Inferior Vena Cava Invasion Research Articles

3D-modeling Capabilities in Assessing Resectability of Pancreatic Head Tumors

Background. Pancreatic head cancer ranks 6–7th among oncologic diseases and 4–5th among causes of mortality, with only 5% of patients achieving 5-year survival rate to date. Despite the successes of modern diagnostics and surgical treatment, the problem of early detection, staging of oncologic process and, as a consequence, combined treatment of pancreatic head cancer remains actual.Objective: increasing the accuracy of diagnostics and estimation of resectability of the pancreatic head cancer on the basis of the complex use of the radiation methods of investigation with pancreaticoduodenal zone 3D-reconstructions.Material and methods. The study included 93 patients (44 (47.31%) males and 49 (52.69%) females) with complicated pancreatoduodenal masses treated from 2019 to 2022 at the Surgical Department of the City Mariinsky Hospital. The patients’ age varied from 44 to 90 years, the mean age was 67±0.74 years. All patients underwent magnetic resonance imaging (MRI) on an Ingenia MR tomograph (Philips Medical Systems, Netherlands) with a magnetic field induction of 3 Tesla. The native examination of the abdomen and retroperitoneum, supplemented with MR-cholangiopancreatography protocol, and dynamic contrast enhancement with data collection in arterial, portal, and delayed phases were carried out. T2-weighted images were then performed using turbospin-echo technology, including fat-suppressed images, to evaluate structural changes and the presence of fluid in fascial spaces. Patients also underwent endoscopic ultrasound of the pancreaticoduodenal zone using the push and pull method, and abdominal multislice computed tomography (MSCT). To build 3D models, we used free 3D-slicer and Mimics programs, which allowed to build semi-automatic model for further evaluation of anatomo-topographic relations.Results. MSCT 3D modeling revealed tumor invasion into the superior mesenteric vein in 6 (23.06%) patients, whereas MRI models showed tumor invasion in 4 (15.38%) patients, intraoperatively the results were confirmed in 5 patients (19.23%). According to both MSCT and MRI modeling data, the invasion of the ventral trunk occurred in 1 (5.2%) case, which was confirmed intraoperatively. Inferior vena cava invasion on MSCT and MRI models was detected in 3 (11.54%) patients, whereas intraoperatively – in 4 (15.38%) patients. The MSCT and MRI 3D models coincided with the data on invasion of the ventral trunk in 1 (3.85%) patient and the superior mesenteric artery in 2 (7.69%) patients, which was fully confirmed intraoperatively.Conclusion. 3D modeling on the basis of MRI and MSCT studies is an informative method in preoperative staging of pancreatic head cancer and its resectability. This method allows to objectively determine the localization and prevalence of the tumor process on adjacent anatomical structures, as well as visually demonstrate the metastatic lesion of regional lymph nodes. By the parameters of diagnostic efficiency, 3D models are maximally close to the intraoperative picture, which allows planning both the volume and the course of surgical intervention.

Experience with Modified Makuuchi Incision in the Surgical Treatment of Huge Renal Tumor: A Single Institution’s Experience

Background: Surgical removal of huge renal and retroperitoneal tumors, such as adrenal cortical carcinoma or renal cell carcinoma with inferior vena cava (IVC) invasion, remains a challenge for urologists. Aim: Herein, we describe our experience with the modified Makuuchi incision for huge renal and retroperitoneal tumors. Methods: We applied the modified Makuuchi incision in 10 patients with a huge renal or retroperitoneal tumor. Another 11 patients with a huge renal or retroperitoneal tumor using different surgical incisions other than modified Makuuchi incision were collected for comparison. The modified Makuuchi incision of the abdomen is initiated in the cephalad to the xiphoid, extended 1 cm above the umbilicus, and then extended laterally to the lateral flank. Through the incision, we mobilized the colon, and when the renal space was seen, the tumor was removed. If an invasion of a nearby organ occurred, a general or cardiovascular surgery specialist was consulted for combined surgery. The patients’ age ranged from 43 to 82 years (three men and seven women). Results: The modified Makuuchi incision provided good and rapid exposure. No unexpected organ injuries occurred during surgery. There were no wound-related complications, such as dehiscence or incisional hernia, after 3 months of follow-up. Partial hepatectomy, splenectomy, distal pancreatectomy, and thrombectomy of the IVC thrombus were performed through the same incision. Conclusion: Our experience demonstrated that the modified Makuuchi incision is a good choice for patients with huge renal and retroperitoneal tumors, even those with nearby organ invasion.

Review of outcomes of combination therapy using yttrium 90 radioembolization and sorafenib/nivolumab for HCC with hepatic vein or IVC invasion

Background A systematic review of the outcomes of combination therapy using Yttrium 90 radioembolization (Y90) and sorafenib/nivolumab for patients with hepatocellular carcinoma (HCC), with hepatic vein (HV) or inferior vena cava (IVC) invasion. The aim of this study is to summarise the results of different studies that used the combination therapy for HCC patients with tumor thrombosis involving the HV or IVC. Method A literature search was performed using keywords in Medline and Google Scholar limited to publications from 2010 to 2021. There were 173 articles identified during the initial literature search. During abstract screening, 81 articles were excluded. Another 83 did not contain information on hepatic vein or IVC invasion. Therefore, 9 articles met the eligibility criteria and were included in the synthesis. Results In total, 37 patients with hepatic vein or IVC invasion were identified. There were 31 patients who were given sorafenib, 7 were given nivolumab and 1 was given both sorafenib and nivolumab. Among the 37 patients, 21 had hepatic vein invasion, 22 had IVC invasion and 6 had both HV and IVC invasion. The median OS was 20.55 months and median PFS was 8.18 months. For the results, 23 patients were evaluated via modified RECIST (mRECIST) criteria and 14 were evaluated via RECIST 1.1. Conclusion The combination of local and systemic therapies demonstrated potential results for increased response rates, OS and PFS benefits. Further studies are required to determine the long-term outcomes of the combination therapy for this group of patients.

Retrospective Study of the Efficacy and Safety of Chemoembolization with Drug-Eluting Microspheres Combined with Intra-Arterial Infusion of Bevacizumab for Unresectable Hepatocellular Carcinoma.

PurposeTo evaluate the efficacy and safety of chemoembolization with drug-eluting microspheres (DEM-TACE) combined with intra-arterial infusion of bevacizumab in patients with unresectable hepatocellular carcinoma (uHCC) and to identify possible prognostic factors.Patients and MethodsBetween November 2014 and December 2020, 34 patients underwent DEM-TACE combined with intra-arterial infusion of bevacizumab for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) beyond the Up-to-seven criteria or BCLC stage C HCC. Patients with extrahepatic metastasis or inferior vena cava invasion were excluded. The primary endpoint was overall survival (OS). The secondary endpoints were safety (assessed using Common Terminology Criteria for Adverse Events v5.0), the response rate at 1 month, and the identification of prognostic factors. The median OS was calculated using the Kaplan–Meier method. The response rate was evaluated according to the modified Response Evaluation Criteria in Solid Tumors. Prognostic factors were investigated by univariate and multivariable analysis using the Cox proportional hazards model.ResultsThe median OS was 13 months. BCLC stage and presence of portal vein invasion were not significantly associated with OS. There were no grade ≥3 adverse events. The Child–Pugh class did not decline after treatment in 31 of 34 patients. The overall response rate was 14.2% and the disease control rate was 100%. Significant prognostic factors were alcoholic liver disease, Child–Pugh score of ≥8, and microsphere size of 50–100 μm.ConclusionDEM-TACE combined with intra-arterial infusion of bevacizumab is safe and effective, and it could be a treatment option for unresectable HCCs.

Primitive neuroectodermal tumor of the kidney: an experience of three cases

BackgroundPrimitive neuroectodermal tumors (PNET) are highly aggressive tumors belonging to the Ewing’s sarcoma family. Primitive neuroectodermal tumor is a group of bone and soft tissue tumor arising from neuroectodermal tissues. They are characterized by the expression of MIC2 and neural markers like neuron-specific enolase, synaptophysin, S-100, vimentin, Leu-7, and the presence of the EWS-FLI1 translocation. It is a rare malignancy with only about 150 cases being published worldwide. The tumor usually presents with non-specific symptoms such as abdomen pain and hematuria. Inferior vena cava (IVC) involvement by renal PNET is extremely rare with only a handful cases reported in the literature and is a clinically challenging scenario. There is a dearth of data on the management of this disease; further, the management of this disease in current scenarios is not well reported. We report our experience with three cases over 11 years which spans all three spectrums of the disease: localized, locally advance and metastasis. Case presentationCase 1: 37-year-old gentleman presenting with hematuria found to have right renal tumor with IVC invasion which was found to be unresectable intraoperatively. Patient was started on chemotherapy but deteriorated and died 3 months later. Case 2: 38-year-old gentleman presenting with abdominal pain found to have locally advanced left renal tumor. Patient developed local recurrence and metastasis 15 months after resection but had stable disease for nearly 4 years before developing acute myeloid leukemia and withdrawing consent for treatment. Case 3: 13-year-old girl who presented with right abdominal mass and subsequently found to have localized disease. After aggressive chemotherapy, patient is now recurrence-free after nearly 11 years.ConclusionsOur study aims to show the spectrum of renal primitive neuroectodermal tumors with outcomes in all three clinical scenarios, with the aim of reinforcing that high index of suspicion for this disease is required in young patients presenting with aggressive disease, and immunohistochemistry should be used when in doubt, as outcomes are greatly improved with adjuvant chemotherapy.

Advances in the pharmacological treatment of hepatic alveolar echinococcosis: From laboratory to clinic.

Hepatic alveolar echinococcosis (HAE) is a zoonotic parasitic disease caused by the larvae of Echinococcus multilocularis. Because of its characteristics of diffuse infiltration and growth similar to tumors, the disability rate and mortality rate are high among patients. Although surgery (including hepatectomy, liver transplantation, and autologous liver transplantation) is the first choice for the treatment of hepatic alveolar echinococcosis in clinic, drug treatment still plays an important and irreplaceable role in patients with end-stage echinococcosis, including patients with multiple organ metastasis, patients with inferior vena cava invasion, or patients with surgical contraindications, etc. However, Albendazole is the only recommended clinical drug which could exhibit a parasitostatic rather than a parasitocidal effect. Novel drugs are needed but few investment was made in the field because the rarity of the cases. Drug repurposing might be a solution. In this review, FDA-approved drugs that have a potential curative effect on hepatic alveolar echinococcosis in animal models are summarized. Further, nano drug delivery systems boosting the therapeutic effect on hepatic alveolar echinococcosis are also reviewed. Taken together, these might contribute to the development of novel strategy for advanced hepatic alveolar echinococcosis.

Sequential trans-arterial chemoembolization and stereotactic body radiotherapy followed by immunotherapy (START-FIT) for locally advanced hepatocellular carcinoma: A single-arm, phase II trial.

4091 Background: Previous studies proposed therapeutic synergy between loco-regional therapies and checkpoint inhibitors in hepatocellular carcinoma (HCC). We aimed to study the safety and efficacy of sequential transarterial chemoembolization (TACE) and stereotactic body radiotherapy (SBRT) followed by Avelumab in patients with locally advanced HCC. Methods: Patients with locally advanced HCC not suitable for curative resections were eligible. All patients had HCC ≥ 5cm, tumor nodules ≤3, and child-Pugh A5-B7 liver function. Tumors with distant metastasis, main portal vein (VP4) invasion, or inferior vena cava (VV3) invasion were excluded. Patients underwent single episode of TACE followed by 5-fraction SBRT (28 days afterwards), followed by Avelumab (10mg per kg) 14 days afterwards and every 2 weeks thereafter. The primary endpoint was percentage of patients amendable to curative surgery, defined as R0 resection with sufficient remnant liver volume and function. Secondary endpoints were objective response rate (ORR) per modified Response Evaluation Criteria in Solid Tumors (mRECIST) version 1.1, survivals, and treatment-related adverse event (TRAE). The sample size assumed that around 20% patients amendable to surgery after experimental treatment compared to 5% of historical institutional results after TACE. Modified Simon two-stage optimal design was used (power, 80%; a = 0.05; P0 = 0.05; P1 = 0.20; n1 = 10; n = 29 with an additional four patients to allow for drop-out or other reasons). Results: Out of 67 patients screened, 33 patients were enrolled. The median sum of diameter of lesion(s) was 15.1cm (range: 5.3-31.1cm), and 21 (63.6%) had marcrovascular invasion (n=13, hepatic vein, n=3 branched portal vein, n=5 both). After a median follow-up of 17.2 months (range: 3.5-31.6 months), 3 (9.1%) patients had tumor downstaged with curative surgery done. The objective response rate was 62.5% (95% CI, 45.3-77.1%), of whom 15 had complete response (CR) (43.8%) and 6 had partial response (18.7%). The median overall survival (OS) and progression-free survival was 30.3 months (95% CI: 22.7-37.8 months) and 20.7 months (95% CI: 14.6-26.8 months) respectively. All three patients with surgery done were alive at 2 years (100%). For 15 patients had CR, the 2-year OS rate was 92.9% without surgery. Ten patients (30.3%) experienced ≥ grade 3 TRAEs, commonly transient increase in alanine / aspartate aminotransferase (n=4, 12.1%) and bilirubin (n=2, 6%) level after TACE. Five patients (15.2 %) developed ≥ grade 3 immune-related adverse events. Conclusions: Although merely 9% of patients were downstaged to receive curative surgery, combined locoregional treatment and immunotherapy is safe and resulted in an unexpectedly high CR rate of 43% and median OS of 30 months in patients with locally advanced unresectable HCC. Clinical trial information: NCT 03817736.

A COMPLETE LBBB REVEALING NON SPECIFIC VENOUS METASTASIS INTO THE RIGHT ATRIUM : A CASE REPORT AND REVIEW OF LITERATURE

The primary heart tumors are rare, whereas metastatic heart tumors occur more frequently. We presente a case of an asymptomatic 71-year-old man diagnosed with isolated right atrium metastasis of a poorly differentiated hepatic carcinoma by direct inferior vena cava invasion the patient opted out of any intervention and was discharged under VKA. The prevalence of secondary cardiac tumors has been reported as 10 to 12% in autopsy studies. Clinically, cardiac metastasis usually remains asymptomatic and detected incidentally. The techniques mainly used in assessment of cardiac lesions include transthoracic and transoesophageal echocardiogram, CT scans and MRI. Treatment of metastatic cardiac tumor is usually palliative, because the overall prognosis is poor. A multidisciplinary approach involving cardiologists, oncologists, and cardiothoracic surgeons is crucial for deciding the best therapeutic regimen for such patients.

Efficacy of preoperative cine magnetic resonance imaging in evaluation of adhesion of renal cancer thrombus to inferior vena cava wall

ObjectiveIn renal cell carcinoma with inferior vena cava (IVC) thrombus, adhesion to, or invasion into, the IVC wall will often increase the level of surgical difficulty and even necessitate resection of the IVC. It will generally be difficult to perform an accurate preoperative assessment using the standard imaging modalities of contrast-enhanced computed tomography and standard magnetic resonance imaging (MRI). Cine MRI is an MRI sequence that captures motion to produce detailed information on both the anatomy and the dynamic motion. In the present study, we evaluated the accuracy of preoperative cine MRI for determining the need for IVC wall resection, with validation of the imaging findings according to the intraoperative findings. MethodsA total of 15 patients who had undergone radical nephrectomy and tumor thrombectomy from May 2018 to April 2020 met the inclusion criteria. The primary outcome of interest was the need for IVC resection because of adhesion or invasion of a venous tumor thrombus. Cine MRI was used to evaluate the blood flow between the tumor thrombus and the IVC wall and the presence of tumor thrombus mobility during free respiration. The sensitivity and specificity were calculated for preoperative cine MRI for determining the need for IVC wall resection. The Fisher exact test was used to determine the association between intraoperative IVC wall resection and the cine MRI findings. Furthermore, receiver operating characteristic curves and the area under the curve were used to compare the accuracy of conventional MRI and cine MRI. ResultsOf the 15 patients, 8 (53.3%) had undergone IVC resection. We found that the absence of both dynamic blood flow and tumor thrombus mobility on cine MRI could reliably predict for IVC resection with 100% (95% confidence interval, 51.8%-100%) sensitivity and 85.7% (95% confidence interval, 42.1%-1.00%) specificity. The area under the receiver operating characteristic curve was 0.821 for conventional MRI and 0.929 for cine MRI. ConclusionsIn the preoperative setting, cine MRI could be a helpful examination modality to predict for the need for IVC wall resection for patients with renal cell carcinoma with venous tumor thrombus.

РЕЗУЛЬТАТЫ ХИРУРГИЧЕСКОГО ЛЕЧЕНИЯ ПАЦИЕНТОВ С КАВОАТРИАЛЬНЫМ ОПУХОЛЕВЫМ ТРОМБОЗОМ ПРИ ПОЧЕЧНО-КЛЕТОЧНОЙ КАРЦИНОМЕ

Objective. Improvement the surgical management for cavoatrial tumor thrombosis due to renal cell carcinoma. Methods. The results of complex clinical, laboratory, instrumental examination, intraoperative observations and morphological studies were analyzed in 62 patients with renal cell carcinoma, complicated by cavoatrial tumor thrombosis, hospitalized to the vascular surgery department of Lviv regional clinical hospital for the period 1993-2019. Surgical treatment included radical nephrectomy, thrombectomy from inferior vena cava and right atrium. Kaplan-Meier method was used to evaluate the long-term survival of patients. Results. The postoperative complications included: posthemorrhagic anemia - 22 (38,6%), acute renal failure - 15 (26,3%), pulmonary embolism - 4 (7,0%), acute liver failure - 3 (5,3%), phlebothrombosis - 3 (5,3%), pneumonia - 3 (5,3%), stroke - 2 (3,5%), wound сomplications - 5 (8,8%) cases. Perioperative mortality was 11,3%. The causes of death included: hemorrhagic shock - 4 (6,5%), pulmonary embolism - 3 (4,8%), stroke - 1 (1,6%) cases. Long-term survival indicators were evaluated among 53 patients. The median follow-up was 36,9±13,3 months. The cumulative 2-, 5-, and 10-year survival rates were 53,5%; 38,2% and 17,2%, in 32 patients without metastases - 58,7%; 43,1% and 18,5% respectively. There was no significant difference іin survival among patients with atrial and retrohepatic venous tumor thrombosis versus infrahepatic and cavarenal venous tumor thrombosis (p>0,05). Conclusion. The accurate preoperative assessment of the level of neoprocess involvement, improvement of surgical tactics, effective prevention of thromboembolic and hemorrhagic complications make it possible to provide acceptable survival rates for patients with renal cell carcinoma, complicated by cavoatrial tumor thrombosis. What this paper adds The role of intraoperative blood reinfusion in the aspect of oncological safety in patients with renal cell carcinoma, complicated by invasion of inferior vena cava and right atrium, was first determined. Based on the results of cytological examination of tumor contamination of blood sediment material from the operating field during the cavatomy and washed autoerythrocytes it has been established that intraoperative reinfusion can provide necessary ablastics and doesn’t pose an additional risk of tumor dissemination during radical nephrectomy and inferior vena cava thrombectomy. The use of combined mini-invasive approaches in the surgical treatment of supradiaphragmatic level of intracaval invasion due to renal cell carcinoma is proposed, which will reduce the volume, trauma and duration of surgery, as well as provide reliable pulmonary embolism prevention. For the first time in Ukraine the immediate and long-term results of surgical treatment of patients with renal cell carcinoma, complicated by invasion of inferior vena cava and right atrium, during the last three decades were analyzed.

Sorafenib Combined with Chemoembolization for Locally Advanced Hepatocellular Carcinoma with Macroscopic Vascular Invasion: A Propensity Score Analysis.

The purpose of this study was to compare the efficacy and safety of transarterial chemoembolization (TACE) plus sorafenib with those of TACE alone in patients with locally advanced hepatocellular carcinoma (HCC). Treatment-naïve patients with preserved hepatic reserve (Child–Pugh score ≤ 7) who received TACE plus sorafenib (n = 91) or TACE alone (n = 109) for locally advanced HCC with macrovascular invasion were retrospectively evaluated. Propensity score matching (PSM) was used to correct selection bias, and 63 pairs were created. In the entire study population, the median progression-free survival (PFS) and overall survival (OS) with TACE plus sorafenib were better than those with TACE alone. After PSM, the median PFS (7.0 vs. 4.3 months; p = 0.017) and OS (17.5 vs. 12.8 months; p = 0.049) were again significantly longer with TACE plus sorafenib than with TACE alone. Stratified Cox regression analysis and doubly robust estimation revealed that treatment type was significantly associated with both PFS and OS. In the subgroup analysis, TACE plus sorafenib did not show a significant survival benefit for patients with main portal vein or inferior vena cava invasion. Major complications were similar in both groups (p = 0.330). In conclusion, TACE plus sorafenib showed better survival outcomes than TACE alone in patients with locally advanced HCC.

P45 Cardiopulmonary Bypass for Renal and IVC Tumour Resection–Our Experiences

Radical nephrectomy with aggressive tumuor resection remains the mainstay of treatment for nephrogenic tumours with inferior vena caval invasion. Frequently, the cardiac surgeon is called on to assist the urologist, as cardiopulmonary bypass and deep hypothermic circulatory arrest is required to facilitate IVC tumour thrombectomy and/or repair. We present a series of 22 cases performed in the Newcastle area with particular emphasis on the operative technique(s) and outcomes.

Efficacy of Local Treatments for Hepatocellular Carcinoma Involving the Inferior Vena Cava and/or Right Atrium.

Major vessel invasion is frequently observed in locally advanced hepatocellular carcinoma (HCC). The most commonly involved major vessel is the portal vein; however, approximately 4% of patients with HCC have inferior vena cava (IVC) and/or right atrium (RA) invasion. Although these conditions have dismal prognoses, local treatments have not been regularly administered because they may affect systemic circulation. Owing to recent technological advances, various local treatments including surgery and external radiotherapy have increasingly been performed in these patients. Since irradiating tumorous lesions in the liver while preserving normal tissues is possible and major vessels are relatively resistant to radiation, external radiotherapy has been a feasible palliative modality for treating vessel-invasive HCC. In addition, systemic fatal complications that were initially a cause of concern have become rare after radiotherapy. While invasive procedures such as extracorporeal circulation or hepatic vascular exclusion may be required, pioneering surgeons have performed surgical resections in selected patients and have obtained promising results. Surgery has shown the best survival outcomes compared to other treatment options including radiotherapy, but the possibility of perioperative morbidity should be considered. In addition, a combination of local treatment and novel systemic agents, which demonstrated better survival and response rates than sorafenib, is expected to maximize therapeutic effects. In this review, we have discussed the most recent treatments for HCC with IVC and/or RA involvement and have provided information intended to guide therapeutic decisions and facilitate future research.

A prediction model for overall survival after transarterial chemoembolization for hepatocellular carcinoma invading the hepatic vein or inferior vena cava.

An effective therapeutic option has not yet been established for hepatocellular carcinoma (HCC) invading the hepatic vein (HV) or inferior vena cava (IVC). This study aimed to determine the therapeutic effect of transarterial chemoembolization (TACE) in HCC patients with HV or IVC invasion, and to build a risk prediction model. Data from patients who underwent TACE as a first-line treatment for HCC invading the HV or IVC between 1997 and 2019 were retrospectively evaluated. Data from 296 patients were included (1997-2006 comprised the training cohort, n = 174; 2007-2019 comprised the validation cohort, n = 122). The median post-TACE survival was 7.3 months and an objective tumor response was achieved in 34.1% of patients. Multivariable Cox analysis of the training cohort identified five pretreatment factors (maximal tumor size > 10 cm, infiltrative HCC, combined portal vein invasion, extrahepatic metastasis, and ECOG performance status 1), which were used to create predictive models for overall survival. Median overall survival times in the validation cohort were 14 and 4.2 months for the low (sum of risk score: 0-3)- and high-risk (sum of risk score: 4-7) groups, respectively (p < 0.001). Time-dependent ROC curves for the predictive models for overall survival applied to the validation cohort showed acceptable AUC values (0.723 and 0.667 at 6 months and 1 year). TACE seems effective for selected patients with HCC invading the HV or IVC. The predictive model may help to identify candidates most likely to benefit from TACE. • To develop a risk prediction model for patients with HCC with HV or IVC invasion treated with TACE, five factors were selected from a multivariate Cox regression model for overall survival. • The combination of these factors helped to identify two prognostic categories: low- and high-risk. • The predictive model can help to select candidates who will benefit most from TACE in this patient group.

Renal Angiomyolipomas with Inferior Vena cava invasion

Angiomyolipomas are benign tumors that can occur in the kidneys. Though venous invasion is a common complication of renal cell carcinoma, it rarely occurs with angiomyolipoma given its benign nature. We aim by this article to conduct an extensive literature review documenting rare cases of angiomyolipomas with venous extension, particularly with inferior vena cava invasion. The literature review was conducted following PRISMA checklist, using PubMed searching for English and non-English articles up to January 2020, and Mesh terms: angiomyolipoma, inferior vena cava, vein. Only cases reporting patients with angiomyolipomas with venous extension were included. Data extraction of different patients’ parameters was conducted by two independent researchers in a uniform manner to a detailed datasheet. The search ended up with 90 cases, after excluding 116 cases for multiple reasons. Venous invasion of angiomyolipoma is a rare phenomenon. Clinical presentation is similar to any other renal tumor. Imaging is primordial for diagnosis and classification. Surgery is indicated as soon as venous involvement is demonstrated. In most cases, the prognosis is favorable with low morbidity and mortality.

Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario

Aim: “To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”.Materials and Methods: Retrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium. Results: “Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypoten-sion intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any sur-vival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus. Conclusion: Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidis-ciplinary approach for a successful surgical outcome.

Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario.

Aim“To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”.Materials and MethodsRetrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium.Results“ Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypotension intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any survival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus.ConclusionRadical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidisciplinary approach for a successful surgical outcome.

Clinical significance of circulating tumor cells detection in renal cell carcinoma with thrombus: A STROBE-compliant study.

The aim of the study was to evaluate the potential role of circulating tumor cell (CTC) detection in the surgical assessment of renal cell carcinoma (RCC) patients with thrombi.Nine patients diagnosed with renal mass and thrombi were enrolled from June 2018 to January 2019. Blood samples were collected for CTC detection using SE-iFISH assay. CD45, DAPI, programmed death ligand 1, and fluorescence in situ hybridization with the centromere of chromosome 8 (CEP8) were immune-stained for analysis. Patient demographics, clinical features, pathological characteristics, and CTC detection results were extracted for analysis.Seven of 9 patients (77.8%) had 12 detectable CTCs, 5 of which were with CEP8-positive signal ≥5 and the others were CEP8-positive signal = 3. All 3 patients (100%) with IVC invasion had detectable CTCs, whereas CTCs were detected in 4 of 6 patients (66.7%) without IVC invasion. CEP8 analysis revealed that CTCs in IVC invasion patients were all of CEP8-positive signal ≥5 status, whereas only half of the CTCs in patients without IVC invasion were of CEP8-positive signal ≥5 pattern.In conclusion, both CTC subtype and total CTC number may serve as a marker for predicting inferior vena cava invasion in RCC patients.

Robot-assisted Cavectomy Versus Thrombectomy for Level II Inferior Vena Cava Thrombus: Decision-making Scheme and Multi-institutional Analysis

BackgroundRobot-assisted thrombectomy (RAT) for inferior vena cava (IVC) thrombus (RAT-IVCT) is being increasingly reported. However, the techniques and indications for robot-assisted cavectomy (RAC) for IVC thrombus are not well described. ObjectiveTo develop a decision-making program and analyze multi-institutional outcomes of RAC-IVCT versus RAT-IVCT. Design, setting, and participantsNinety patients with renal cell carcinoma (RCC) with level II IVCT were included from eight Chinese urological centers, and underwent RAC-IVCT (30 patients) or RAT-IVCT (60 patients) from June 2013 to January 2019. Surgical procedureThe surgical strategy was based on IVCT imaging characteristics. RAT-IVCT was performed with standardized cavotomy, thrombectomy, and IVC reconstruction. RAC-IVCT was mainly performed in patients with extensive IVC wall invasion when the collateral blood vessels were well-established. For right-sided RCC, the IVC from the infrarenal vein to the infrahepatic veins was stapled. For left-sided RCC, the IVC from the suprarenal vein to the infrahepatic veins was removed and caudal IVC reconstruction was performed to ensure the right renal vein returned through the IVC collaterals. MeasurementsClinicopathological, operative, and survival outcomes were collected and analyzed. Results and limitationsAll procedures were successfully performed without open conversion. The median operation time (268 vs 190 min) and estimated blood loss (1500 vs 400 ml) were significantly greater for RAC-IVCT versus RAT-IVCT (both p < 0.001). IVC invasion was a risk factor for progression-free and overall survival at midterm follow-up. Large-volume and long-term follow-up studies are needed. ConclusionsRAC-IVCT or RAT-IVCT represents an alternative minimally invasive approach for selected RCC patients with level II IVCT. Selection of RAC-IVCT or RAT-IVCT is mainly based on preoperative IVCT imaging characteristics, including the presence of IVC wall invasion, the affected kidney, and establishment of the collateral circulation. Patient summaryIn this study we found that robotic surgeries for level II inferior vena cava thrombus were feasible and safe. Preoperative imaging played an important role in establishing an appropriate surgical plan.

Intraoperative Cardiogenic Shock Caused by Intracardiac Tumor Thrombi Obstruction

A 60-year-old man presented with left flank pain, a palpable abdominal mass, and hematuria for months. Computed tomography revealed a large tumor in the left kidney (approximately 17.7 cm in diameter) with evidence of left adrenal, left renal vein, and inferior vena cava (IVC) invasion. He underwent left nephrectomy with IVC thrombectomy. Transesophageal echocardiography (TEE) was used during the whole procedure and the tumor was found in the IVC (Fig-1) before resection.