Extrapleural pneumonectomy with venous confluence resection for stage IVA thymic tumors

We report 4 patients with stage IVA thymic tumors who underwent extrapleural pneumonectomy and thymectomy with venous confluence resection using a temporary percutaneous venous jugular-femoral bypass technique. The superior vena cava was replaced in 2 patients, and the innominate vein was resected in 2 patients. Complete tumor resection was obtained in all patients. There was no 90-day postoperative mortality. One patient died at 6 months postoperatively of an unrelated cause, without recurrent disease, and 3 are alive and disease-free with a follow-up ranging from 19 to 80 months. Extrapleural pneumonectomy can be combined with thymectomy and venous confluence resection for stage IVA thymic tumors.     

Complete resection of a mediastinal solitary extramedullary plasmacytoma and reconstruction of right pulmonary artery and superior vena cava

Solitary extramedullary plasmacytoma located in the thorax is a rare tumor. We present a 21-year-old patient who was diagnosed with a mediastinal solitary extramedullary plasmacytoma. Complete resection of the tumor with reconstruction of the right pulmonary artery and superior vena cava was performed. The patient is alive without evidence of recurrence 8 months after the operation. Extensive resection and reconstructive surgery with the addition of radiotherapy can prolong the patient's life.     

Right superior vena cava draining in the left atrium: anatomical, embryological, and surgical considerations

A newborn, with SDS (S = situs viscero-atrialis solitus, D = D-loop of the ventricles, S = solitus, normally related great arteries) anomalous drainage of the right superior vena cava in the left atrium, intact atrial septum, and anomalous drainage of the right superior pulmonary veins in the right superior vena cava, underwent surgical repair at our institution. This rare cyanotic, congenital, cardiac malformation is herein described with particular regard to its anatomical, embryological, and surgical implications.     

肾脏恶性肿瘤并静脉转移的外科治疗

目的：探讨肾脏恶性肿瘤并发静脉内转移的外科治疗方法及预后。方法：报告10例肾脏恶性肿瘤，其中肾细胞癌6例，肾母细胞瘤2例，肾盂癌1例，肾平滑肌肉瘤1例。肾静脉内转移4例，肝下型腔静脉转移5例，肝后和肝上的腔静脉内转移1例。在根治性切除患肾的同时阻断瘤栓上下的腔静脉和对侧肾静脉，完整取除瘤栓，腔静脉壁受累者同时切除腔静脉壁，术后辅以免疫治疗和放射治疗。结果：随访7年，平均5年生存率40％，肾母细胞瘤生存期小于3年，腔静脉壁受累者生存期小于1年，并发区域淋巴结转移者5年生存率33％。结论：手术切除静脉内转移癌是提高患者生存期的惟一手段，其预后取决于原发癌肿的性质和癌栓是否完全切除，而与癌栓的位置无直接相关。静脉内肿瘤转移同时并发腔静脉壁受累或区域淋巴结阳性的患者预后较差。     

Fibrosing mediastinitis as a cause of superior vena cava syndrome.

Fibrosing mediastinitis is a rare, chronic inflammatory process that can cause superior vena cava syndrome, and can mimic malignancy. We present two cases of this disease where surgical resection was not possible and review the treatment options.     

En bloc resection of 3 vertebra in a pancoast patient: long-term stability using a free vascularized fibular graft

Vertebral involvement is no longer a contraindication for resection in superior sulcus tumors. We describe the reconstruction of thoracic vertebras 2 to 4 using a free vascularized fibular graft combined with dorsal and ventral stabilization using rods, screws, and hooks after resection of a superior sulcus tumor that invaded the thoracic spine. No complications have occurred after 7 years of follow-up, and the reconstruction has been durable and stable.     

The difficult approach to neoplastic superior vena cava syndrome: surgical option

AIM: Superior vena cava syndrome is a dramatic event that can be cured in specialized centers. METHODS: Between 1989 and 1995 6 patients with superior vena cava syndrome underwent surgical treatment for thoracic tumors. In all cases the vena was restricted by a neoplastic sleeve. A median sternotomy was performed in all cases. Two patients received an associated right anterolateral thoracotomy to obtain good surgical exposure for tumor resection and grafting. A 12 mm diameter polytetrafluoroethylene graft was inserted in all cases. The tumor resection was radical in 4 cases (2 thymic carcinomas, 2 malignant germ cell tumors) and palliative in 2 (1 non-small cell lung cancer and 1 mediastinal fibrosis). RESULTS: We had no in-hospital mortality. All patients had immediate relief of obstruction after by-pass. Three patients were alive without disease at the end of follow-up (40-96 mo), one patient died of postoperative complications after 4 mo, 2 patients died of disease after 4 and 12 mo. CONCLUSION: PTFE by-pass graft for treatment of the obstructed SVC relieves SVC syndrome and has good medium term patency.     

Curative surgery for locally advanced retroperitoneal mature teratoma in an adult. Case report

INTRODUCTIONPrimary teratomas of retroperitoneum are not usual in the adult population. These tumors most commonly seen at the gonadal and sacrococcygeal regions. Herein we describe a case of an 18-year-old female who had a benign cystic teratoma at the retroperitoneum.PRESENTATION OF CASEThe patient underwent an operation at another hospital following a misdiagnosis of hydatid cyst. The patient was referred to our hospital because of the detection of an unresectable tumor during her operation. A computerized tomography (CT)–angiography revealed a cystic mass, with a diameter of 14 cm which was invaded into the retrohepatic suprarenal inferior vena cava and also extended to the posterior aspect of the liver. Additionally the mass invaded the posterior wall of the inferior vena cava and the right renal vein. The tumor was completely resected with a vascular resection. The inferior vena cava was reconstructed with a 12 cm Dacron^® graft and the renal vein was implanted. The patient's postoperative period was uneventful.DISCUSSIONGerm cell tumors of retroperitoneum are usually seen in children, but there are also some reports of adult cases in the literature. Adult cases are especially seen in females. Imaging studies are paramount for diagnosis, preoperative strategy and safe surgical excision. CT scans and MRIs can identify various components of these tumors.CONCLUSIONEven though primary retroperitoneal teratomas are quite rare in adults. Preoperative radiology imaging and strategy is critical for performing a safe surgery. The gold standard treatment strategy for this neoplasm is the surgical resection.     

上腔静脉成形术在胸部恶性肿瘤治疗中的应用

目的探讨上腔静脉(SVC)置换或成形术治疗胸部恶性肿瘤侵及SVC患者的手术技术选择和麻醉管理特点。方法2000年1月至2006年10月行SVC成形或置换术治疗胸部恶性肿瘤侵及SVC患者73例,其中行肺切除(含支气管成形术) SVC成形/置换术42例;纵隔肿瘤切除 SVC成形/置换31例。直接修复21例,SVC阻断下补片修补22例,腔内引流技术下补片修补15例;人造血管置换15例。结果手术死亡3例。术后所有患者SVC梗阻症状于24～48h内明显缓解,未见脑部损害及严重并发症。随访6～42个月,随访率78.57%,3个月后再发SVC梗阻症状患者1例;1年和2年生存率分别为74.55%和58.19%。结论肿瘤侵及SVC给外科手术带来一定的难度和风险,合理恰当的外科手术技术和麻醉管理可保障SVC重建术安全实施,改善患者生存质量,延长生存时间。     

Partial anomalous pulmonary venous connection to the superior vena cava

We describe the surgical technique of reimplantation of the right superior pulmonary vein into the left atrium in 2 patients with partial anomalous pulmonary venous connection to the superior vena cava without atrial septal defect. A right axillary minithoracotomy is done through the fourth intercostal space. The pulmonary vein is detached from its origin in the superior vena cava. This is sutured with 6-0 reabsorbable polydioxanone suture (Ethicon, Somerville, NJ). A lateral clamp is applied to the left atrium, and the pulmonary vein is reimplanted. The patient is extubated in the operating room. Neither cardiopulmonary bypass nor blood transfusion was required. It is simple, safe, and reproducible.     

Resection of malignant tumors invading the vena cava: perioperative complications and long-term follow-up

OBJECTIVE: Invasion of the vena cava by malignant tumors is generally considered an absolute contraindication for surgery as a result of high surgical risk. Surgical treatment with resection of the vena cava may be beneficial for selected patients. This study was performed to evaluate our experiences with resection of the vena cava for malignant tumors, with a special focus on secondary tumors involving the inferior caval vein. METHODS: A total of 35 patients underwent extended resection of malignant tumors invading the vena cava. Prosthetic repair was performed in 13 patients by using a ringed polytetrafluoroethylene graft. Preoperative risk factors, mortality and morbidity, and long-term follow-up and graft patency rates were examined. RESULTS: The operative mortality rate was 6%. Minor complications occurred in 12 patients (34%). The graft patency rate was 85%, and there was no graft-related perioperative morbidity. The 1-, 3-, and 5-year survival rates were 76%, 32%, and 21%, respectively, with a median survival of 29 months. Incomplete resection and cardiopulmonary risk have a significant negative effect on survival. CONCLUSIONS: Radical resection of the vena cava is a feasible procedure in highly selected patients, with low morbidity and mortality and acceptable survival rates, especially in patients with complete resection of the tumor.     

Superior vena cava bypass with cryopreserved ascending aorta allograft

Initially superior vena cava obstruction is typically managed by an endovascular approach. However, in some patients, particularly those in whom angioplasty and stenting is not technically possible, or those who have recurrent disease after previous endovascular repair, an open surgical approach may be indicated. Conduit choices for caval reconstruction are less than ideal; hence we describe a case using a cryopreserved aortic allograft.     

Surgery insight: management of renal cell carcinoma with associated inferior vena cava thrombus

Renal cell carcinoma with inferior vena cava thrombus can be a diagnostic and therapeutic challenge; however, the surgical resection of these tumors can be facilitated by appropriate preoperative imaging and planning. First and foremost, we believe that this procedure should be considered an operation on the inferior vena cava rather than on the kidney. The level and extent of the tumor thrombus dictates the surgical approach used. Although the patient should be given an appropriate explanation of the procedure and its risks, the surgeon needs to be adequately prepared and have intraoperative versatility in order to maintain the safety of this operation. In this Review, we describe our approach to surgical resection in patients who have renal cell carcinoma with inferior vena cava thrombus, and outcomes for the management of patients with this disorder.     

Osteosarcoma invading adrenal gland: rare cause of adrenal mass

Adrenal gland metastasis from osteogenic sarcoma is extremely rare and is an atypical location for metastasis. Vascular hepatic exclusion techniques and the use of venovenous bypass with cardiac surgical techniques may be required to resect large adrenal masses that have invaded the inferior vena cava to achieve curative resection. The use of newer chemotherapeutic agents and aggressive surgical resection have prolonged the survival of patients with osteosarcoma.     

A successful surgical repair of anomalous right pulmonary venous connection with Goldenhar syndrome

A ten-year-old girl with Goldenhar syndrome underwent intracardial repair for partial anomalous right pulmonary venous connection into the superior vena cava. In surgical procedure the proximal tract of superior vena cava was reconstructed into double floor, low floor was tract for anomalous pulmonary venous blood drained into left atrium through the atrial septal defect which was made with resection of prinum septum, upper floor was a real tract for superior venous blood. After operation, arrhythmia did not detect. One month after operation, no stenosis along the superior vena cava or right pulmonary vein were evidenced in catheterization. This surgical technique is superior to using baffle for preventing thrombogenesis. The result suggested that this surgical technique is preferable to the reconstruction of baffle in superior vena cava.     

Superior vena cava replacement in thymic tumours treated with radio-chemotherapy

From 1987 to 2000 108 patients were operated on for thymic tumours. Two of these underwent replacement of the superior vena cava with polytetrafluoroethylene prostheses because the tumours invaded the superior vena cava. One of these was affected by myasthenia gravis, and was treated preoperatively with concurrent radio-chemotherapy and lymphocytopheresis. The other received preoperative chemotherapy and post-operative radio-chemotherapy because of minimal residual disease. The clinical courses of the two patients are reported here and we conclude that eradication of thymic malignancies is suitable even when superior vena cava replacement is required, and that neither antimyasthenic therapy nor adjuvant and/or neoadjuvant treatment interfere with aggressive surgical management or vice versa. Moreover, the long-term survival of one of these patients despite relapse of disease shows that extended surgery is indicated in these cases.     

The role of radical surgery for renal cell carcinoma with extension into the vena cava

PURPOSE: New operative technologies, such as the bypass procedures that have become established in the last decade, have led to improved prognosis in patients with renal cell carcinoma and vena caval thrombi. We report the outcome of stage dependent surgical strategies in patients with renal cell carcinoma extending into the vena cava. MATERIALS AND METHODS: From January 1987 to August 1998, 93 patients with renal cell carcinoma invading the inferior vena cava were seen at our institution. Of the patients 79 underwent radical nephrectomy, phlebotomy and thrombus extraction, including 74 who underwent surgical treatment with cardiopulmonary bypass and deep hypothermic circulatory arrest. In 2 patients with retrohepatic thrombi we placed a pump driven femoro-axillary shunt during surgical resection of the retrohepatic tumor portion. RESULTS: Distant metastases and lymph node involvement proved to be highly significant prognostic factors for survival, while the cranial extent of the tumor thrombi had no prognostic impact. Patients without distant metastases had a 5-year survival rate of 34%, which improved to 39% if regional lymph nodes were not involved. There were 5 perioperative deaths (6.3%) and the highest perioperative mortality rate (40%) was seen in patients with supradiaphragmatic thrombi. CONCLUSIONS: Radical surgery for renal cell carcinoma extending to the vena cava is justified when the tumor thrombus does not extend beyond the level of the diaphragm in the cranial direction. In view of the high perioperative mortality decisions about radical surgery must be made individually in patients with level IV thrombi, even if long-term survival is possible.     

Repair of lacerated intrapericardial inferior vena cava after cardiac massage

We successfully undertook surgical treatment of intrapericardial laceration of the inferior vena cava caused by external cardiac massage in a patient with acute coronary syndrome. Injury to the inferior vena cava without blunt trauma is very rare, and diagnostic imaging does not show it clearly, making it difficult to diagnose. Rapid and accurate judgment and management are necessary, because the mortality due to this injury is very high.     

腹膜后肿瘤术中腹主动脉及下腔静脉的切除与重建

目的 探讨累及腹主动脉及下腔静脉的腹膜后肿瘤切除时,受累血管的切除与重建的最佳方法。方法回顾性总结1990年1月至2003年6月33例累及腹主动脉及下腔静脉的腹膜后肿瘤的手术切除及血管重建的临床资料。结果全部病人均成功实施了肿瘤完整切除,包括受累血管的切除与重建,无手术死亡。随访29例,其3、5年存活率分别为60,1％和40．6％,平均存活期为53．9个月。结论累及腹主动脉及下腔静脉的腹膜后肿瘤不是根治性切除的手术禁忌证,腹主动脉及下腔静脉的切除与重建术,安全、有效、可行;重建腹主动脉及下腔静脉可以提高肿瘤的切除率,降低局部复发率,延长病人存活时间。     

Surgical treatment of stage III and IV thymoma

During past 15 years, 39 cases of thymoma were underwent surgical intervention. In these cases, invasive type, so called stage III and IV in Masaoka's classification were 19 cases. This report documents the results of extended operation in 19 patients treated for malignant thymoma. All patients had neoplasm which invaded adjacent structures; superior vena cava, pericardium, and lung. Eight patients had disseminated lesions in the pleural or pericardial cavities. All patients were underwent surgical exploration through median sternotomy (18 patients) or left thoracotomy (1 patient). Our surgical management to malignant thymoma is to have complete resection, even if tumor invades the great veins. Of 8 patients, superior vena cava and left innominate vein were resected with tumor and reconstructed with ringed PTFE. Mediastinal pleura and pericardium should be widely opened and intrapericardial or intrapleural disseminated lesions should be removed as far as possible. Malignant thymoma could be resected completely applying technique of vascular surgery. Good results were expected when tumor was resected with invading adjacent structures completely. Reoperation to the recurrent tumor is also important.