Large adrenocortical carcinoma extending into the inferior vena cava and right atrium

A case of large adrenocortical carcinoma extending into the inferior vena cava and right atrium is reported. Computed tomography showed a large mass displacing the left kidney inferiorly with an intravascular tumour thrombus extending into the inferior vena cava and right atrium. Radical surgery under hypothermia and cardiopulmonary bypass was performed and the tumour mass, together with the tumour thrombus, was successfully removed. The presence of intravascular tumour extension alone should not be a contraindication to radical surgical therapy, as it is the best hope for prolonged survival.     

Renal cell carcinoma extending into vena cava and right atrium

We report on a patient who underwent complete removal of a renal cell carcinoma extending into the vena cava and the right atrium. A review of the literature confirms the rarity of vena caval obstructive symptoms. Emphasis is on preoperative diagnosis, thoracoabdominal exposure, and team approach. Survival rates warrant aggressive surgical treatment in these patients.     

Surgical approach to renal cell carcinoma extending into the right atrium through the inferior vena cava

Successful management of a patient with an intracardiac tumor thrombus of renal carcinoma is described. This case and a few others in the literature have led us to consider the clinical signs of cavo-atrial obstruction, frequently silent and unspecific; the diagnostic methodology, especially based upon CAT scan and cavography, and the type of surgery and surgical technique called for, especially as regards the approach and the possible use of extracorporeal circulation (ECC).     

经腹手术取出下腔静脉及右心房肾癌癌栓

目的:探讨在非体外循环下,经腹手术取出转移至下腔静脉及右心房内的肾癌栓的效果。方法:采用肝移植术中背驮式游离肝脏的技术,在充分暴露肝后下腔静脉的前提下,将右心房内癌栓挤至膈肌以下,纵形切开下腔静脉取除。结果:成功取出长13cm、直径3cm的癌栓,术中出血600ml。随访30个月,患者恢复正常工作,肝肾功能正常。结论:经腹游离肝脏后,可取出高达膈肌以上的下腔静脉和右心房内的癌栓,操作要点是减少术中出血并防止癌栓脱落。     

Testicular carcinoma with inferior vena cava thrombosis extending into the right atrium treated with chemotherapy and anticoagulation.

A 34-year-old male with pulmonary emboli and thrombosis of the inferior vena cava extending into the right atrium was found at presentation to have a mixed seminoma and embryonal cell testicular carcinoma with high-volume retroperitoneal disease and visceral metastases. The patient was free of disease 19 months after treatment with combination chemotherapy and anticoagulation followed by resection of the residual mass. We could not find any previous report of a patient with bulky retroperitoneal disease and vena cava thrombosis successfully treated with chemotherapy without vena cava resection.     

Left kidney cancer grossly extending into left-sided inferior vena cava of duplicated inferior vena cava

The left radical nephrectomy with tumor thrombectomy in the presence of a duplicated inferior vena cava is of high surgical risk because the venous tumor thrombus renders the anomalous venous structures dilated and tortuous, making injury more likely. We present a case of a left kidney cancer grossly extending into the left side of a duplicated inferior vena cava. What is more important is to bring such an aberrant vascular anatomy with tumor thrombus to the attention of urologists with high-resolution pictorial illustrations.     

A case of intravenous leiomyomatosis of uterine origin, extending through the inferior vena cava to right atrium

Intravenous leiomyomatosis (IVL) is a rare benign tumor that originates from uterus, and sometimes extends to the right heart. We report a case of IVL that extended to right atrium through the inferior vena cava (IVC) which was resected using partial cardiopulmonary bypass. Multi detector computed tomography and ultrasound played a vital role in arriving at the diagnosis. Complete resection of tumor in the heart and great vein, and separation of the tumor stump from the IVC are essential in the treatment of IVL.     

经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用

目的 探讨经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用价值. 方法 经CT、MRI及彩色多普勒超声等检查确诊为肾或肾上腺肿瘤合并肝后型或肝下型下腔静脉瘤栓患者12例.男7例,女5例.年龄20～76岁,平均51岁.右侧肿瘤11例,左侧1例.肾肿瘤11例,肾上腺肿瘤1例.12例均于术前经皮穿刺右侧颈内静脉,于瘤栓近心端下腔静脉内预置一球囊导管,术中经导管充盈球囊阻断下腔静脉后,再行下腔静脉瘤栓切除术. 结果 12例肿瘤合并下腔静脉瘤栓的根治性切除术全部完成.手术时间210～670 min,平均324 min.术中出血量600～7960 ml,平均2563 ml.无手术或围手术期死亡.术后患者恢复良好,肝肾功能正常,无并发症发生.术后平均12(9～15)d出院.术后病理报告:肾细胞癌9例,转移性肝细胞癌1例,良性血管平滑肌脂肪瘤1例,肾上腺平滑肌肉瘤1例.肾癌术后TNM分期:T3b N0M08例,T3bNxM11例.术后平均随访(21±10)个月,中位随访时间24个月.4例分别于术后6、9、15、22个月死于肺转移、肝转移及肝癌复发,其余8例术后已存活6～35个月,平均26个月.9例肾癌患者术后1、3年肿瘤特异生存率分别为78%和67%. 结论 经皮球囊导管阻断技术在低位肝后型或肝下型下腔静脉瘤栓的根治性切除术中是一种安全、简便、有效的方法,具有重要的临床应用价值.     

Laparoscopic inferior vena cava and right atrial thrombectomy utilizing deep hypothermic circulatory arrest

BACKGROUND AND PURPOSE: Surgery for renal cancer associated with a level III or IV tumor thrombus often involves cardiopulmonary bypass, deep hypothermia, and exploration of the right atrium and inferior vena cava (IVC). This major open operation necessitates a large median sternotomy incision and a midline abdominal or chevron incision. Herein, we investigate the feasibility of purely laparoscopic IVC and right atrial thrombectomy utilizing deep hypothermic circulatory arrest. MATERIALS AND METHODS: In six male calves weighing 70 to 80 kg, the right common carotid artery and right internal jugular vein were cannulated for subsequent cardiopulmonary bypass. One laparoscopic team performed right radical nephrectomy and complete mobilization of the intra-abdominal IVC by a four-port approach. Simultaneously, a second laparoscopic team obtained three-port thoracoscopic access to incise the pericardium and expose the right atrium. In sequence, cardiopulmonary bypass, complete exsanguination, cardiac arrest, and core hypothermia of 18 degrees C were achieved. A coagulum thrombus was created by needle injection into the IVC. Combined laparoscopic and thoracoscopic incision, exploration, and thrombectomy of the IVC and the right atrium were then performed in a bloodless field. An angioscope was inserted inside the heart and the IVC to confirm complete thrombus clearance visually. The IVC and right atrium were then laparoscopically suture repaired, cardiopulmonary bypass was reestablished, and the animal was gradually rewarmed. Once sinus rhythm was reestablished at normal body temperature, the animal was weaned off the pump. RESULTS: The mean total operative time was 494.5 minutes (range 355-705 minutes). The mean time needed to lower the core temperature was 63.5 minutes (range 50-120 minutes), and the mean time required to rewarm the animal was 101.8 minutes (range 70-130 minutes). The mean blood volume drained into the pump was 2633.3 mL (range 1400-3200 mL), and the mean estimated blood loss was 350 mL (range 200-750 mL). Reestablishment of sinus cardiac rhythm and weaning off the pump was successful in all animals prior to acute euthanasia. CONCLUSIONS: Laparoscopic radical nephrectomy with thrombectomy for level III or IV tumor thrombi utilizing deep hypothermic circulatory arrest is feasible in the calf model using minimally invasive techniques exclusively. The procedure is technically complex and requires the combined efforts of expert urologic and cardiac operative teams. Survival studies are planned.     

Surgical treatment of malignant renal tumors invading the inferior vena cava and right atrium

Invading the inferior vena cava and right atrium is the most serious, but fortunately not common complication of renal cell carcinoma. Radical nephrectomy with tumor-thrombus extraction is the only way to improve these patients survival. Cardiopulmonary bypass with or without deep hypothermia and total circulatory arrest might be necessary during surgery. Between 1998 and 2003 at the Department of Cardiac Surgery of University of Debrecen, 5 patients, with renal cell carcinoma extending into the right atrium, had radical nephrectomy and thrombectomy. We used cardiopulmonary bypass, in 2 patients in total circulatory arrest, in deep hypothermia. There was no operative death and neurological complications. One patient died 3 years after the operation due to cardiac failure. In average 42 months after surgery, 4 surviving patients are under regular follow up, they have a good quality of life, without recurrence. In our opinion cardiopulmonary bypass and total circulatory arrest, if necessary, gives the best way for surgical resection of renal cell carcinoma extending into the right atrium.