Venous Thrombus Research Articles

The Significant Role of Tumor Volume on the Surgical Approach Choice, Surgical Complexity, and Postoperative Complications in Renal Cell Carcinoma With Venous Tumor Thrombus From a Large Chinese Center Experience.

ObjectiveTo explore the role of tumor volume (TV) on surgical approach choice, surgical complexity, and postoperative complications in patients with renal cell carcinoma (RCC) and inferior vena cava tumor thrombus.MethodFrom January 2014 to January 2020, we retrospectively analyzed the clinical data of 132 patients who underwent radical nephrectomy with inferior vena cava thrombectomy (RN-IVCT). Primary renal tumor volume (PRTV), renal vein tumor thrombus volume (RVTTV), inferior vena cava tumor thrombus volume (IVCTTV), and total tumor thrombus volume (TTTV) were measured with the help of an internationally recognized 3D volume measurement software. The patients were divided into three groups according to the tumor volume within the inferior vena cava (IVC). Group 1 included 48 patients with IVCTTV between 0 and 15 cm3 (36.6%), group 2 included 38 patients with IVCTTV between 16 and 30 cm3 (28%), and group 3 included 46 patients with IVCTTV above 30 cm3 (35%). The three IVCTTV groups, as well as four different volume groups, were compared in terms of surgical approach choice, surgical complexity, and postoperative complications. One-way ANOVA and a non-parametric test were used to compare the clinicopathological characteristics and distribution differences between the three groups.ResultThis study found significant differences among the three groups in the proportion of open surgery (P < 0.001), operation time (P < 0.044), intraoperative bleeding (P < 0.001), and postoperative complications (P < 0.001). When the four different volumes were compared, we found that for higher volumes IVCTTV and TTTV, open surgery is used more often compared with laparoscopic surgery (P < 0.001). In addition, with the increase in renal vein tumor thrombus volume, inferior vena cava tumor thrombus volume, and total tumor thrombus volume, the operation time also increased. Finally, with the increase in tumor thrombus volume and total tumor thrombus volume, the amount of intraoperative bleeding increased.ConclusionWith the increase in tumor volume, the proportion of open surgery and the incidence of postoperative complications increased. In addition, larger tumor volume prolongs operation time, increases intraoperative blood loss, and makes the surgery more complicated.

Histopathological findings of umbilical cord in intrauterine growth restriction

Background: Intrauterine growth restriction is one of the causes of perinatal mortality and morbidity. Intrauterine growth of fetus depends on maternal, fetal and genetic factors. Aim of the study was to find the histopathology of umbilical cord in IUGR and normal pregnancies. Materials &amp; methods: This prospective case control study included 100 umbilical cord samples which were equally distributed as cases and control. Routine histological procedures were followed for staining of tissue. Histopathology readings were photographed and noted. Results: In our study we found 24 % Wharton’s jelly oedema and 28 % venous dilatations in IUGR. We didn’t observe any thrombus, fibrinoid necrosis, perivascular or intraparietal hemorrhage, arterial or venous thrombus in our study both in cases and control. Conclusion: Umbilical cord and placental histopathology provides insight to predict reoccurrence of IUGR and for timely management.

Fibrinogen and Factor XIII in Venous Thrombosis and Thrombus Stability.

As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombosis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.

Acute Pulmonary Embolism in COVID-19: A Potential Connection between Venous Congestion and Thrombus Distribution.

Background: Vascular abnormalities, including venous congestion (VC) and pulmonary embolism (PE), have been recognized as frequent COVID-19 imaging patterns and proposed as severity markers. However, the underlying pathophysiological mechanisms remain unclear. In this study, we aimed to characterize the relationship between VC, PE distribution, and alveolar opacities (AO). Methods: This multicenter observational registry (clinicaltrials.gov identifier NCT04824313) included 268 patients diagnosed with SARS-CoV-2 infection and subjected to contrast-enhanced CT between March and June 2020. Acute PE was diagnosed in 61 (22.8%) patients, including 17 females (27.9%), at a mean age of 61.7 ± 14.2 years. Demographic, laboratory, and outcome data were retrieved. We analyzed CT images at the segmental level regarding VC (qualitatively and quantitatively [diameter]), AO (semi-quantitatively as absent, <50%, or >50% involvement), clot location, and distribution related to VC and AO. Segments with vs. without PE were compared. Results: Out of 411 emboli, 82 (20%) were lobar or more proximal and 329 (80%) were segmental or subsegmental. Venous diameters were significantly higher in segments with AO (p = 0.031), unlike arteries (p = 0.138). At the segmental level, 77% of emboli were associated with VC. Overall, PE occurred in 28.2% of segments with AO vs. 21.8% without (p = 0.047). In the absence of VC, however, AO did not affect PE rates (p = 0.94). Conclusions: Vascular changes predominantly affected veins, and most PEs were located in segments with VC. In the absence of VC, AOs were not associated with the PE rate. VC might result from increased flow supported by the hypothesis of pulmonary arteriovenous anastomosis dysregulation as a relevant contributing factor.

Characterization of tumor thrombus in renal cell carcinoma with prostate specific membrane antigen (PSMA) positron emission tomography (PET)/computed tomography (CT).

Venous tumor thrombus (TT) occurs as part of the natural history of renal cell carcinoma (RCC) local progression in a small minority of cases. MRI is currently the most accurate imaging modality for determining TT extent. PSMA PET/CT may improve RCC staging and IVC TT characterization. The objective of this study was to investigate the role of PSMA PET/CT in defining superior extent of TT in RCC and TT IVC tributary vessel spread, with comparative accuracy vs. MRI, to assess suitability for resection and inform preoperative surgical planning. Patients who underwent PSMA PET/CT for assessment of renal malignancy with TT from 2015 to 2020 at 3 tertiary hospitals in Brisbane, Australia, were retrospectively identified. TT extent was classified using Mayo Clinic levels and compared according to imaging modality. Fourteen patients were included, all of which were clear cell RCC. Ten patients also underwent MRI, 6 of which were concordant in extent according to MRI and PSMA PET. Discordant extent occurred in 4 patients, of which 2 patients had non-PSMA avid thrombus (Mayo level 0 and level 3 on MRI). Further discordance was seen in a patient with adrenal vein and lumbar vein TT only seen on MRI and PSMA PET/CT, respectively. Finally, discordant extent was seen in another patient with Mayo level 4 TT without lumbar vein involvement on MRI vs. level 3 on PSMA PET/CT with lumbar vein involvement. PSMA PET/CT can provide additional information about TT extent in RCC which may not be seen on MRI. Additional information from PSMA PET/CT in this setting may assist surgical planning, in addition to detection of metastatic disease.

Real‐world staging computed tomography scanning technique and important reporting discrepancies in pancreatic ductal adenocarcinoma

BackgroundComputed tomography (CT) is the first‐line staging imaging modality for pancreatic ductal adenocarcinoma (PDAC) which determines resectability and treatment pathways.MethodsBetween January 2016 and December 2019, prospectively collated data from two Australian cancer centres was extracted from the PURPLE Pancreatic Cancer registry. Real‐world staging CTs and corresponding reports were blindly reviewed by a sub‐specialist radiologist and compared to initial reports.ResultsOf 131 patients assessed, 117 (89.3%) presented with symptoms, 74 (56.5%) CTs included slices ≤3 mm thickness and CT pancreas protocol was applied in 69 (52.7%) patients. Initial reports lacked synoptic reporting in 131 (100%), tumour identification in 2 (1.6%) and tumour measurement in 13 (9.9%) cases. Tumour‐vascular relationship reporting was missing in 69–109 (52.7–83.2%) for regarding the key arterial and venous structures that is required to assess resectability. Initial reports had no comment on venous thrombus or venous collaterals in 80 (61.1%) and 109 (83.2%) and lacked locoregional lymphadenopathy interpretation in 13 (9.9%) cases. Complete initial staging report was present in 72 (55.0%) patients. Sub‐specialist radiological review resulted in down‐staging in 16 (22.2%) and up‐staging in 1 (1.4%) patient. Staging discrepancies were mainly regarding metastatic disease (12, 70.6%) and tumour‐vascular relationship (5, 29.4%).ConclusionReal‐world staging imaging in PDAC patients show low proportion of dedicated CT pancreas protocol, high proportion of incomplete staging reports and no synoptic reporting. The most common discrepancy between initial and sub‐specialist reporting was regarding metastases and tumour‐vascular relationship assessment resulting in sub‐specialist down‐staging in almost every fifth case.

Deep vein thrombosis and pulmonary embolism after heart transplantation.

Venous thromboembolism (VTE), such as deep vein thrombosis (DVT) and pulmonary embolism (PE), is an important and serious postoperative complication after heart transplantation. We sought to characterize in-hospital VTE after heart transplantation and its association with clinical outcomes. Adult (≧18 years) patients undergoing heart transplantation from 2015 to 2019 at our center were retrospectively reviewed. Post-transplant VTE was defined as newly diagnosed venous system thrombus by imaging studies. There were 254 patients. The cohort's median age was 55 years. A total of 61 patients were diagnosed with VTE, including one with right atrial thrombus, 54 with upper extremity DVT in which one patient subsequently developed PE, four with lower extremity DVT, and two with upper and lower extremity DVT. The cumulative incidence of VTE was 42% at 60-days of post heart transplant. Patients with VTE had longer hospital stay (P<.001), higher in-hospital mortality (P=.010), and worse 5-year survival (P=.009). On the multivariable Cox analysis, history of DVT/PE and intubation for more than 3 days were associated with an increased risk of in hospital VTE. The incidence of VTE in heart transplant recipients is high. Post-transplant surveillance, and appropriate preventive measures and treatment strategies after diagnosis are warranted.

Clinical Experience and Management Strategy of Retroperitoneal Tumor With Venous Tumor Thrombus Involvement.

BackgroundThis study aims to report the surgical management, complications, and outcomes for patients with retroperitoneal tumor and venous thrombus.MethodsWe retrospectively analyzed 19 cases of retroperitoneal tumor with venous tumor thrombus from August 2015 to March 2021. A new tumor thrombus PUTH-RT grading system was proposed on the basis of the characteristics of the surgical techniques.ResultsTwo cases of PUTH-RT-1a, two cases of PUTH-RT-1b, six cases of PUTH-RT-2, six cases of PUTH-RT-3, and three cases of PUTH-RT-4 were included. Surgeries were successfully performed in all 19 patients. Among them, five cases (26.3%) were operated via a completely laparoscopic approach and 13 cases (68.4%) via an open approach. One case (5.3%) was converted from laparoscopic to open approach. Five cases (26.3%) experienced postoperative complications. All patients were followed for a median of 14 months. Cancer-associated death occurred in three cases. Distant metastases occurred in seven cases.ConclusionsWe propose a new tumor thrombus grading system based on the anatomical characteristics of retroperitoneal tumors with venous tumor thrombus. Retroperitoneal tumor resection and removal of venous tumor thrombi are safe and effective for the treatment of such diseases.

Evaluation of PD-L1 (E1L3N, 22C3) expression in venous tumor thrombus is superior to its assessment in renal tumor in predicting overall survival in renal cell carcinoma.

Renal cell carcinoma (RCC) frequently invades renal vein forming neoplastic thrombus. The expression of immune checkpoint receptors in RCC was addressed in multiple studies, but little is known about the expression and prognostic significance of programmed death ligand-1 in tumor thrombus. The study aimed to evaluate the expression of PD-L1 within venous tumor thrombus and primary tumor using 2 independent antibody clones (22c3 and E1L3N) and to assess its value in predicting overall survival (OS) in the subgroup of patients with RCC and renal vein thrombus. Eighty-two patients with RCC and venous tumor thrombus that underwent nephrectomy were enrolled. The expression of PD-L1 was assessed utilizing tissue microarrays separately on tumor cells (TCs) and tumor-infiltrating lymphocytes (TILs). The frequency of PD-L1 expression on TCs and TILs varied between tumor and thrombus compartments and was dependent on the antibody clone used. The expression of PD-L1 on TCs and/or TILs was associated with worse OS irrespectively of the antibody and the analyzed compartment. Nevertheless, the best prognostic performance was noted for the combined assessment of PD-L1 expression on TCs and TILs in venous tumor thrombus with the use of 22c3 antibody. The multivariable Cox regression model predicting OS incorporated PD-L1 22c3 in venous tumor thrombus (hazards ratio [HR] = 3.64, 95% confidence interval [CI] = 1.63-8.14, P = 0.002) and nodal status (HR = 2.88, 95% CI = 1.18-7.03, P = 0.02). PD-L1 may become a valuable tool for prognostic purposes in this specific subgroup of patients and be incorporated into the respective models qualifying for adjuvant treatment.

MP50-06 RADICAL NEPHRECTOMY AND CAVAL THROMBECTOMY WITH HEART BEATING TECHNIQUE FOR RENAL CELL CANCER WITH TUMOR THROMBUS EXTENSION INTO INFERIOR VENA CAVA AND RIGHT ATRIUM: A LESS INVASIVE MULTIDISCIPLINARY APPROACH

You have accessJournal of UrologyCME1 May 2022MP50-06 RADICAL NEPHRECTOMY AND CAVAL THROMBECTOMY WITH HEART BEATING TECHNIQUE FOR RENAL CELL CANCER WITH TUMOR THROMBUS EXTENSION INTO INFERIOR VENA CAVA AND RIGHT ATRIUM: A LESS INVASIVE MULTIDISCIPLINARY APPROACH Sonia Guzzo, Sebastiano Nazzani, Chiara Vaccaro, Roberto Di Benedetto, Claudia Signorini, Damiano Vizziello, Andrea Conti, Elisabetta Finkelberg, Giacomo Bortolussi, Pietro Acquati, Carlo De Vincentiis, and Luca Carmignani Sonia GuzzoSonia Guzzo More articles by this author , Sebastiano NazzaniSebastiano Nazzani More articles by this author , Chiara VaccaroChiara Vaccaro More articles by this author , Roberto Di BenedettoRoberto Di Benedetto More articles by this author , Claudia SignoriniClaudia Signorini More articles by this author , Damiano VizzielloDamiano Vizziello More articles by this author , Andrea ContiAndrea Conti More articles by this author , Elisabetta FinkelbergElisabetta Finkelberg More articles by this author , Giacomo BortolussiGiacomo Bortolussi More articles by this author , Pietro AcquatiPietro Acquati More articles by this author , Carlo De VincentiisCarlo De Vincentiis More articles by this author , and Luca CarmignaniLuca Carmignani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002625.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical nephrectomy with inferior vena cava thrombectomy for renal cell carcinomas (RCCs) with Mayo levels III and IV thrombus is considered one of the most challenging urological procedures. Serious intraoperative complications, such as bleeding and embolism may occur. In this setting, extracorporeal circulation and deep hypothermic circulatory arrest has become the gold standard treatment for Mayo levels III and IV RCC. The latter involves full heparinization, coagulopathy secondary to hypothermia and long operative time. Hence, we describe a less invasive operative strategy aimed at minimizing the complication rate associated with treatment of tumour thrombus at Mayo level III and IV. METHODS: Between 2016 and 2020, 12 patients diagnosed with Renal Cell Cancer and extended venous tumour thrombus were treated with radical nephrectomy and thrombectomy at our Institution. Among them, 5 had supradiaphragmatic extension (Mayo level IV) seeking a complex and multidisciplinary surgical approach. Therefore, a coordinated thoracic and abdominal procedure was performed between urological and cardiosurgical teams. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for thrombus retrieval from the right atrium. On the other hand, Mayo level III only needed abdominal access. Perioperative complication and mortality rates within 30 and 90 days of surgery were recorded. RESULTS: Of 12 patients 5 were male (41.7%) and 7 were female (58.3%). Median age was 70,5 years [Interquartile Range (IQR): 6,1]. Median BMI was 26,6 (IQR:20,8-28). ASA score was 2 in 4 (33.3%) and 3 in 8 (66.6%). According to tumour characteristics, cT stage was cT3b in 3 (25%), cT3c in 5 (41,7%) and cT4 in 4 (33,3%). cN stage was cN0 in 9 (75%) and cN+ in 3 (25%). Finally, 4 patients (33,3%) had metastatic disease. Median surgical time was 240 minutes (IQR:210-281). Median CPB time was 40 minutes (IQR:40-48). Median blood loss was 1500 mL (IQR:1200-2500). Median intensive care stay was 2 days (IQR:1-3) and median duration of hospitalization was 10,5 (IQR: 8-15,3). No patients died during the procedure. Overall 50% of patients had postoperative complications. Specifically, 4 (33,3%) patients had Grade II surgical complications, according to the Clavien-Dindo classification, 1 (8,3%) had Grade IIIb and 1 (8,3%) Grade IV. All patients were discharged home or for rehabilitation. At final pathology pT stage was pT3b in 5 (41,7%), pT3c in 6 (50%) and pT4 in 1 (8,3%). CONCLUSIONS: The use of beating heart on simplified CPB is a less invasive method for radical resection of renal cell carcinomas with intracardiac tumour extension, while extended intracaval tumour thrombus, as Mayo level III, can still be treated exclusively with abdominal approach. Source of Funding: None.Encore presentation at EAU21 Congress © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e866 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sonia Guzzo More articles by this author Sebastiano Nazzani More articles by this author Chiara Vaccaro More articles by this author Roberto Di Benedetto More articles by this author Claudia Signorini More articles by this author Damiano Vizziello More articles by this author Andrea Conti More articles by this author Elisabetta Finkelberg More articles by this author Giacomo Bortolussi More articles by this author Pietro Acquati More articles by this author Carlo De Vincentiis More articles by this author Luca Carmignani More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP47-14 THE ROLE OF COMBINED SARCOPENIA AND ALBUMIN IN THE SURGICAL PROGNOSTICATION OF LOCALLY ADVANCED RENAL CELL CARCINOMA WITH VENOUS TUMOR THROMBUS

You have accessJournal of UrologyCME1 May 2022MP47-14 THE ROLE OF COMBINED SARCOPENIA AND ALBUMIN IN THE SURGICAL PROGNOSTICATION OF LOCALLY ADVANCED RENAL CELL CARCINOMA WITH VENOUS TUMOR THROMBUS Eric Midenberg, Dattatraya Patil, Alexandra Medline, Michelle Higgins, Milton Williams, Sarah P. Psutka, Kenneth Ogan, Mehmet A. Bilen, and Viraj A. Master Eric MidenbergEric Midenberg More articles by this author , Dattatraya PatilDattatraya Patil More articles by this author , Alexandra MedlineAlexandra Medline More articles by this author , Michelle HigginsMichelle Higgins More articles by this author , Milton WilliamsMilton Williams More articles by this author , Sarah P. PsutkaSarah P. Psutka More articles by this author , Kenneth OganKenneth Ogan More articles by this author , Mehmet A. BilenMehmet A. Bilen More articles by this author , and Viraj A. MasterViraj A. Master More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002618.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Baseline evaluation of skeletal muscle index (SMI; cm2/m2) and serum albumin have demonstrated value in the preoperative risk assessment of patients with renal cell carcinoma (RCC). We hypothesize that sarcopenia, defined as a critical deficiency in skeletal muscle mass, and hypoalbuminemia will be associated with decreased overall survival (OS) and cancer specific survival (CSS) in nonmetastatic RCC patients undergoing radical nephrectomy and tumor thrombectomy. METHODS: We retrospectively analyzed 103 nonmetastatic RCC patients who underwent radical nephrectomy and tumor thrombectomy from 2005 to 2020. Optimally fit body mass index (BMI; kg/m2) and sex-stratified sarcopenia thresholds were calculated: BMI<30, SMI <47 for males and SMI <38 for females; BMI≥30, SMI<54 for males and SMI <47 for females. Sarcopenia and albumin risk groups were created based on their individual hazard ratios in univariable analysis and defined as low-risk (non-sarcopenic, normal albumin), medium-risk (hypoalbuminemia only), high-risk (sarcopenia only), and very high-risk (sarcopenia, hypoalbuminemia). Multivariable and Kaplan-Meier analyses were used to determine associations between independent and combined sarcopenia and hypoalbuminemia (albumin <3.5 g/dL) with OS and CSS. RESULTS: Preoperatively, 51.2% and 44.7% of our cohort had sarcopenia and hypoalbuminemia, respectively. In the independent multivariable analysis, sarcopenia was significantly associated with decreased OS (p=0.003) and CSS (p=0.006) whereas no relationship between hypoalbuminemia and OS and CSS was found (OS: p=0.096; CSS: p=0.718). In a separate model analyzing the combined sarcopenia and albumin risk groups, the high and very high-risk groups were significantly associated with decreased OS (high-risk: p=0.011; very high-risk: p <0.001) and CSS (high-risk: p=0.011; very high-risk: p=0.017). Kaplan-Meier curves showed a stepwise decline in median OS (p=0.007) and CSS (p=0.007) times with increasing risk. CONCLUSIONS: Simultaneous preoperative sarcopenia and hypoalbuminemia conveyed nearly a seven-fold decrease in OS and CSS in patients undergoing surgery for nonmetastatic RCC with venous tumor thrombus. Source of Funding: N/A © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e815 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Eric Midenberg More articles by this author Dattatraya Patil More articles by this author Alexandra Medline More articles by this author Michelle Higgins More articles by this author Milton Williams More articles by this author Sarah P. Psutka More articles by this author Kenneth Ogan More articles by this author Mehmet A. Bilen More articles by this author Viraj A. Master More articles by this author Expand All Advertisement PDF DownloadLoading ...

V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH

You have accessJournal of UrologyCME1 May 2022V13-09 TRICUSPID INSUFFICIENCY CAUSED BY RENAL ANGIOMYOLIPOMA WITH EXTENSION TO THE INFERIOR VENA CAVA AND RIGHT ATRIUM. A MULTIDISCIPLINARY APPROACH Ruben Santiago, Omar Vieyra, Rodrigo Perez, Victor Osornio, Gerardo Garza, Roberto Lopez, and Mario Ortega Ruben SantiagoRuben Santiago More articles by this author , Omar VieyraOmar Vieyra More articles by this author , Rodrigo PerezRodrigo Perez More articles by this author , Victor OsornioVictor Osornio More articles by this author , Gerardo GarzaGerardo Garza More articles by this author , Roberto LopezRoberto Lopez More articles by this author , and Mario OrtegaMario Ortega More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Renal angiomyolipoma (AML) is a mesenchymal tumor benign composed by vascular, smooth muscle and adipose tissue. There are two types of AMLs: The classic variant is the most common and is characterized by thick walled vessels, spindle smooth-muscle-like cells and adipose tissue. The epithelioid variant has an epithelial cell component to it with minimal adipose tissue and has the potential to undergo malignant transformation. The objective of this video is presented the multidisciplinary approach from surgical technique to medical intensive care during and after the surgery. METHODS: A 44-year-old woman was referred by his primary care physician with symptoms characterized by shortness of breath, tachycardia, intermittent hematuria and right lumbar pain. Physical examination with holosystolic murmur. Computerized tomography (CT) scan demonstrated a 6.1x5.1cm right renal tumor, the attenuation was - 83 Hounsfield Units (HU) with tumor thrombus invasion into the inferior vena cava, which extended from renal vein ostium to right atrium. Magnetic resonance imaging (MRI) showed non-infiltration of the vena cava wall. Echocardiogram presented systolic protrusion of the thrombus towards the right ventricle, developing moderate tricuspid regurgitation. RESULTS: With multidisciplinary management (Urology, cardiology, cardiothoracic surgery, perfusionists and intensive care therapy) were performed an open right radical nephrectomy, sternotomy, cavotomy with extraction of intra-atrial thrombus and primary cavorrhaphy. With support of cellular recuperator and extracorporeal circulation pump (pump time 100 min) trans-surgical transfusions were: 3 erythrocyte concentrates, 2 fresh frozen plasmas and 1 platelet apheresis. Surgical time was 380 min. During the surgery a real-time transesophageal echocardiogram was used. Bleeding was 2500 ml and no intraoperative complications were reported. Hospital stay of 20 days, discharged without complications with serum creatinine 1.0 mg / dl and hemoglobin 11.5 g / dl. Pathology report was renal classic AML, size 8.0x6.0x4.0cm, immunohistochemistry: HMB45 (+) and smooth muscle actin (+). CONCLUSIONS: This is a rare case of a classic AML presenting with a venous tumor thrombus involving the inferior vena cava from renal vein ostium to right atrium. Radical nephrectomy with tumor thrombectomy is the most widely accepted surgical treatment following established vascular principles of venous tumor thrombectomy. Source of Funding: Non Disclousure © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1033 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ruben Santiago More articles by this author Omar Vieyra More articles by this author Rodrigo Perez More articles by this author Victor Osornio More articles by this author Gerardo Garza More articles by this author Roberto Lopez More articles by this author Mario Ortega More articles by this author Expand All Advertisement PDF DownloadLoading ...

Abstract 310: MRI Characterization Of Thrombus For Differentiating Acute And Chronic Dvt

Background: Optimal patient selection for the endovascular treatment of iliofemoral DVTs remains a significant clinical challenge. 2 Symptom onset is used as a gross surrogate for determining the composition of the clot to determine if it is amenable to endovascular treatment. As thrombus ages, collagen deposition increases, and the bulk of fibrin within the thrombus becomes crosslinked and resistant to lysis 3 . Symptom onset has poor correlation with collagen content 4 and is not a predictor of endovascular success. The goal of this study is to relate MRI characteristics to clot composition to guide patient selection for endovascular treatment of iliofemoral DVT in the future. 5 Methods: 2 patients with popliteal deep venous thrombus that presented within a week of symptom onset underwent Inari thrombectomy. Patient 1 was imaged in the 7T MRI and patient 2 was imaged with 3T Both patients had T2-weighted (T2W) and UTE sequences. Results: Patient 1 had a thrombus with high collagen content indicated by low signal intensity on T2W imaging and high signal intensity on UTE MRI. The extracted clot had gross chronic characteristics and was extremely challenging to extract despite multiple passes. Patient 2 had a thrombus with low collagen content indicated by low signal intensity on T2W imaging and isointense on ultrashort echo time imaging. The clot had acute gross characteristics and was easy to extract. Conclusion: Symptom onset is not always reflective of the composition of deep venous thrombus. MRI characterization of thrombus can aid patient selection for endovascular treatment by differentiating patients with high and low collagen content.

Metachronous isolated inferior vena cava tumour thrombus in renal cell cancer: a rare aftermath.

Renal cell cancer (RCC) accounts for 3% of all solid malignancies. Synchronous tumour thrombus in the renal vein or inferior vena cava is reported in 4-10% cases and is a surgical challenge. Contemporary imaging modalities that are used to define the presence and extent of venous thrombus include colour Doppler, contrast-enhanced computed tomography and magnetic resonance venography. Surgical management depends upon the degree of tumour thrombus. We report isolated recurrence of RCC in the inferior vena cava 2 years after radical nephrectomy, and discuss its pathophysiology and management.

Abstract 157: Role Of Systemic Platelet Levels In Venous Thrombosis And Resolution In A Murine Model Of Inferior Vena Cava Constriction

Background: Platelet role in primary clot formation in response to vessel wall injury is well established; however, the role of systemic platelet levels in deep vein thrombosis (DVT) and its sequelae is unclear. Their interaction with the venous endothelium under low shear stress, regulation of thrombosis, and mediation of both innate and adaptive immune responses through selectin and toll-like receptor expression, respectively, warrants further investigation into their role in DVT formation and resolution. In this study, we present a role for systemic platelet levels in regulating thrombus resolution. Methods: Wildtype, male or female CD1 mice were treated with a thrombopoietin antisense oligonucleotide (TPO-ASO) at 10 mg/kg, eltrombopag at 75 mg/ kg, saline (control), or a scrambled TPO-ASO (control) at 8 mg/ kg prior to surgical creation of a venous thrombus by ligation of the infra-renal inferior vena cava (IVC). Peak scaled thrombus weights (i.e., linear density measured using a ratio of the clot and IVC weight scaled to the length of the IVC) were measured to characterize the early resolution of the thrombus through involution and recanalization. Mice were euthanized on postoperative days 3 and 7 to measure the formation and resolution of the thrombus, respectively. Results: Platelet levels were elevated and decreased by over 30% by the day of surgical treatment after TPO-ASO and eltrombopag treatments, respectively. Scaled thrombus weights were significantly different (p = 0.045, Kruskal Wallis) between groups on day 7 after IVC constriction. Post-hoc analysis (Dunn Test with Benjamini-Hochberg correction) revealed that the TPO-ASO group (mean = 25.4 +/- 0.9 mg/cm) had significantly decreased (p = 0.018) scaled thrombus weights compared to the mice treated with eltrombopag (mean = 35.3 +/- 6.5 mg/cm) on day 7. Thrombus formation on day 3 was not statistically different between treatment groups. Conclusion: Achieving a minimum threshold of 30% reduction of systemic platelet levels by TPO-ASO enhanced thrombus resolution, but not thrombus formation, in our stasis model of rodent DVT resolution. These data suggest a potential role for systemic platelet levels in regulating thrombus resolution.

Nomogram for predicting survival of renal cell carcinoma with tumor thrombus based on perioperative clinicopathological factors from a Chinese high-volume center.

To investigate perioperative clinicopathological predictors and establish a predictive nomogram for survival in patients with renal cell carcinoma and venous tumor thrombus undergoing nephrectomy and thrombectomy. Patients with renal cell carcinoma and venous tumor thrombus undergoing nephrectomy and thrombectomy were included in the study between January 2014 and June 2020. Cox regression analysis was used for univariate and multivariate survival analyses. A predictive nomogram for survival was established and internally validated using bootstrap resampling method. A total of 228 patients were enrolled in this study. The median age was 60 years (interquartile range 53-66 years), consisting of 174 (76.3%) males and 54 (23.7%) females. The median follow-up time was 17.5 months (range 1-74 months), 26.8% (61 of 228) patients died of all causes. In multivariable analysis, hemoglobin less than the lower limit of normal (hazard ratio 1.73; 95% confidence interval 1.01-2.96; P = 0.045), sarcomatoid feature (hazard ratio 3.67; 95% confidence interval 1.97-6.82; P < 0.001), perirenal fat invasion (hazard ratio 1.80; 95% confidence interval 1.05-3.09; P = 0.033), histological subtype (hazard ratio 2.74; 95% confidence interval 1.39-5.41; P = 0.004), and metastasis at surgery (hazard ratio 1.71; 95% confidence interval 1.01-2.90; P = 0.047) were independently associated with overall survival. The result of internal validation presented that the predictive performance of the nomogram for survival measured by C-index was 0.77. We developed a predictive nomogram with well-internal validation for survival in patients with renal cell carcinoma and venous tumor thrombus, which can greatly promote risk stratification and treatment planning.

Lumbar Artery Perforator Flaps: A Systematic Review of Free Tissue Transfers and Anatomical Characteristics.

The lumbar artery perforator (LAP) flap has gained popularity as a versatile flap in reconstructive surgery; however, few studies have analyzed salient characteristics of this flap. We set out to provide a comprehensive appraisal of free tissue transfers of LAP flaps with specific attention to anatomic features and clinical outcomes. Using preferred reporting items for systematic reviews and meta-analyses guidelines, we identified clinical, radiographic, and cadaveric studies of LAP flaps and assessed outcomes, complications, and anatomic parameters, such as pedicle length, diameter, location, and course. A total of 254 articles were initially reviewed, of which 18 met the final inclusion criteria. Ten studies were primarily concerned with anatomic characteristics, and most clinical studies related to breast reconstruction. The operative durations varied between 4.8 and 9.2 hours. Partial and total flap losses were estimated at 2.6% and 7.6%, respectively. Acute revision rates ranged from 16% to 24% related to hematoma, arterial thrombus, and venous thrombus. Donor-site seromas were frequently encountered in breast reconstruction with an incidence of 17% to 78%. The LAP flap has demonstrated favorable outcomes in various reconstructive scenarios. The caudal perforators generally offer more pedicle length, greater pedicle diameter, and septocutaneous course and may be better suited for flap design. For breast reconstruction, the LAP flap is a useful alternative to abdominal-based flaps, and special attention should be given to optimizing pedicle length using interposition grafts and methods that minimize seroma formation at the donor site.

Thromboembolic Events Burden in Patients With Solid Tumors and Their Predisposing Factors.

Introduction: The relationship between cancers and thromboembolic events is well established. In our study, we aim to determine the burden of thromboembolic events in patients with solid tumors and identify the risk factors related to their development.Materials & Methods: Data on patients with solid tumors and thromboembolism between January 2013 and September 2014 were collected and analyzed.Results: During the study period 174 patients were identified. Of which, 172 (98.9%) had venous thrombus embolism, 137 (79%) were diagnosed with deep vein thromboses, 67 (38.5%) with pulmonary embolism, 84 (48.3%) were symptomatic and 90 (51.7) were incidental at diagnosis. The most common patients and disease characteristics were female sex, high body mass index (BMI), metastatic stage, colorectal and breast primaries, and anti-neoplastic therapy.Conclusion: Our study confirmed the high burden of thromboembolic events in cancer patients and the relevant factors associated with its development.

Acute Limb Ischemia Caused by Embolus of Primary Lung Cancer Complicating Trousseau's Syndrome.

Limb ischemia caused by tumor embolus is rare. In this study, we report the case of a 77-year-old woman who suffered from acute ischemic limb. Computed tomography showed a tumor in the right bronchus invading the left atrium. The tumor fragments scattered resulting in the occlusion of the right iliac artery. The excluded embolus was revealed as a squamous cell carcinoma. Regarding the popliteal venous thrombus, Trousseau’s syndrome was complicated. The patient was discharged without any complications. We believe that advanced lung cancer is a differential diagnosis of acute ischemic limbs and that successful limb rescue contributed to a patient’s quality of life.

A Nomogram Predicting the Progression-Free Survival of Nonmetastatic Renal Cell Carcinoma Patients With Venous Thrombus After Surgery.

ObjectivesTo demonstrate the progression-free survival (PFS) of nonmetastatic renal cell carcinoma (RCC) patients with venous thrombus after radical nephrectomy and venous thrombectomy (RN-VT) and to develop and validate a nomogram to predict the PFS of patients after RN-VT.Materials and MethodsWe reported our prospective follow-up data of RCC patients with venous thrombus from January 2014 to September 2020 (n = 199). We used the Kaplan–Meier method to assess the PFS. The Cox proportional hazards regression model was used to determine the predictors. Nomograms predicting the PFS was established, and external validation was performed. Calibration curves and decision curves were generated to assess the predictive efficacy and clinical benefit.ResultsAfter a median follow-up of 32 months, 79 patients (39.7%) had disease progression and the median PFS was 41.0 months (95% CI 34.8–53.2 months). The 1-year, 3-year, and 5-year PFS rates were 78.4%, 45.4%, and 30.0%, respectively. Multivariate analysis showed that Fuhrman grade [grade 4: hazard ratio (HR) 1.92, 95% CI 1.10–3.34, P = 0.02], pathological type (papillary RCC: HR 3.02, 95% CI 1.79–5.10, P < 0.001), perinephric fat invasion (HR 1.54, 95% CI 1.12–2.10, P = 0.007), sarcomatoid differentiation (HR 2.97, 95% CI 1.24–7.13, P = 0.02) were associated with a worse PFS, and adjuvant therapy (HR 0.32, 95% CI 0.18–0.59, P < 0.001) could lead to a better PFS. A nomogram based on the predictors was externally validated to have good discrimination and calibration, and it could improve PFS prediction to obtain a clinical benefit.ConclusionsWe constructed and validated a nomogram to predict the 1-year, 3-year, and 5-year PFS of M0 RCC patients with venous thrombus after surgery. The model can help identify patients who can benefit the most from surgery and develop the criteria for clinical trial enrollment.