The initial division of left renal vein in left renal cancer with intracaval tumor thrombus: a case report

A 30-year-old female was admitted to our hospital with a 3-month history of general fatigue and one month history of left flank mass. Computed tomography revealed a huge left renal tumor (20 × 13 × 10 cm) with intracaval tumor thrombus. The tumor thrombus extended into the right atrium. The left renal vein (lt-RV) was expanded 3.5 cm in diameter by the tumor thrombus. The tumor was surrounded by a tortuous dilated capsular vein. The strategic issue was how to ligate the left renal artery (lt-RA) behind the expanded lt-RV. We first divided the lt-RV occluded by the tumor thrombus using a Linear Cutter? and then divided the lt-RA before the dissection of the tumor to avoid excessive bleeding. Even transarterial embolization of lt-RA were to be performed,the tumor was too large to dissect without division of lt-RV and lt RA. After the left kidney was removed,the lower half of the tumor thrombus was excised,clamping the inferior vena cava,three right renal arteries,two right renal veins,and the lumber vein. Finally,we removed the upper half of the tumor thrombus extending to the right atrium through atriotomy and cavotomy under an extracorporeal cardiovascular bypass. Operation time was 9 h 22 m,and total blood loss was 1670 ml. Convalescence was uneventful except for abdominal lymphocele.     

A case report of retroaortic left renal vein with tumor thrombus of renal cell carcinoma

A 75-year-old woman was referred to our department for evaluation of a left renal tumor. Computed tomography and other imaging studies demonstrated a left renal mass and tumor extension into the left renal vein passing caudally behind the aorta. We clinically diagnosed the tumor as renal cell carcinoma (RCC) associated with a retroaortic left renal vein thrombus, and performed a radical nephrectomy. Pathological examination of the surgical specimen showed a grade 2, clear cell carcinoma with a renal vein thrombus and negative surgical margin. Retroaortic left renal vein is a rare anomaly with a prevalence of 1.8–2.4%. RCC associated with a retroaortic left renal vein thrombus is rarer still. To our knowledge, this is only the third case report to describe an RCC associated with a tumor thrombus in the retroaortic left renal vein.     

Further experience with division of the left renal vein

The left renal vein (LRV) has numerous tributaries including, but not limited to, the inferior phrenic, suprarenal, and gonadal veins. The resultant potential for collateral LRV outflow through these tributaries in instances of LRV division is obvious. One of us has previously reported 10 such cases of LRV division (close to its confluence with the inferior vena cava and without reanastomosis) for the purpose of facilitating proximal abdominal aortic exposure for reconstructive procedures. One of the 10 patients had moderate renal insufficiency at follow-up. We present herein an additional 19 patients who underwent LRV division predominantly for aneurysmal disease of the abdominal aorta. Sixteen patients were available for follow-up. Three patients died in the intraoperative and early postoperative periods. Multivariate analysis of variance of preoperative, postoperative, and follow-up laboratory data--serum creatinine and BUN--showed no significant change in renal function as assessed.     

Effect of left renal vein division during aortic surgery on renal function

A total of 398 consecutive patients underwent surgery for an aneurysm or occlusive disease of the aorta at Norfolk and Norwich Hospital between December 1994 and October 1998. It was necessary to divide the left renal vein in 58 (14.6%) cases. We examined the effect of this division on the mortality rate and renal function. Renal function was assessed by measuring serum creatinine pre-operatively, peri-operatively and long-term postoperatively. There was no significant difference in the mortality rate between patients who had the left renal vein divided (LRVD) and in whom the left renal vein remained intact (LRVI)--31% versus 32%, P = 0.83. There was no significant difference in the pre-operative serum creatinine level between both groups (107 +/- 21 mumol/l in LRVD versus 103 +/- 29 mumol/l in LRVI, P = 0.14). There was an insignificant rise in the mean serum creatinine 7 days postoperatively (111 +/- 21 mumol/l in LRVD versus 107 +/- 31 mumol/l in LRVI, P = 0.05). The mean serum creatinine returned back to the pre-operative level at 30 days postoperatively (106 +/- 16 mumol/l in LRVD and 105 +/- 29 mumol/l, P = 0.20). After 1 month, there was no significant difference in the number of patients who had a sustained elevation of serum creatinine level (7.5% in LRVD versus 2.7% in LRVI, P = 0.11). We feel that division of the left renal vein is a safe and helpful procedure during juxtarenal aortic surgery.     

Primary retroperitoneal plasmacytoma with tumor thrombus within the renal vein.

A case of primary retroperitoneal plasmacytoma causing a tumor thrombus within the renal vein is described. The use of radiographic techniques, including ultrasonography, computerized tomography and angiography, facilitated an accurate diagnosis. Tumor thrombi within the renal vein are rare except in cases of primary renal or adrenal neoplasms. In a patient with radiological evidence of retroperitoneal tumor and tumor thrombus within the renal vein plasmacytoma should be considered in the differential diagnosis of retroperitoneal neoplasms.     

Metastatic melanoma to the kidney presenting with renal vein tumor thrombus

We report on a patient with metastatic melanoma to the kidney who presented with a renal vein thrombus to the inferior vena cava. Three years after his initial lesion of the scalp, a 34-year-old Egyptian man was found to have two brain metastases and an 11-cm left renal metastasis with a tumor thrombus in the renal vein. After resection of the brain metastases, with no evidence of additional metastases, the patient underwent left radical nephrectomy and tumor venous thrombectomy. The patient later had tumor recurrence at multiple sites. He did not respond to systemic treatment and died 5 months later.     

Hand-assisted laparoscopic radical nephrectomy using intraoperative ultrasonography for left renal cell carcinoma involving a level I renal vein tumor thrombus

This report concerns two male patients, 65 (case 1) and 72 (case 2) years old, with a left renal tumor involving a level I renal vein tumor thrombus, who underwent hand-assisted laparoscopic radical nephrectomy using intraoperative ultrasonography. With the patient in the flank position, a midline supraumbilical hand port and two other ports were placed. Intraoperative ultrasonography identified the extent of the tumor thrombus. After hilar control, complete resection with intact removal was performed. Surgery lasted 305 min for case 1 and 237 min for case 2, with respective estimated blood loss of 410 mL and 572 mL. No postoperative complications occurred. Pathological examination showed a clear cell carcinoma with a level I tumor thrombus and negative surgical margins. Because the ultrasound probe can be easily inserted and the specimen can be extracted safely and intact, hand-assisted laparoscopic radical nephrectomy is practicable and effective for left renal cell carcinoma involving a level I renal vein tumor thrombus.     

Pulmonary vein stump thrombus: an early complication following upper division segmentectomy of the left lung

We report a rare case of a pulmonary vein stump thrombus detected by a contrast-enhanced computed tomography for transient syncope 2 days after upper division segmentectomy of the left lung for metastatic pulmonary tumor. The thrombus disappeared without embolic events after anticoagulation with intravenous heparin followed by oral warfarin. Considering this case and previous reports, thoracic surgeons should be aware of pulmonary vein stump thrombus, a latent source of systemic embolization, after pulmonary resection, especially lobectomy or segmentectomy of the left upper lobe. This possible serious complication can occur at any time from the early postoperative period.     

Vena cava tumor thrombus from renal cell carcinoma arising from adrenal vein

Renal cell carcinoma is a highly vascular tumor with the propensity to propagate along venous channels. Vena cava tumor thrombi are reported to occur in approximately 4-10 per cent of cases and requires modification of the standard radical nephrectomy. We report the first 3 cases of vena caval tumor thrombus emanating not from the renal vein, but from the adrenal vein. The recognition of this occurrence is essential in order to avert an intraoperative catastrophe.     

Laparoscopic radical nephrectomy incorporating intraoperative ultrasonography for renal cell carcinoma with renal vein tumor thrombus

The purpose of this study was to describe the technique of laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography in the management of renal cell carcinoma with level 1 renal vein tumor thrombus. With the patient in a modified flank position, a transperitoneal four-port approach was used to laparoscopically resect an 8.5-cm right renal mass with tumor thrombus extending to, but not into, the inferior vena cava. Early arterial control with gentle traction on the right renal vein provided a short proximal renal venous segment devoid of tumor on laparoscopic inspection. Intraoperative laparoscopic ultrasonography allowed confident identification of the proximal extent of the tumor thrombus. After hilar control, complete resection and intact removal of the renal specimen was performed using standard non-hand-assisted laparoscopic techniques. The actual surgical time was 180 minutes. Surgical resection was successfully performed laparoscopically. No postoperative complications or hospital readmission occurred. Pathologic examination confirmed T3b renal cell carcinoma with negative surgical margins. Laparoscopic right radical nephrectomy incorporating intraoperative, real-time ultrasonography is feasible in the management of renal cell carcinoma with a large-sized level 1 renal vein thrombus. Additional studies are necessary to evaluate its role in urologic oncologic surgery.     

Wilms' tumor with intracaval thrombus in the UK Children's Cancer Study Group UKW3 trial

Background/Purpose

To define the clinical characteristics and surgical management of intracaval involvement in patients enrolled in the UKW3 trial (1991-2001), which recommended elective preoperative chemotherapy for such cases.

Methods

Cases were identified from preoperative imaging and surgical trial forms. These asked specific questions about whether the surgeon suspected intracaval extension at diagnosis or found it at nephrectomy. For tumors with Wilms' histology, original case notes were examined.

Results

Of 842 patients registered in UKW3, 730 (87%) had Wilms' tumor. Among them, 59 (8.1%) had evidence of intracaval extension, either documented at diagnosis (53) or found unexpectedly at nephrectomy (6). Intracaval extension was also seen in tumors of other histology. The level of thrombus was intraatrial (10), suprahepatic (9), retrohepatic (8), infrahepatic (26), and unknown (6). The median age at diagnosis was 3.75 years compared to 2.97 years in patients without inferior vena cava thrombus (P < .0001). Fifty-two of 59 received preoperative chemotherapy. Thirty-one (52%) needed cavotomy, and 3 (30%) with intraatrial extension required cardiopulmonary bypass. The commonest operative complication was significant hemorrhage and resulted in mortality in 3 cases.

Conclusions

Preoperative chemotherapy is a useful adjunct to shrink the tumor and thrombus. This reduces the requirement for cavotomy and cardiopulmonary bypass. Intraoperative hemorrhage remains a significant cause of operative morbidity and mortality.     

肝癌合并门静脉癌栓的治疗

【摘要】〓门脉癌栓是肝癌患者不良预后的重要指标,然而对于合并门脉癌栓的肝癌患者,国际上并没有统一的治疗标准。尽管临床尝试了各种方法,如肝动脉栓塞化疗(TACE),全身药物的系统治疗,局部消融治疗及积极的手术治疗,但治疗效果不尽理想。随着外科技术的发展以及新的技术和药物的研发,希望通过综合的治疗,提高此类患者的治疗效果,延长患者的生存。     

Recidive of renal cell carcinoma tumor thrombus in inferior vena cava via lumbar vein

Renal cell carcinoma (RCC) develops tumor thrombus in the renal vein and inferior vena cava (IVC) in 10% of cases. Surgical treatment is radical nephrectomy and thrombectomy of the IVC. Local recidive can develop in the lumbar fossa, lymph nodes, and the IVC. We report a 58-year-old patient admitted to the Clinic for Urology at the Military Medical Academy, Belgrade, Serbia, in February 2009 with RCC of the left kidney and tumor thrombus in the IVC. After ultrasonography exam and multislice computed tomography scan, we performed radical nephrectomy and thrombectomy of the IVC (level II). Four months after the operation, ultrasound exam and cavography showed intracaval and paracaval recidive tumor masses in the renal part of the IVC. On operation we removed intraluminal IVC thrombus, which arises from the lumbar vein on the IVC posterior wall, with paracaval thrombus in the lumbar vein. We conclude that RCC tumor thrombus can spread from the kidney to the IVC through the lumbar vein.