Inferior Vena Cava Invasion Research Articles

RENAL ANGIOMYOLIPOMA ASSOCIATED WITH INFERIOR VENA CAVAL AND RIGHT ATRIAL THROMBUS

A 40-year-old woman with no stigmata of tuberous sclerosis presented with sudden onset of pain in the right flank. Routine laboratory data were normal except for mild anemia. Computerized tomography revealed a ruptured lesion with low attenuation values in the fat range as well as tumor thrombus extending into the right renal vein and inferior vena cava. Magnetic resonance imaging confirmed a right renal mass extending into the right atrium through the right renal vein and inferior vena cava (fig. 1). A 1 cm. tumor was also noted in the left kidney. All findings were diagnostic of bilateral renal angiomyolipoma associated with right renal vein and inferior vena caval invasion as well as right atrial thrombosis and right renal rupture. Conservative treatment resulted in improved laboratory findings and symptoms. However, the potentially lethal nature of an atrial thrombus prompted radical surgery. Right nephrectomy and

With advances in medical imaging can the radiologist reliably diagnose Wilms' tumours?

AIM: To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone. METHODS: From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis. RESULTS: The radiologists were concordant and reached the correct diagnosis in 20 23 cases (87 unsure of the diagnosis in one case (4.3%) and discordant in two cases (8.7%). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma. CONCLUSION: In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.

Prognostic value of clinical parameters for renal cell carcinoma

– Clinical evaluation of patients with kidney tumours should provide several parameters with possible prognostic value, such as age, sex, incidental discovery, duration of symptoms, weight loss, fever, disease-free interval, performance status, elevated ESR, hypercalcemia, elevated gamma-enolase, local tumour extension, invasion of renal vein and inferior vena cava, lymphatic metastases, distant metastases, tumour dimension, multicentricity, bilaterality and growth velocity. Some of these factors correlate to prognosis in univariate statistical analysis; in multivariate analysis, however, tumour stage is the best prognostic factor, while the other parameters show less or no prognostic value. Besides tumour stage, parameters with an independent value are performance status, weight loss, elevated ESR. Using these prognostic factors, patients can be divided into groups with different prognosis and treatment.

Intracaval endovascular ultrasonography for preoperative assessment of retrohepatic inferior vena cava infiltration by malignant hepatic tumors

The accurate diagnosis of inferior vena cava infiltration is important not only for preoperative staging but also for performing surgery for hepatic tumor involving the inferior vena cava (IVC). We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) in the diagnosis of invasion of the IVC by a prospective study of 30 consecutive patients with hepatic tumors with possible invasion of the IVC. The procedure was performed using an 8F, 20-MHz intravascular ultrasonography (US) from the right femoral vein. Twenty-nine of the 30 patients underwent surgery, and the tumor was resected in 25 cases, including 3 cases of combined resection of the IVC. The diagnostic criterion for IVC infiltration with ICEUS was obliteration of a single echogenic layer of the IVC wall or intracaval tumor mass. The results of ICEUS were compared with those of computed tomography (CT), cavography, conventional US, and intraoperative US. Vascular invasion was identified in 7 of 30 cases and was subsequently confirmed by pathological examination of four resected specimens, including one autopsy and two operative findings. The sensitivity, specificity, and overall accuracy of ICEUS for the diagnosis of the IVC invasion was 100%, 95.8%, and 96.7%, respectively, against 85.7%, 60.8%, and 66.7% for CT, and 71.4%, 73.9%, and 73.3%, respectively, for cavography. The sensitivity, specificity, and overall accuracy of conventional US was 87.5%, 59%, and 66.7%, respectively; those of intraoperative US were 100%, 81.8%, and 86.2%, respectively. ICEUS is a useful technique that can precisely evaluate the IVC for possible hepatic tumor invasion. (Hepatology 1996 Nov;24(5):1121-7)

Intracaval Endovascular Ultrasonography for Preoperative Assessment of Retrohepatic Inferior Vena Cava Infiltration by Malignant Hepatic Tumors

The accurate diagnosis of inferior vena cava infiltration is important not only for preoperative staging but also for performing surgery for hepatic tumor involving the inferior vena cava (IVC). We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) in the diagnosis of invasion of the IVC by a prospective study of 30 consecutive patients with hepatic tumors with possible invasion of the IVC. The procedure was performed using an 8F, 20–MHz intravascular ultrasonography (US) from the right femoral vein. Twenty–nine of the 30 patients underwent surgery, and the tumor was resected in 25 cases, including 3 cases of combined resection of the IVC. The diagnostic criterion for IVC infiltration with ICEUS was obliteration of a single echogenic layer of the IVC wall or intracaval tumor mass. The results of ICEUS were compared with those of computed tomography (CT), cavography, conventional US, and intraoperative US. Vascular invasion was identified in 7 of 30 cases and was subsequently confirmed by pathological examination of four resected specimens, including one autopsy and two operative findings. The sensitivity, specificity, and overall accuracy of ICEUS for the diagnosis of the IVC invasion was 100%, 95.8%, and 96.7%, respectively, against 85.7%, 60.8%, and 66.7% for CT, and 71.4%, 73.9%, and 73.3%, respectively, for cavography. The sensitivity, specificity, and overall accuracy of conventional US was 87.5%, 59%, and 66.7%, respectively; those of intraoperative US were 100%, 81.8%, and 86.2%, respectively. ICEUS is a useful technique that can precisely evaluate the IVC for possible hepatic tumor invasion.

Adrenal cortical carcinoma with tumor thrombus invasion of inferior vena cava

A case of adrenal cortical carcinoma with inferior vena cava (IVC) involvement is presented. Ultrasonography, computed tomography, and venacavography all presumptively showed a large mass over the upper pole of the left kidney with tumor thrombus in the IVC. However, aortography demonstrated that this mass was receiving its blood supply from the left inferior phrenic artery, aorta, and left renal artery. Radical surgery, including resection of the tumor and its adjacent organs (kidney, distal pancreas, spleen) and the tumor thrombus in the IVC, with the aid of cardiopulmonary bypass, was performed. We emphasize that adrenal cortical carcinoma can have tumor thrombi invading the IVC, and in such cases we suggest radical surgical removal of the tumor and the thrombus.

Role of intravascular ultrasonography in detecting intravascular tumor thrombi: A preliminary report

We evaluated the role of intravascular ultrasonography in the diagnosis of intravascular tumor thrombi. During the past 2 years intracaval endovascular ultrasonography was performed in 26 selected patients to diagnose inferior vena cava invasion. Results of positive intracaval endovascular ultrasonogram were correlated with the pathologic findings of resected specimens and autopsy and with other imaging technologies such as computed tomography and angiography. Six patients had positive studies of intracaval tumor thrombus. In all cases detailed horizontal images perpendicular to the inferior vena cava axis were studied. Five of the six patients underwent resection. Intravascular ultrasonography correctly predicted the extent of the tumor thrombus, the degree of tumor adherence to the vessel wall, and the intraluminal movement of the tumor thrombus. Floating thrombi were visualized as an intraluminal to-and-fro movement. Thrombus adhesion to the vessel wall appeared as an absence of space between the tumor and the wall, with no respiratory movement of the thrombus. Intravascular ultrasonography was useful for the accurate diagnosis of intravascular tumor thrombi and aided in formulating the operative strategy.

Preoperative Computerized Tomography Detection of Extensive Invasion of the Inferior Vena Cava by Renal Cell Carcinoma: Possible Indication for Resection with Partial Cardiopulmonary Bypass and Patch Grafting

The relationship of the diameter of the inferior vena cava as measured by computerized tomography (CT) and tumor invasion of the inferior vena caval wall was determined in patients with renal cell carcinoma. In addition, the indications and usefulness of surgery using partial cardiopulmonary bypass and a polytetrafluoroethylene (Gore-Tex) patch graft are discussed. In all 7 patients with an inferior vena caval diameter of 40mm. or larger on CT tumor had extensively invaded the vessel wall macroscopically and microscopically. Therefore, resection of the inferior vena caval wall and repair with a patch graft were necessary. Partial cardiopulmonary bypass was used in 6 of these 7 patients. On the other hand, of 11 patients with an inferior vena cava less than 40mm. in diameter only 2 with extensive tumor invasion of the vessel wall underwent a patch graft procedure without partial cardiopulmonary bypass. One patient who had massive hemorrhage before bypass was started died while in a coma. The survival of the remaining patients ranged from 6 to 131 months (median 19 months). Blood loss in patients who underwent surgery with partial cardiopulmonary bypass was much less than that in patients without bypass. In our series, there were no complications related to the graft itself and graft patency was excellent. Our results indicate that an inferior vena caval diameter of 40 mm. or more on CT probably indicates extensive tumor invasion. Although further experience and observation are necessary to evaluate whether partial cardiopulmonary bypass and/or a patch graft improves the prognosis of patients with extensive inferior vena caval invasion by renal cell carcinoma, this method was relatively safe and decreased blood loss.

Inferior Vena Caval Invasion by Renal Cell Carcinoma: False Positive Diagnosis by Venacavography

We reviewed the records of 22 renal cell carcinoma patients who were referred to this hospital to determine inferior vena caval extension of tumor. Preoperative radiological studies from referring hospitals and this institution were compared to the operative findings. Four cases of false positive inferior vena caval involvement on preoperative venacavograms performed and interpreted elsewhere were identified. In 3 of these cases a repeat preoperative inferior venacavogram performed at this hospital made the correct diagnosis. In the remaining case an inferior venacavogram was not repeated but no tumor was found at operation. One patient who did not undergo an operation was believed to have vena caval involvement by computerized tomography but venacavography was negative. Reasons for the false positive studies included suboptimal technique and misinterpretation of normal flow defects. Our technique for venacavography is presented. The importance of satisfactory preoperative radiological studies is stressed.

Conversion by new treatment modalities of nonresectable to resectable hepatocellular cancer.

Eleven patients with hepatocellular cancer had nonresectable lesions, ten as determined by laparotomy and one by computed tomographic (CT) evidence of inferior vena caval invasion. These patients were treated with a variety of new modalities, particularly radiolabeled antiferritin antibodies. Following treatment, seven of the 11 patients were considered to have converted their lesions to possible resectability. Six patients had complete resections, and one patient was partially resected. All patients had the common features of either nodular massive or nodular multifocal hepatocellular cancer. Relative to the patient's initial status, the quality of life remains high, and a new approach in the treatment of the nodular form of nonresectable hepatoma has been demonstrated. The present rate of such conversion to resectability is unknown. However, with further advances in radiolabeled antibody therapy, these results offer a new opportunity in the management of hepatocellular cancer.

Surface coil MR imaging of abdominal viscera. Part II. The adrenal glands.

Magnetic resonance (MR) imaging of the adrenal glands with a prototype surface coil was compared with conventional body coil images in five healthy volunteers and 15 patients with adrenal disease. The spectrum of abnormalities included five nonfunctioning cortical adenomas, of which two were in hyperplastic glands, four adrenal metastases, three pheochromocytomas, a functioning adenoma, a myelolipoma, and a partially calcified, cystic adrenal mass. In both body and surface coil images, anatomic detail was superior on T1-weighted images compared with T2-weighted images obtained with identical imaging time because of decreased motion artifact and superior contrast. In the T1-weighted studies, high-resolution surface coil images showed a threefold improvement in signal-to-noise ratio (SNR) over body coil images, which was manifest by better intrinsic resolution of small adrenal lesions and clearer definition of the extrinsic relationships of large masses to nearby organs. In addition, inferior vena caval invasion by two right adrenal metastases was better demonstrated using the surface coil than body coil MR or computed tomography (CT). Limitations of surface coil imaging include restriction in the field of view to a single gland and additional time required for patient positioning. Since the sensitivity of surface coils diminishes with depth, gains in SNR were limited in large patients with deeper adrenal glands. Despite these limitations, dramatic improvements in SNR and anatomic resolution indicate that surface coil MR imaging will be competitive with CT for examining the adrenal glands.

Tumor invasion of the upper inferior vena cava: The use of profound hypothermia and circulation arrest as a surgical adjunct

Two children presented with abdominal tumors invading the upper inferior vena cava. To facilitate removal of the tumors, cardiopulmonary bypass with profound hypothermia and circulation arrest were utilized. This technique simplifies tumor excision and is worthwhile even in children with advanced malignant disease.