Inferior vena caval thrombus associated with double neoplasms of the retroperitoneum and kidney: Report of a case

We report herein the case of a patient we recently encountered who was found to have a giant retroperitoneal tumor coincident with tumor thrombus in the inferior vena cava (IVC). On the assumption that the origin was retroperitoneal, the two lesions were resected using an intracaval filter. However, histopathological examination of the specimens revealed neurilemoma for the retroperitoneal tumor and adenocarcinoma for the tumor thrombus. A right renal tumor was subsequently detected, which led to right nephrectomy being performed en bloc with part of the IVC using a venoarterial bypass. Microscopy revealed carcinoma of the Bellini duct, or collecting duct, which is an extremely rare tumor. Retrospectively, a lesion with soft tissue density was noted in the renal vein. Surgical management focused on the prevention of pulmonary embolism. We describe this case because of its extreme rarity and its significance from the viewpoint of diagnosis and therapeutic strategies.     

Foley尿管在肾癌合并下腔静脉癌栓中的应用

目的探讨应用Foley尿管在肾癌合并下腔静脉癌栓肾癌根治术时取出癌栓的效果。方法2001年10月~2008年6月收治肾癌合并腔静脉癌栓患者15例,肾癌根治术术中应用Foley尿管取出癌栓11例,其中Ⅲ型癌栓5例,Ⅳ型癌栓6例。术中先游离肾脏及肾动、静脉,结扎肾动脉,游离出对侧肾静脉及癌栓上下的腔静脉并阻断,在患肾对侧的腔静脉壁纵行剪开3~4 cm,插入Foley尿管,气囊内注入20 mL生理盐水,用Foley尿管将癌栓牵出腔静脉外,取下患肾和癌栓,阻断腔静脉进行缝合。结果11例手术顺利,全部将癌栓完整取出,手术时间3~5 h,出血量200~1 000 mL。结论肾癌合并腔静脉癌栓在肾癌根治术中用Foley尿管取出癌栓可避免开胸或体外循环,减少手术损伤,疗效良好。     

肾癌伴Ⅳ级下腔静脉癌栓非体外循环辅助下的手术治疗

目的探讨肾癌伴Ⅳ级下腔静脉癌栓,在癌栓未进入右心房及未侵犯下腔静脉壁的情况下,非体外循环辅助下的手术治疗。方法对肾癌伴Ⅳ级下腔静脉癌栓患者6例,采取非体外循环辅助下实施标准的根治性肾切除和腔静脉癌栓取出术。结果手术均获得成功,未出现大出血及肺梗塞,术后肾功能正常。随访1例Ⅲ期T3CN1M0型术后16个月CT检查发现肺转移,术后18个月死亡。5例随访18个月,均未发现肿瘤复发和远处转移。结论肾癌伴Ⅳ级下腔静脉癌栓,采取非体外循环辅助下的手术治疗是安全可行的方法之一。     

Malignant pheochromocytoma with IVC thrombus

A 61-year-old man presented with feeling of bloating, remarkable sweating, and body weight loss. We diagnosed right pheochromocytoma with inferior vena cava (IVC) thrombus by some plasma and urine catecholamine and their metabolites data and imaging findings. The patient underwent right adrenalectomy and IVC thrombectomy without use of cardiopulmonary bypass. Pathological finding showed potentially malignant pheochromocytoma. After operation, his subjective symptom disappeared, and abnormal plasma and urine catecholamine and their metabolites data fell to normal range. It is very important to get preoperative information of the exact location of tumor thrombus for the safe surgical management of pheochromocytoma with IVC thrombus. Magnetic resonance imaging (MRI) and ultrasound imaging more useful for diagnosis of the exact location of IVC thrombus.     

Transitional cell carcinoma of the renal pelvis forming tumor thrombus in the vena cava

A 47-year-old man presented with a left renal incidentaloma without hematuria. The tumor was complicated by inferior vena cava (IVC) thrombus extending from Th11 to L4. A temporary IVC filter was introduced prior to surgery. A midline incision was used to perform a left radical nephrectomy and en bloc lymphadenectomy with excision of the inferior vena cava from above the level of the left renal vein to 2.5 cm above the confluence of the common iliac veins. The pathological diagnosis was invasive transitional cell carcinoma. The tumor thrombus consisted of transitional cell carcinoma that histologically invaded the walls of the IVC. He died of cancer 17 months after the operation for the liver metastases. This is the 18th case report of such a presentation in the literature.     

三维可视化重建技术在机器人辅助巨大嗜铬细胞瘤/副节瘤切除术中的应用价值(附11例报告)

目的:探讨三维可视化重建技术在机器人辅助腹腔镜下巨大嗜铬细胞瘤/副节瘤切除术中的应用价值。方法:回顾性分析2019年7月—2020年1月我院收治的11例嗜铬细胞瘤/副节瘤患者的临床资料。其中男5例,女6例,中位年龄44(21~68)岁;肿瘤最大径中位值7.1(6.2~10.2)cm;病变位于右肾上腺3例,左肾上腺5例,右肾门旁腔静脉后方2例,左肾门旁1例。术前所有患者均行CT增强扫描,并采集dicom数据通过VitaWorks重建技术完成三维可视化模型。借助模型,观察肿瘤大小、受累脏器以及术中可能干涉的组织器官和血管,模拟手术路径,指定三维可视化指导的手术方案。结果:利用VitaWorks技术得到了所有肿瘤的精细、完整的三维可视化模型,结合肿瘤大小、部位指定精准手术方案。8例行机器人辅助经腹径路腹腔镜嗜铬细胞瘤切除术;2例行机器人辅助经腹径路腹腔镜副节瘤切除术;1例行机器人辅助经腹腹腔镜左肾上腺嗜铬细胞瘤切除术加左肾切除术。所有手术均顺利完成,无术中转开放。结论:基于CT增强扫描检查的三维可视化重建技术在机器人辅助腹腔镜下巨大嗜铬细胞瘤/副节瘤切除术方面具有应用价值,帮助术者制订精准的个体化手术方案,减少了围手术期间并发症的发生风险,提高了手术的成功率及安全性。     

Successful management of inferior vena cava thrombus complicating advanced germ cell testicular tumor with temporary inferior vena cava filter

We report a case of right testicular tumor with inferior vena cava (IVC) thrombus. Due to the risk of pulmonary embolization, a temporary IVC filter had been inserted during chemotherapy. There were no complications with the temporary IVC filter during the implantation period. The patient was safely treated with systemic chemotherapy using a temporary IVC filter followed by retroperitoneal lymph node and vena cava dissection.     

Adrenocortical carcinoma with tumor thrombus in the right hepatic vein

Adrenocortical carcinoma is an unusual neoplasm with very poor prognosis. Patients present with an abdominal mass often exceeding 5 cm or as a functional tumor. Computed tomography is effective to demonstrate the neoplasm as an inhomogeneous adrenal lesion with irregular margins, and magnetic resonance imaging is helpful to visualize invasion into large vessels as well. Reported herein is a case of large adrenocortical carcinoma with tumor thrombus extending into the right hepatic vein.     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。     

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma

BACKGROUND: We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). METHODS: Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. RESULTS: In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. CONCLUSIONS: Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.     

Intracaval endovascular ultrasonography for large adrenal and retroperitoneal tumors

BACKGROUND: An accurate diagnosis of inferior vena cava (IVC) invasion is important in deciding the surgical strategy for a large adrenal tumor. We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) for invasion of the IVC by a large adrenal tumor. METHODS: Nine of 163 patients with adrenal and retroperitoneal tumors underwent ICEUS between 1993 and 2002. Intravascular ultrasonography was performed through the right femoral vein with the use of an 8Fr, 20-MHz transducer. The diagnostic criterion for detecting IVC invasion with ICEUS was identification of destruction of a single echogenic layer of the IVC wall or identification of an intracaval tumor mass. The ICEUS finding was confirmed by pathologic examination. RESULTS: The mean diameter of the tumors in 9 patients undergoing ICEUS and resection was 12.6 cm (range, 8.6-16 cm). Pathologic diagnosis varied: adrenocortical carcinoma, 4; malignant pheochromocytoma, 1; leiomyosarcoma, 1; metastatic lung cancer, 1; paraganglioma, 1; and neurilemmoma, 1. Vascular invasion was identified in 2 patients by ICEUS and confirmed by examination of resected specimens. The sensitivity, specificity, and positive predictive values of ICEUS for the diagnosis of the IVC invasion were 100%, 100%, and 100%, respectively. However, these values for computed tomography were 100%, 14%, and 25%, respectively; and for cavography, 100%, 57%, and 40%, respectively. CONCLUSIONS: ICEUS provides confirmatory information regarding tumor invasion of the IVC. This modality also can assist in formulating an operative strategy for large adrenal or retroperitoneal tumors.     

Testicular cancer with tumor thrombus extending to the inferior vena cava successfully removed using veno-venous bypass: A case report

A 33-year-old man with a left testicular tumor was referred to Shinshu University Hospital for advanced therapy. Radiographic imaging revealed multiple metastases in the retroperitoneal lymph nodes (RPLN) and bilateral lungs, as well as tumor thrombus that extended from the left renal vein to the inferior vena cava (IVC) adjacent to the right atrium. After orchidectomy, a diagnosis of embryonal carcinoma was made with a clinical stage of T1N2M1bS3, which has a poor prognosis, based on the International Germ Cell Cancer Collaborative Group consensus. After eight courses of chemotherapy, the patient's tumor markers normalized and the lung metastases disappeared, but the RPLN and tumor thrombus remained. Retroperitoneal lymph node dissection and thrombectomy were performed using a veno-venous bypass (VVB). The pathological examination of the thrombus revealed a mature teratoma. The patient has been disease-free since surgery.     

Prognostic factors of renal cell carcinoma with extension into inferior vena cava

Objective:   To evaluate the prognosis of our series of patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC) treated with nephrectomy and thrombectomy.
Methods:   In 46 patients with unilateral RCC extending into IVC who underwent nephrectomy and thrombectomy (T3b in 38 patients, T3c in 6, T4 in 2, N+ in 15, M1 in 21), overall and cancer-specific survival rates were estimated, and the univariable and multivariable analysis were carried out to determine the prognostic factors among age, gender, performance status, fever, inflammatory laboratory parameters, nodal and distant metastasis, tumor thrombus level, pathological parameters and postoperative interferon-α administration.
Results:   The median age was 66.5 (range 35–79) years. The median follow-up was 18.0 (mean 36.7 ± 38.7) months. The overall and cancer-specific 5-year survival rates were 32.9% and 40.0%, respectively. The univariate analysis revealed that fever (hazard ratio: HR 4.03), C-reactive protein (HR 4.89), grade of tumor cell (HR 3.83), and lymph node metastasis (HR 5.99) were independent prognostic factors of cause-specific survival in all patients. The multivariate analysis demonstrated that lymph node metastasis (HR 4.13) was the only independent prognostic factor of cause-specific survival. The extension level or postoperative interferon-α administration did not influence the prognosis of patients with tumor thrombus involving IVC.
Conclusions:   Aggressive surgery should be considered first in RCC patients with any levels of tumor thrombus. However, patients with both IVC involvement and nodal metastasis showed significantly poor prognosis, and development of novel intensive multidisciplinary therapies will be needed.     

Solitary floating vena caval thrombus as a late recurrence of renal cell carcinoma

We report an unusual case of solitary thrombus floating in the inferior vena cava (IVC) in a patient who underwent radical nephrectomy for a renal cell carcinoma (RCC) of the right kidney extended into the renal vein with no capsular and perinephric tissue invasion (pT3b). Twenty months after surgery, a routine computed tomography scan identified an intraluminal mass floating in the IVC. Cavotomy and thrombectomy with no caval resection were successfully performed. A review of the literature showed only three previous published cases of RCC recurring in the IVC only, with no local recurrence or distant metastases. We outline the possible etiology of these unusual and solitary recurrences in the IVC and we emphasize the need for a strict surveillance for all patients with RCC and especially for those with pT1b, pT2 and pT3 disease. An early diagnosis of this rare recurrence can permit an easy removal of the thrombus with no caval resection and graft replacement, making this disease potentially curable by surgery.     

A new classification for hepatocellular carcinoma with hepatic vein tumor thrombus

BackgroundHepatic vein tumor thrombus (HVTT) is a significant poor risk factor for survival outcomes in hepatocellular carcinoma (HCC) patients. Currently, the widely used international staging systems for HCC are not refined enough to evaluate prognosis for these patients. A new classification for macroscopic HVTT was established, aiming to better predict prognosis.MethodsThis study included 437 consecutive HCC patients with HVTT who underwent different treatments. Overall survival (OS) and time-dependent receiver operating characteristic (ROC) curve area analysis were used to determine the prognostic capacities of the new classification when compared with the different currently used staging systems.ResultsThe new HVTT classification was defined as: type I, tumor thrombosis involving hepatic vein (HV), including microvascular invasion; type II, tumor thrombosis involving the retrohepatic segment of inferior vena cava; and type III, tumor thrombosis involving the supradiaphragmatic segment of inferior vena cava. The numbers (percentages) of patients with types I, II, and III HVTT in the new classification were 146 (33.4%), 143 (32.7%), and 148 (33.9%), respectively. The 1-, 2-, and 3-year OS rates for types I to III HVTT were 79.5%, 58.6%, and 29.1%; 54.8%, 23.3%, and 13.8%; and 24.0%, 10.0%, and 2.1%, respectively. The time-dependent-ROC curve area analysis demonstrated that the predicting capacity of the new HVTT classification was significantly better than any other staging systems.ConclusionsA new HVTT classification was established to predict prognosis of HCC patients with HVTT who underwent different treatments. This classification was superior to, and it may serve as a supplement to, the commonly used staging systems.     

Clinical outcome of surgical management for patients with renal cell carcinoma involving the inferior vena cava

BACKGROUND: The objective of this study was to evaluate the clinical outcome after surgical management of renal cell carcinoma (RCC) extending to the inferior vena cava (IVC). METHODS: This study included a total of 55 patients (41 men and 14 women; mean age, 59.3 years) with RCC (39 right- and 16 left-sided tumors) involving the IVC, who underwent radical nephrectomy and tumor thrombectomy between 1983 and 2005 at a single institution in Japan. The level of thrombus was classified as follows: level I, infrahepatic; level II, intrahepatic; level III, suprahepatic; and level IV, extending to the atrium. Clinicopathological data from these patients were retrospectively reviewed to identify factors associated with survival. RESULTS: There were 11 and 18 patients who were diagnosed as having lymph node and distant metastases, respectively. Twenty-two patients had tumor thrombus in level I, 20 in level II, 10 in level III, and 3 in level IV. Pathological examinations demonstrated that 34 and 21 patients had clear cell carcinoma and non-clear cell carcinoma, respectively, 42, 9 and 4 were pT3b, pT3c and pT4, respectively, and 6, 35 and 14 were Grades 1, 2 and 3, respectively. Cancer-specific 1-, 3- and 5-year survival rates of these 55 patients were 74.5%, 51.4% and 30.3%, respectively. Among several factors examined, clinical stage (P = 0.047), lymph node metastasis (P = 0.016), histological subtype (P = 0.034) and tumor grade (P < 0.001) were significantly associated with cancer-specific survival by univariate analysis. Furthermore, multivariate analysis demonstrated clinical stage (P = 0.037) and tumor grade (P < 0.001) as independent predictors of cancer-specific survival irrespective of other significant factors identified by univariate analysis. CONCLUSIONS: In patients with RCC involving the IVC, biological aggressiveness characterized by tumor grade rather than tumor extension would have more potential prognostic importance; therefore, more intensive multimodal therapy should be considered in patients with high grade RCC with tumor thrombus extending into the IVC.     

Successful resection of a retroperitoneal malignant fibrous histiocytoma with caval tumor thrombus

We report herein the case of a 56-year-old man who presented with a huge, fast-growing abdominal tumor. Renal angiograms revealed a hypervascular tumor stain from the renal capsular arteries, and magnetic resonance imaging revealed a caval tumor thrombus. The tumor was resected en bloc with the tumor thrombus, the right kidney, and part of the liver. The histological diagnosis confirmed malignant fibrous histiocytoma (MFH) both in the tumor and the caval tumor thrombus. This is the first report of the successful resection of a MFH originating in the renal capsular tissue and extending into the inferior vena cava.     

Extra-Adrenal Retroperitoneal Paraganglioma with Extensive Duodenal Invasion and Inferior Vena Cava Tumor Thrombus

We report a case of extra-adrenal retroperitoneal paraganglioma (RP) with extensive duodenal invasion and tumor thromboses both in the right testicular vein and in the inferior vena cava (IVC). Because there was rigid adherence between the RP and the abdominal aorta, pancreatoduodenectomy with replacement of the IVC and aorta was performed for complete surgical resection. In the present case, both the mode of progression of the RP and the surgical approach were extremely rare.