Surgical treatment of renal cell carcinoma involving the inferior vena cava

Renal cell carcinoma extends into the inferior vena cava in 5% of patients undergoing exploratory surgery for this malignancy. If the tumor is left unresected, death within 1 year is certain. In addition, caval occlusion may result in massive lower extremity edema, ascites, hepatic failure, and pulmonary embolus. During the past 17 years, 12 patients with renal cell carcinoma extending into the inferior vena cava were treated at a single institution by radical nephrectomy and caval tumor extraction. There were 10 men (83%) and ages ranged from 50 to 78 years (mean 63 years). There was one operative death (8%) caused by refractory coagulopathy. Long-term follow-up was achieved for all survivors. One- and 3-year survival rates by life-table method were 73% and 27%, respectively. Mean survival time after resection was 32 months. Careful preoperative planning is essential. The optimal approach for venacaval tumor extraction or resection is dictated by the cephalad extent of tumor seen on preoperative thoracoabdominal CT scan, ultrasound, or inferior venacavography. Disease limited to the infrahepatic vena cava is best approached with a thoracoabdominal incision through the eighth intercostal space. Extension of tumor to the hepatic veins or right atrium requires median sternotomy in combination with an abdominal incision for complete removal. An ellipse of vena cava around the origin of the renal vein is excised with the specimen. The resultant incision is closed by lateral phleborrhaphy. Late sequelae of the mild caval narrowing were not observed. An aggressive multispecialty surgical policy for caval extraction and resection of renal cell carcinoma resulted in extended patient survival and excellent palliation.     

Management of renal tumors involving the inferior vena cava

Purpose: We reviewed our experience of the resection of renal tumors involving the inferior vena cava (IVC) from 1987 to 1992 with the hypothesis that retrohepatic IVC involvement of renal tumors can be managed without cardiopulmonary bypass (CPB) and circulatory arrest with acceptable morbidity and mortality rates. Methods: We retrospectively reviewed our experience of radical nephrectomies for renal tumors from 1987 to 1992 (n = 69). Of these, 13 had involvement of the IVC (19%). Three of the patients had right atrial extension requiring CPB with circulatory arrest. Three patients had retrohepatic involvement, and seven had infrahepatic involvement. All thirteen patients underwent operative removal of the tumor and tumor thrombus. Results: The patients with atrial extension who were treated with CPB and circulatory arrest had hospital and 1-year survival rates of 100% (three of three). The patients with retrohepatic extension treated without CPB and circulatory arrest had hospital and 1-year survival rates of 100% (three of three). The patients with infrahepatic extension treated without CPB and circulatory arrest had hospital and 1-year survival rates of 85% (six of seven) and 50% (three of six), respectively. There was no statistically significant difference between groups. The hospital death occurred in a patient who had a massive pulmonary embolism and disseminated intravascular coagulation before operation. The deaths that occurred before 1 year were due to metastatic disease and unresectable disease at the time of operation. Conclusion: CPB with circulatory arrest is not required in patients with retrohepatic IVC extension of renal tumors, and aggressive resection can be performed in these patients with acceptable morbidity and mortality rates. (J VASC SURG 1994;20:385-8.)     

Renal tumors involving the inferior vena cava: plan for management.

Our experience in the management of 12 malignant renal tumors involving the inferior vena cava is analyzed and a plan to manage the different degrees of caval involvement is discussed. The use of Pringle maneuver to control hepatic circulation during removal of suprahepatic caval extensions is recommended. Followup to date supports aggressive operative management in these patients.     

Surgical treatment of thrombosis of the inferior vena cava

Personal experience of thromboses of the inferior vena cava is presented and pathogenetic and symptomatological aspects stressed. In addition, in relation to the results presented and reported data, it is concluded that the role of surgical therapy is fundamental to integrate the thrombolytic and anticoagulant treatment of these severe forms of deep venous thrombosis.     

复杂下腔静脉恶性肿瘤的外科处理

目的 探讨手术治疗复杂重症下腔静脉恶性肿瘤的方法及其效果.方法 2004年12月至2008年7月对8例下腔静脉肿瘤行手术治疗,其中7例患者8次在体外循环或右心房插管灌注下手术切除下腔静脉肿瘤或(和)延及右心房/室内肿瘤;1例下腔静脉平滑肌肉瘤局部复发行下腔静脉置换术.术前CT或MRI检查均已除外远处转移.结果 1例患者于术后2个月死于肝衰竭,其他7例术后症状均缓解并顺利出院.7例患者随访5～45个月,平均(15±4)个月.其中3例术后随访14～24个月,效果良好,无复发;3例术后4、5及32个月后原位复发并全身多处转移,其中1例是罕见的下腔静脉多形性恶性纤维组织细胞瘤,5个月后复发并右肾上腺转移癌,9个月后再次切除下腔静脉及右心房/室内肿瘤,术后11个月第3次复发死于心衰;另2例复发者未再次手术,其中1例术后7个月行化疗后症状缓解.1例45个月后失访.结论对于复杂腔静脉恶性肿瘤如未发现其他部位转移可采取积极手术治疗,如此可明显改善患者近期生存质量.     

复杂下腔静脉恶性肿瘤的外科处理

目的 探讨手术治疗复杂重症下腔静脉恶性肿瘤的方法及其效果.方法 2004年12月至2008年7月对8例下腔静脉肿瘤行手术治疗,其中7例患者8次在体外循环或右心房插管灌注下手术切除下腔静脉肿瘤或(和)延及右心房/室内肿瘤;1例下腔静脉平滑肌肉瘤局部复发行下腔静脉置换术.术前CT或MRI检查均已除外远处转移.结果 1例患者于术后2个月死于肝衰竭,其他7例术后症状均缓解并顺利出院.7例患者随访5～45个月,平均(15±4)个月.其中3例术后随访14～24个月,效果良好,无复发;3例术后4、5及32个月后原位复发并全身多处转移,其中1例是罕见的下腔静脉多形性恶性纤维组织细胞瘤,5个月后复发并右肾上腺转移癌,9个月后再次切除下腔静脉及右心房/室内肿瘤,术后11个月第3次复发死于心衰;另2例复发者未再次手术,其中1例术后7个月行化疗后症状缓解.1例45个月后失访.结论对于复杂腔静脉恶性肿瘤如未发现其他部位转移可采取积极手术治疗,如此可明显改善患者近期生存质量.

Abstract：

Objective To explore the surgical strategy and effects for treating complex malignant tumors of the inferior vena cava (IVC) or/and the tumors extending into right atrium/ventricle.Methods Between Dec 2004 and Jul 2008, eight patients underwent surgical resections, among those seven patients with tumors of IVC or the tumors extending into right atrium/ventricle were operated on under deep hypothermia with cardiopulmonary bypass( CPB), and one patient with recurrence of leiomyosarcoma of the IVC successfully underwent en bloc resection and caval reconstruction. The prosthetic graft was used for IVC reconstruction in two patients and vascular patch in the other two patients. Preoperative chest roentgenography, computed tomography, ultrasonography, or magnetic resonance imaging was used to exclude the presence of metastatic disease, to assess local resectability of the tumour and the extent of involvement and obstruction of the IVC. Results One patient died of liver failure postoperatively. The postoperative course was uneventful in other 7 patients. On follow-up two patients died 2 and 5 months later due to functional disorder of the liver. Three patients have been followed up for 14 - 24 months and were     

复杂下腔静脉恶性肿瘤的外科处理

目的 探讨手术治疗复杂重症下腔静脉恶性肿瘤的方法及其效果.方法 2004年12月至2008年7月对8例下腔静脉肿瘤行手术治疗,其中7例患者8次在体外循环或右心房插管灌注下手术切除下腔静脉肿瘤或(和)延及右心房/室内肿瘤;1例下腔静脉平滑肌肉瘤局部复发行下腔静脉置换术.术前CT或MRI检查均已除外远处转移.结果 1例患者于术后2个月死于肝衰竭,其他7例术后症状均缓解并顺利出院.7例患者随访5～45个月,平均(15±4)个月.其中3例术后随访14～24个月,效果良好,无复发;3例术后4、5及32个月后原位复发并全身多处转移,其中1例是罕见的下腔静脉多形性恶性纤维组织细胞瘤,5个月后复发并右肾上腺转移癌,9个月后再次切除下腔静脉及右心房/室内肿瘤,术后11个月第3次复发死于心衰;另2例复发者未再次手术,其中1例术后7个月行化疗后症状缓解.1例45个月后失访.结论对于复杂腔静脉恶性肿瘤如未发现其他部位转移可采取积极手术治疗,如此可明显改善患者近期生存质量.     

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.     

累及下腔静脉的腹膜后肿瘤手术处理经验

目的探讨累及下腔静脉的腹膜后肿瘤手术时下腔静脉的处理方法 ,以提高切除率及手术安全性。方法回顾性分析 1990年 1月至 2 0 0 3年 4月收治的 4 1例腹膜后肿瘤累及下腔静脉的手术切除及血管重建的临床资料。结果 4 1例累及下腔静脉的腹膜后肿瘤的手术方式有 :下腔静脉部分切除、修补术 17例 ;部分下腔静脉并右肾切除术 11例 ;部分下腔静脉切除、残端结扎术 10例 ,其中 3例行人工血管植入术。结论B超、CT、MRI是术前必不可少的检查 ,选择性血管造影可以明确下腔静脉受压、移位、畸形及有无闭塞。累及下腔静脉并非腹膜后肿瘤行根治性切除的手术禁忌证 ,下腔静脉部分切除与重建安全、有效、可行 ,可以大大提高肿瘤的切除率、降低复发率。     

Angiomyolipoma of kidney involving the inferior vena cava

We successfully treated a case of angiomyolipoma of the right kidney involving the inferior vena cava. Tissue sections of the tumor were immunostained and immunohistochemically tested with the smooth muscle related antibodies, namely, calponin h1, h-caldesmon and alpha-smooth muscle actin, and were then compared with the five cases of common type of angiomyolipoma. Furthermore, we reviewed and analyzed 25 case reports of invasive renal angiomyolipomas.     

肾癌合并下腔静脉癌栓的多学科联合治疗

目的 探讨肾癌合并下腔静脉癌栓多学科联合治疗的临床意义.方法 经B超和CT检查诊断为右肾癌合并下腔静脉癌栓的患者2例,下腔静脉癌栓Ⅱ级和Ⅳ级各1例.全麻下取腹部人字形切口.泌尿外科行右肾切除;肝胆外科游离腔静脉至第二肝门,于癌栓上下阻断腔静脉和周围分支静脉;血管外科切开腔静脉完整取出癌栓,缝合腔静脉.例2患者腔静脉癌栓距右心房2-3cm,肿瘤侵及腔静脉血管壁及血管内膜,术中建立左股静脉-右心房转流,心肺转流241 min,阻断主动脉18 min,行自体血液回输、腔静脉置换及第二肝门肝静脉-人工血管吻合.分析手术适应证、手术时间、术中出血量、术后住院时间等.结果 2例均成功行根治性右肾切除术,完整取出癌栓.2例分别于术后15、27 d出院.分别随访1、16个月,未发现肿瘤局部复发及远处转移.结论 对于没有淋巴结侵犯和远处转移的肾癌合并下腔静脉癌栓患者,应积极行根治性肾切除术及癌栓取出术,多学科联合协作可缩短手术时间、降低手术风险、减少肿瘤复发、提高患者生存率.

Abstract：

Objective To evaluate the surgical treatment for renal cell carcinoma with inferior vena cava tumor thrombus and the clinical significance of multidisciplinary treatment. Methods Two cases of renal cell carcinoma with inferior vena cava thrombus diagnosed by Doppler ultrasonography and CT were included in this retrospective analysis. The tumor thrombus was in level Ⅱ in one case and in level Ⅳ in the other. Coagulation test and complete blood count were done again before surgery. Human albumin, fibrinogen, prothrombin complex, plasma, platelet, UW and irrigating solution were prepared before the operation.Under general anesthesia, surgery was performed using abdomen inverted Y shaped incision. Right radical nephrectomy was finished by the urological surgeon; the vena cava was completely dissected from the renal vein level to the secondary porta of the liver by the hepatobiliary surgeon, the vena cava and the surrounding branch vein were blocked in the upper and lower vena cava tumor thrombus; tumor thrombus was removed completely by the vascular surgeon. In one case (patient with level Ⅳ thrombus ) where the tumour thrombus invaded the wall of the vena cava, the thrombus was found to be extending to the cavo-atrial junction but not into the right atrium. The left femoral venous-right atrial bypass was established, the cardiopulmonary bypass lasted for 241 mia, and the aorta was blocked for 18 min. Salvage autotransfusion was used during surgery, and the hepatic vein of the secondary liver porta was anastomosed to artificial vascular graft.The data for surgical indication, operation time, operative blood loss and postoperative hospital stay were analyzed. Results Right radical nephrectomy and inferior vena cava thrombectomy were performed successfully, and the two patients were discharged on the 15th and 27th day after surgery, respectively. The two patients were followed up for 1 and 16 months after surgery, respectively, and both survived without local recurrence and distant metastasis. Conclusion Radical nephrectomy and inferior vena cava thrombectomy is the preferred method for patients without metastasis, and multidisciplinary cooperation could shorten the operation time, reduce the tumor recurrence and increase the survival rate of patients.     

肾癌伴下腔静脉癌栓的诊断与治疗

目的 探讨肾癌伴下腔静脉癌栓的诊断及治疗。方法 回顾性分析1997年1月至2003年11月21例肾癌伴下腔静脉癌栓患者资料，男13例，女8例，平均年龄50岁。右侧13例，左侧8例。临床表现主要为腰痛和（或）血尿。经彩色多普勒超声、CT和MRI确诊。Ⅰ型癌栓3例，Ⅱ型10例，Ⅲ型6例，Ⅳ型2例。其中行肾癌根治术加下腔静脉癌栓取出术15例，肾癌根治术加下腔静脉节段切除术4例。结果 19例手术者中，8例术后仅存活3～13个月，11例随访4～57个月至今，无瘤生存8例，带瘤生存3例。2例未行手术者分别于3、5个月后死亡。结论 彩色多普勒超声、CT和MRI对肾癌伴下腔静脉癌栓诊断率较高，可准确判断癌栓位置。对无淋巴结和远处转移者，积极行肾癌根治术加下腔静脉癌栓取出术或下腔静脉节段切除术治疗效果满意。     

Surgical removal of an inferior vena cava thrombus.

Studies on the management of inferior vena cava (IVC) thrombosis have rarely focused upon the risk of later development of post-thrombotic syndrome of the lower limbs. From 1983-1989, 52 patients with ilio-femoral thrombosis with an extension of thrombus into the IVC were treated. In addition to lower limb pain and swelling, 12 (23%) patients had symptomatic pulmonary embolism on admission. Perfusion/ventilation pulmonary scans were positive in 63%. Twelve patients received only anti-coagulant treatment. Thrombectomy was attempted in 40 patients, but failed in 13 patients due to old thrombi. Twenty-seven patients had surgical removal of thrombus combined with anti-coagulation [temporary arterio-venous fistula (AVF) and IVC interruption (n = 15); AVF alone (n = 9); and without fistula n = 3)]. The mortality and morbidity were low and hospital stay was not prolonged. Thirty-eight legs were examined at 7-66 months (mean: 23 +/- 3) after initial treatment. The limbs in which the IVC thrombus could not be removed (n = 20) were symptomatic in 25% of patients, venous ulcer developed in 4 of 20 limbs. The ilio-femoral segment was patent in only 35%. The thrombectomised limbs (n = 18) were asymptomatic in 56%; none had developed ulcer and iliac patency was 72%. Doppler investigations and refilling times were normal in 39% of the thrombectomised limbs. All patients without surgical IVC thrombus removal developed contralateral deep venous thrombosis during the follow-up period. This study shows that femoro-ilio-caval thrombectomy is successful only in patients with a short history and fresh clot, and can be safely performed with low morbidity and mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment of malignant lip tumors. Personal experience

The malignant tumours of the lip account for nearly 1-2% of the cervicofacial neoplasms. These lesions are frequently spinous cell carcinomas and basal cell carcinomas (25% of all oral cancers). The spinous cell carcinoma is mainly located in the lower lip, the basal cell carcinoma is more common in the upper lip. The incidence of lip cancer in males is much high than in females. The etiopathogenesis of these lesions is connected with exposure to sun, smoking, genetics predisposition (mutation of the p53 suppressor factor) and with the evolution of precancerous lesions (radiodermatitis, chronic cheilitis, xeroderma pigmentosum). Some Authors emphasized the viral etiopathogenesis: HPV16, HPV24, HSV1, HSV2. The treatment of lip carcinoma is surgical: excision and reconstruction. The numerous reconstructive techniques are mostly the cutaneous local sliding flaps and the rotation flaps. The lip reconstruction require a remarkable diligence for preserve, as much possible, the shape and functions of lip. The Authors report their experience about the surgical treatment of 19 patients with lip carcinoma (16 spinous cell carcinomas, 3 basal cell carcinomas) and describe the main surgical reconstructive techniques to preserve the feeding, phonation and mimic expression.