi, according to Choi criteria, nine patients (40.9 %) demonstrated PR and longer survival than patients with stable disease (7.2 vs 23.3 months; p = 0.014). In multivariable analysis, response to IVC thrombus according to Choi criteria was the only significant predictive factor. Patients with IVC thrombus who demonstrate the PR according to Choi criteria were at 0.35-fold greater overall risk of death compared with patients who did not demonstrate this response (p = 0.043). A response according to Choi criteria in IVC tumor thrombus was an independent prognostic predictor in patients with RCC and IVC thrombus who receive targeted therapy.

Clinical value of transesophageal echocardiography for surgical resection of inferior vena caval tumor thrombus with cardiac extension

Inferior vena caval (IVC) tumor thrombus with cardiac extension is a very rare phenomenon,which proliferates fast and could be very challenging to the surgery.This paper was designed to investigate the clinical value of transesophageal echocardiography (TEE) for the surgical resection of IVC tumor thrombus extending into right cardiac cavities.Six cases from our medical institute,preoperatively diagnosed as IVC tumor thrombus with cardiac extension and scheduled for the surgical resection,were retrospectively analyzed.In addition to real-time and dynamic monitoring,comprehensive TEE exams were performed for all the patients respectively after anesthesia induction,namely before tumor resection and after tumor resection.Cardiac extension was defined by the preoperative finding of cardiac mass originated from IVC tumor thrombus by transthoracic echocardiography,computerized tomography or CT angiography.In all the cases,intraoperative TEE provided an accurate and excellent view of the IVC tumor thrombus.For case three,the IVC tumor thrombus was found at the IVC entrance to right atrium without further cardiac extension; for case five,the IVC tumor thrombus proliferated into right atrium but the extended cardiac mass was very slim and flexible and the tricuspid valve was untouched; for case four,the IVC tumor thrombus extended into right atrium and even cross the tricuspid valve but the extended cardiac mass was also very slim and flexible.Based on the TEE-provided information,the originally scheduled surgical decision was modified and the surgical resection was performed without cardiopulmonary bypass (CPB).For the other three cases,the intraoperative TEE showed similar results to preoperative findings.The huge IVC tumor thrombus extended into the right heart,presented almost no flexibility and dramatically compromised the intracardiac blood flow.For the three cases,CPB support was indispensable for the tumor resection.The full TEE exam after tumor resection in all the six patients displayed clear surgical resection without tumor residuals,but in those three patients suffered with severely compromised cardiac extension,severe tricuspid regurgitation was noticed.All the six patients were closely monitored until discharged,and no TEE-related complications were observed.This paper reports about TEE' s utilization in a series of consecutive patients undergoing surgical resection of IVC tumor thrombus with cardiac extension.In addition to its safety and effectiveness,TEE can provide valuable information for surgical decision making,surgical intervention assessment and anesthesiamanagement strategies. Key words: Echocardiography, transesophageal ; Thrombectomy ; Vena cava, inferior; Heart

Radiologic methods in evaluation of prevalence and structure of IVC tumor thrombus in patients with renal cell carcinoma

Renal cell carcinoma (RCC) is the most common primary tumor of the kidney; it accounts for approximately 3% of newly diagnosed cancers. The incidence of venous extension to the inferior vena cava (IVC) and renal vein in RCC is markedly increased recently mostly due to the advances in diagnostic modalities. Knowledge of the tumoral stage and determination of tumor thrombus extension at the time of diagnosis is essential for prognosis and surgical planning. Nowadays abdominal ultrasound (US), computed tomography (CT) and magnetic resonance (MR) scanning techniques are used for the detection and staging of RCC. In this study, the accuracy of recent diagnostic tools in determination of IVC thrombus is outlined. Also the role of positron emission tomography (PET) scanning is briefly addressed.

Level III-IV Inferior Vena Caval Thrombectomy Without Cardiopulmonary Bypass: Long-Term Experience with Intrapericardial Control

Inferior vena cava tumor thrombectomy requires experienced surgical teams due to complex hemodynamic considerations. The teams often use vascular bypass techniques that introduce additional risk. Inferior vena caval control in the pericardium obviates the need for cardiopulmonary bypass. We reviewed our experience with intrapericardial control during inferior vena caval tumor thrombectomy to evaluate perioperative outcomes and determine factors associated with overall survival. We retrospectively reviewed the records of 87 patients who underwent nephrectomy with inferior vena caval tumor thrombectomy using intrapericardial inferior vena caval control from 1978 to 2012. This technique was performed in all 43 and 35 cases of intrahepatic and supradiaphragmatic thrombi, respectively, and in 9 select cases of intra-atrial thrombi. Patient demographics, operative variables and postoperative outcomes were examined. Multivariate regression analysis was used to determine associations between clinical variables and overall survival. Mortality 30 days perioperatively was 9.2% and the incidence of high grade complications was 19.5%. Median survival was 3.1 and 2.5 years in patients with pT3bN0 and pT3cN0, respectively. Extended regional lymphadenectomy, which was performed in all cases, revealed nodal metastasis in 38%. Onmultivariate analysis ECOG greater than 2 and pT3c stage were associated with worse survival. Histological grade, perinephric fat invasion and lymph nodeinvolvement were not associated with worse survival. Intrapericardial control of the inferior vena cava enables a single surgical team to safely perform tumor thrombectomy for intrahepatic and supradiaphragmatic thrombi, eliminating the risk and morbidity related to cardiopulmonary bypass. Although supradiaphragmatic extent and ECOG greater than 2 are associated with worse survival, complete resection with lymphadenectomy can allow for long-term survival in patients with locally advanced disease.

Oncologic Outcomes Following Surgical Resection of Renal Cell Carcinoma with Inferior Vena Caval Thrombus Extending Above the Hepatic Veins: A Contemporary Multicenter Cohort

Suprahepatic inferior vena caval tumor thrombus in renal cell carcinoma cases has historically portended a poor prognosis. With advances in perioperative treatment of patients with high level thrombus contemporary outcomes are hypothesized to be improved. We evaluated long-term oncologic outcomes of contemporary surgical treatment of patients with renal cell carcinoma in whom level III-IV inferior vena caval thrombus was managed at high volume centers. We examined clinical and pathological data on patients with renal cell carcinoma and level III-IV thrombus treated with surgery from January 2000 to June 2013 at 4 tertiary referral centers. Survival outcomes and associated prognostic variables were assessed by Kaplan-Meier and multivariate Cox regression analyses. We identified 166 patients, including 69 with level III and 97 with level IV thrombus. Median postoperative followup was 27.8 months. Patients with no evidence of nodal or distant metastasis (pN0/X, M0) had 5-year 49.0% cancer specific survival and 42.2% overall survival. There was no difference in survival based on tumor thrombus level or pathological tumor stage. Variables associated with an increased risk of death from kidney cancer on multivariate analysis were regional nodal metastases (HR 3.94, p <0.0001), systemic metastases (HR 2.39, p= 0.01), tumor grade 4 (HR 2.25, p = 0.02), histological tissue necrosis (HR 3.11, p = 0.004) and increased preoperative serum alkaline phosphatase (HR 2.30, p = 0.006). Contemporary surgical management achieves almost 50% 5-year survival in patients without metastasis who have renal cell carcinoma thrombus above the hepatic veins. Factors associated with increased mortality included nodal/distant metastases, advanced grade, histological necrosis and increased preoperative serum alkaline phosphatase. These findings support anaggressive surgical approach to the treatment of patients with renal cell carcinoma who have advanced tumor thrombus.

MP64-07 CORRELATION OF RENAL VEIN INVASION AND IVC INVASION IN RCC WITH CAVAL THROMBUS

You have accessJournal of UrologyKidney Cancer: Localized V1 Apr 2014MP64-07 CORRELATION OF RENAL VEIN INVASION AND IVC INVASION IN RCC WITH CAVAL THROMBUS Karin Westesson, Christopher Przybycin, and Venkatesh Krishnamurthi Karin WestessonKarin Westesson More articles by this author , Christopher PrzybycinChristopher Przybycin More articles by this author , and Venkatesh KrishnamurthiVenkatesh Krishnamurthi More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1924AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Tumor extension into the inferior vena cava (IVC) occurs in 5% of renal cell carcinoma (RCC) cases. Invasion into the venous endothelium is not discernible prior to surgery. If present, it poses a surgical challenge and carries a worse prognosis. If IVC endothelium invasion were identifiable preoperatively, alternative techniques, such as IVC resection, could be employed to render patients disease free. We hypothesized that depth of invasion into the renal vein (RV) wall is predictive for IVC endothelium invasion. The objective of this study was to determine the correlation between renal vein invasion and IVC invasion. METHODS Following IRB approval we reviewed 26 cases of nephrectomy and IVC thrombectomy performed between 2010 and 2012. Clinical data was obtained from a database of patients with IVC tumors. Operative notes were reviewed to determine intraoperative assessment of tumor thrombus adherence to the IVC endothelium and cases were categorized as adherent (AD) or non-adherent (NA). Tissue sections containing tumor within the RV and IVC were reviewed to determine invasion into the venous intima and/or muscularis. Clinical assessment of adherence and histopathological findings were analyzed with Fishers’ Exact test. RESULTS Mean patient age was 63 years and 65% of patients were men. IVC thrombus extension was level II, III and IV in 7 (27%), 7 (27%) and 12 (46%) cases, respectively. RCC subtype was clear cell in 18, papillary in 5 and unclassified in 3. Of the 26 cases, 7 (27%) were identified as AD and 19 (73%) were NA. Histopathological results are noted in Table 1. Of the 7 AD tumors, 6 had IVC sections for examination. Of the 19 NA tumors, 3 tumors (25%) were non-adherent and were removed without adjacent IVC; therefore 12 had sections of IVC with tumor for examination. There was no significant correlation between RV muscularis invasion and clinical adherence to the IVC endothelium (P=0.461) CONCLUSIONS Intraoperative impression of IVC adherence is supported by histopathological findings of IVC muscularis invasion in 50% of cases. Depth of invasion at the RV margin does not correlate with the intraoperative assessment of IVC adherence and histopathological findings of IVC endothelial invasion. Tumor invasion at the RV margin is presently not a useful intraoperative parameter to facilitate complete resection of IVC tumor thrombi. Table 1: Clinical adherence versus depth of invasion Group Depth of Invasion IVC intima IVC muscularis RV intima RV muscularis AD (N=7) 6 (100%)∗ 3 (50%)∗ 5 (71%) 2 (29%) NA (N=19) 9 (75%) 1 (8%) 17 (89%) 7 (37%) ∗IVC sections with tumor were only available in 6 of the 7 sticky tumor cases © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e703 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Karin Westesson More articles by this author Christopher Przybycin More articles by this author Venkatesh Krishnamurthi More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

MP57-06 LIMITED BENEFIT OF TARGETED THERAPIES ON IVC THROMBUS IN RENAL CELL CARCINOMA

INTRODUCTION AND OBJECTIVES: The standard treatment for patients with renal cell carcinoma extending into the inferior vena cava is radical nephrectomy and tumor thrombectomy. However, not all patients are eligible for surgery, and in some cases targeted therapies are needed because of their potential to downsize the tumor. But the clinical benefit of targeted therapies on vena caval tumor thrombus of RCC remains unclear. Objective: To evaluate the cytoreductive effects of targeted therapies on renal cell carcinoma with inferior vena caval tumor thrombus (IVC thrombus). METHODS: 19 patients with IVC thrombus who were treated with targeted molecular therapies (TMT) at our hospital were retrospectively analyzed. Sunitinib was administered in 17 patients, sorafenib in 1, and temsirolimus in 1. Thrombus size and level before and after TMT were measured by enhanced CT or MRI. Patients and tumor characteristics were compared between the patients who showed decrease of IVC thrombus height with TMT and those who did not show any decrease. RESULTS: 14 (74%) of the patients were male, and the mean age of the group was 66 years. The left side of the kidney had primary tumors in 11 patients and the right side in 8. Before the therapy thrombus level waszTin 2 patients (11%), zU in 9 (47%), zV in 4 (21%), and zW in 4 (21%). The median duration of therapy was 2 cycles. Following therapy, the tumor thrombus increased in height in 4 patients (21%), remained the same in 1 casei5%j, and decreased in 14 (74%). However, the mean reduction of the thrombus height was only 14mm. The thrombus level decreased only in 3 patients (16%), all of whom were treated with sunitinib. After TMT, 10 patients (43%) received thrombectomy. Comparison of all the data collected between the two groups failed to demonstrate any statistically significant factors, although a high neutrophil count and clinical node metastases were marginally statistic. CONCLUSIONS: Our study showed the clinical benefit of targeted therapies on IVC thrombus of the renal cell carcinoma was limited. Thus targeted therapy in the neoadjuvant setting can be considered in selected patients.

Technical considerations in robotic nephrectomy with vena caval tumor thrombectomy.

Robotic surgery has been applied to increasingly complex urologic procedures since its initial widespread adoption for prostatectomy. While laparoscopic nephrectomy was initially reported over 2 decades ago, renal tumors involving the inferior vena cava (IVC) appeared to be a limitation to the application of laparoscopy. Laparoscopic management had only been reported in a limited fashion for short tumor thrombi not requiring cross-clamping of the IVC. The first robotic nephrectomy for renal cancer with IVC tumor thrombus was performed in 2008 with the first series reported in 2011, including for larger tumor thrombi requiring IVC cross-clamping for thrombus extraction. Since then, several surgeons at various institutions have adopted robotic surgery for these complex procedures. With experience and meticulous surgical technique, the procedure can be reproduced in properly selected cases. Further adoption and reports of multi-institutional experiences are necessary to validate this still relatively new procedure, and such work is already underway.

Perioperative Outcomes Following Surgical Resection of Renal Cell Carcinoma with Inferior Vena Cava Thrombus Extending Above the Hepatic Veins: A Contemporary Multicenter Experience

BackgroundSurgery for renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus above the hepatic veins is technically complex and associated with an increased risk of perioperative morbidity and mortality. However, minimal data exist that describe contemporary perioperative outcomes at major referral centers or the prognostic factors associated with poor outcomes. ObjectiveTo determine the preoperative predictors of major complications and 90-d mortality after surgery in RCC patients who have IVC thrombus above the hepatic veins. Design, setting, and participantsWe reviewed medical records of all RCC patients who had IVC tumor thrombus above hepatic veins and had had surgery between January 2000 and December 2012 at the Mayo Clinic, M.D. Anderson Cancer Center, University of Texas Southwestern Medical Center, and the University of Wisconsin Hospital. Outcome measurement and statistical analysisMajor complications recorded were defined as ≥3A according to the Clavien-Dindo system within 90 d of surgery. Univariate and multivariate analyses were used to evaluate associations of preoperative variables with risk of major complications or 90-d mortality. Results and limitationsA total of 162 patients were identified for study (level 3, 4 in 69, 93 patients, respectively, according to the Neves classification). Cardiopulmonary bypass was used in 60 of 162 patients (37.5%), and 40 patients (24.7%) had preoperative angioembolization. Major complications were reported in 55 patients (34.0%), with the most common being respiratory, cardiac, and hematologic issues. After multivariate analysis, preoperative systemic symptoms and level 4 thrombus were independently associated with increased risk of major complications. Mortality was reported in 17 patients (10.5%) within 90 d after surgery. After multivariate analysis, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and low serum albumin were preoperative factors independently associated with increased risk of 90-d mortality. ConclusionsContemporary perioperative mortality and major complication rates for RCC patients who have upper-level thrombus are 10% and 34%, respectively. Patients who have ECOG PS >1 or low serum albumin have increased risk for perioperative mortality.

Inferior vena cava tumor thrombus that directly infiltrated from paracaval lymph node metastases in a patient with recurrent hepatocellular carcinoma

Herein, we present the case of a patient with recurrent hepatocellular carcinoma (HCC) who had paracaval lymph node (LN) metastases with an inferior vena cava (IVC) tumor thrombus after a hepatectomy. A 65-year-old man with chronic hepatitis B virus infection received an extended anterior segmentectomy because of two hepatic tumors, located in segments 7 and 8. Histological examination of both resected specimens showed mostly moderately differentiated HCC with some poorly differentiated areas, and liver cirrhosis (A2/F4). Because the patient had an elevated α-fetoprotein serum level, abdominal computed tomography (CT) was performed. Abdominal CT revealed a 9-mm-diameter recurrent tumor in hepatic segment 3 and paracaval LN metastases with an IVC tumor thrombus at 8 months after the first operation. The patient received transcatheter arterial chemoembolization as treatment for the intrahepatic recurrence, following resection of the paracaval LN metastases and removal of the IVC tumor thrombus. In this case, the paracaval LN metastases had directly infiltrated the IVC via the lumbar veins, resulting in an IVC tumor thrombus, which usually develops from an intrahepatic tumor via the hepatic vein. The development of an IVC tumor thrombus with HCC recurrence, as in this case, is very rare, and based on a PubMed search, we believe this report may be the first to describe this condition.

Robotic Right Nephrectomy and Inferior Vena Cava Tumor Thrombectomy with Caval Patch Graft Reconstruction

Abstract Introduction: Despite the increasing popularity of laparoscopic and robotic approaches for renal tumors, open surgery is the standard approach for the surgical management of renal tumors with extension into the inferior vena cava (IVC).1 Abaza reported the first robot-assisted radical nephrectomy with IVC tumor thrombectomy in a series of five patients with good outcomes. Two patients necessitated cross-clamping of the IVC, and in all cases, the IVC cavotomy was closed using a two layer suture.2 We present our technique and perioperative results of the first robot-assisted radical nephrectomy and IVC tumor thrombectomy and reconstruction using a synthetic patch graft. Materials and Methods: A 61-year-old woman presented with an 8-cm right renal mass, bilateral pulmonary embolism, and IVC tumor thrombus extending into the subhepatic IVC. After counseling and discussion of all available treatment options, the patient opted for robotic-assisted surgical management. The procedure was performed by a s...

Leiomyosarcoma of the Inferior Vena Cava: Segment II

Leiomyosarcoma is the most common primary malignancy of the inferior vena cava (IVC) with poor prognosis. The 5and 10-year actuarial malignancy-free survival rates after wide surgical resection are 31.4% and 7.4%, respectively, in the international registry of IVC leiomyosarcoma. 1 Surgical excision of these tumors is difficult if they arise from the IVC above the renal veins. Here we report a case of successful excision of the leiomyosarcoma arising from the supra renal part of the IVC. CASE REPORT A woman aged 45 years was admitted with history of upper abdominal discomfort and pain which had progressed over a period of one year. Ultrasound scan and CT scan of the abdomen showed a tumor in the supra renal region adjacent to the IVC (Fig. 1). Many types of tumors were considered in the differential diagnosis but IVC tumor was not mentioned in that list. During surgery, tumor was dissected and separated from duodenum, liver, kidney, retroperitoneal tissues and portal vein. Surprisingly it was found to arise from the right lateral wall of the supra renal IVC. The IVC was taped above and below the tumor (Fig. 2). It was difficult to place a side clamp on the IVC without significantly occluding the lumen as the tumor was also growing into the lumen of IVC. Cross clamping of the IVC increased the distal venous pressures and congestion of blood. A temporary clamp was placed over the infra renal abdominal aorta to reduce blood flows and pressure. Then clamps were placed across the IVC above and below the tumor. The tumor was excised and rent in the IVC was repaired by lateral venorrhaphy with minimal narrowing (Fig. 3). The clamps were removed and flows returned.

Inferior vena cava thrombus

Summary Background: The inferior vena cava (IVC) thrombus is an entity with many different causes and clinical presentations. Methods: In the past five years, we treated 16 patients with IVC thrombus and a diagnosis of primary hepatic carcinoma in 6 (37.5%), metastatic hepatic carcinoma in 8 (50%), and Budd-Chiari syndrome in 2 patients (12.5%). Results: Conservative treatment with enhanced immunotherapy, chemotherapy, and transcatheter arterial chemoembolization for the hepatic malignancies led to an overall survial of 82.2% at 16-month follow-up. Discussion: The prognosis of IVC tumor thrombus is usually poor and the surgical techniques are quite challenging. Surgical re-section combined with chemotherapy for advanced hepatocellular carcinoma with tumor thrombus has led to promising results. Aggressive radical nephrectomy with IVC thrombectomy remains the most effective therapeutic option in patients with renal cell carcinoma and IVC tumor thrombus. With the development of minimally invasive surgical techniques and the avoidance of cardiopulmonary bypass, less trauma and prolonged survival can be expected for IVC thrombus of malignant etiology.