Application of cardiopulmonary bypass for resection of renal cell carcinoma and adrenocortical carcinoma extending into the right atrium

AIM: The application of cardiopulmonary bypass to atrial involvement represents an important advance that has improved the safety and technical efficacy of a difficult surgical undertaking. Our experiences of the management of extended thrombi into the right atrium in patients with retroperitoneal malignancy using a cardiopulmonary bypass were discussed. METHODS: Data were reviewed for five patients (two men and three women; mean age, 60.4 years; range, 49-79 years) with retroperitoneal tumors displaying intracardiac tumor extension. Tumors originated in the right kidney in four patients, and in left adrenal gland in one patient. Cardiopulmonary bypass was used in all cases. RESULTS: Mean total blood loss was 6059 mL. Mean operative time was 14.7 h. No intra- or postoperative complications due to surgical technique were encountered, and no significant bleeding occurred during incision of the inferior vena cava or after removal of tumor thrombus. The follow-up period ranged from 3 to 20 months with a mean of 12.6 months. Of the five patients, three died of metastatic diseases, one died of liver dysfunction and one remains disease free as of 18 months postoperatively. CONCLUSIONS: Our experience indicates that this procedure can be safely used for atrial involvement. Although superior long-term survival cannot be shown yet, favorable early results and a lack of perioperative complications were identified.     

Renal angiomyolipoma extending into the right atrium

Renal angiomyolipomas (AMLs) are benign renal tumors that may possess the features of a malignant neoplasm, such as local and vascular invasion. We describe the diagnosis and management of a rare case of AML associated with tumor thrombus extending into the right atrium.     

Adrenal leiomyosarcoma extending into the right atrium

Primary soft tissue sarcoma of the adrenal gland is very rare and aggressive. In right adrenal tumors, because of direct venous drainage into inferior vena cava, the tumor may invade the vena caval wall toward the right atrium. We present a case of adrenal leiomyosarcoma extending into the right atrium.     

Hepatocellular carcinoma with tumor thrombus extending into the right atrium: report of a successful resection with the use of cardiopulmonary bypass.

Hepatocellular carcinoma with a tumor thrombus extending into the right atrium has been considered beyond the reach of resection. These patients usually die within a short period because of pulmonary embolism, heart failure, or cancer progression. The only treatment is hepatic resection with removal of the tumor thrombus. A 38-year-old woman underwent left lobectomy with removal of the tumor thrombus with the use of cardiopulmonary bypass. The patient had an uneventful course and is doing well 15 months after surgery, without signs of recurrence. We have proved that hepatic resection with removal of a tumor thrombus extending into the right atrium can be carried out successfully. The next problem is whether the lives of these patients can be prolonged by this operation.     

Three staged approach to the surgical management of renal cell carcinoma extending into the right atrium. Case report

Left renal cell carcinoma extending into the right atrium was treated by angioinfarction, removal of right atrial tumour using cardiopulmonary bypass and ten days later abdominal radical nephrectomy and inferior vena cava thrombectomy. Twenty four months later the patient remains well with no evidence of tumour recurrence.     

A case report of left renal cell carcinoma with tumor thrombus extending into the right atrium

A case report of left renal cell carcinoma with tumor thrombus extending into the right atrium is reported. A 76-year-old woman was found to have a left renal tumor with tumor thrombus extending into the inferior vena cava and right atrium by computed tomographic-scanning. Left nephrectomy and removal of an intra-atrial tumor thrombus were performed under a cardiopulmonary bypass. The post-operative course was uneventful and the patient was discharged from the hospital 22 days postoperatively. The pathological diagnosis was clear cell carcinoma. After surgery, the patient received interferon-gamma. However, the patient developed lung metastases 26 months after the operation and is currently being observed while receiving interferon-alpha.     

Clinical experience with assisted venous drainage cardiopulmonary bypass in elective cardiac reoperations

Reoperative cardiac surgery is associated with substantial morbidity and mortality due to technical problems at sternal reentry, which can result in laceration of the right ventricle, innominate vein injury, or embolization from patent grafts. To minimize the risk associated with reentry, we adopted the method of assisted venous drainage in the cardiopulmonary bypass circuit with peripheral cannulation for cardiac reoperations. From March 1999 to May 2003, a series of 52 patients (38 males; mean age 48.7 years, range 4 months to 78 years) underwent cardiac reoperations performed with centrifugal pump venous-assisted cardiopulmonary bypass. EuroSCORE was 7.34 +/- 3.9 (range, 4-19). The reoperations were coronary artery bypass graft (25 patients), valve replacement/repair (18 patients), and complex pediatric procedures (11 patients). The studied adverse events were structural damage at reentry, mortality, blood loss, stroke, and hemolysis. Complications at sternotomy were damage to the innominate vein (1 patient) and aorta (1 patient) with blood loss of 625 and 225 mL, respectively. Four patients required intraaortic balloon pump or extracorporeal membrane oxygenation (n = 1) for hemodynamic support on weaning off cardiopulmonary bypass. Three patients died in the postoperative period. Our experience with centrifugal pump-assisted venous drainage in cardiac reoperations has shown excellent results, with reduced risk of damage to vital structures on sternal reentry. In cases in which structural damage did occur, blood loss was minimal.     

Adrenal cortex carcinoma with right atrium involvement. Surgery with cardiopulmonary bypass

INTRODUCTION: Primary adrenal carcinoma is a low incidence tumour. About 50% are functional and the majority result in Cushing's syndrome, while detection of the rest is commonly incidental. Surgical management is through radical surgery. CASE REPORT: A 36-year old female who presented with a one-month old abdominal pain in the hypochondrium and the right lumbar fossa. Physical examination found a discretely painful mobile mass. Adrenal hormones values were normal. Ultrasound and CT studies detected a 14-cm adrenal tumour with cava vein thrombosis up to the right auricle. The surgical procedure included laparotomy, liver mobilisation and cardiopulmonary by-pass. The thrombus was completely removed by auriculotomy. Therapy with mitotane and 5-fluorouracil was then instituted. Thirteen months after surgery the patient is asymptomatic and tumour free. REMARKS: Dissemination of adrenal tumours to veins ranges between 6 to 30%. Clinical manifestation of cava vein and auricle involvement is variable but it may develop with no symptoms due to collateral circulation. Pre-operative diagnosis is critical to plan for adequate surgical approach. Ultrasound and computerised tomography can adequately diagnose the process, but nuclear magnetic resonance provides more information on the thrombus extension and location. In the absence of node spread, local extension, or invasion of the cava wall prognosis is similar to that of patients with no vein involvement. The best therapeutic option is surgery with removal of the lesion and cardiopulmonary by-pass. Survival at 5 years is 43%. Post-operative administration of chemotherapy with mitotane is a useful and recommendable choice.     

Resection of advanced stage malignant retroperitoneal neoplasms with tumor thrombus extending into the right atrium: Report of four cases

Surgery for retroperitoneal neoplasms with a tumor thrombus extension into the right atrium is challenging. This study reviewed four surgical cases of advanced stage malignant neoplasms with the tumor thrombus extending into the right atrium. The malignant neoplasms involved the kidney in two patients, and the liver and adrenal gland in one each. The tumor thrombus was removed through a longitudinal cavotomy and right atriotomy in all cases. The inferior vena cava reconstruction was performed by directly closing it in one patient and by pericardial patch suturing in another. Cardiopulmonary bypass was used for all procedures and a Pringle maneuver was used to reduce bleeding from the liver in three. There was no perioperative or hospital death. Two of the four with renal cell carcinoma were alive 7 and 13 months after the surgery. One with hepatocellular carcinoma died of recurrent malignancy after 4 months, while the patient with an adrenal carcinoma remained disease free after surgery. These cases indicate the safety of the present procedure. Although the long-term results are still unknown, there were favorable early results and a lack of perioperative complications. Surgical challenges in resecting an intracardiac extension of retroperitoneal malignancy require close cooperation among the attending urologist, and both gastrointestinal and cardiovascular surgeons.     

Removal of renal cell carcinoma extending into the right atrium: report of a case]

A 65-year old man presented with a seven-month history of macrohematuria and left back pain. Abdominal ultrasonography, enhanced computed tomographic (CT) scanning, magnetic resonance imaging (MRI), selective renal angiography and vena cavography revealed a left renal tumor extending into the inferior vena cava and right atrium. Surgery was performed using the cardiopulmonary bypass and the whole tumor was resected grossly except for the tumor invading into the lumbar vein. The patient recovered promptly but died from cancer metastasis six months after operation.     

Successful resection of cecal hepatic metastasis extending into the right side of the heart under cardiopulmonary bypass

Resection is the best hope for the cure of colorectal metastasis to the liver. However, surgery is indicated for only a few patients, especially those who have major vascular involvement. We report a 55-year-old woman with a liver metastasis from the cecum that showed a tumor thrombus in the right side of the heart. She had undergone laparoscopic right hemicolectomy for cecal cancer 6 months before, and presented with a palpable mass in the epigastrium. Abdominal ultrasonography, computed tomography, hepatic angiogram, and echocardiography showed a huge mass on the left lobe of the liver, with a tumor thrombus which extended to the right ventricle through the left hepatic vein and inferior vena cava. Tumor thrombectomy, through a right atriotomy, was success-fully performed under cardiopulmonary bypass, followed by left hepatic lobectomy. The patient's postoperative course was uneventful. Received for publication on Oct. 5, 1998; accepted on Jan. 11, 1999     

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).     

Pulmonary artery embolization of intravenous leiomyomatosis extending into the right atrium

A 43-year-old woman was diagnosed with an intravenous leiomyomatosis at a previous hospital and transferred to our hospital to undergo surgical treatment. Emergency one-stage operation for coincidental removal of intra-abdominal, right atrial, and intravenous masses were planned. Upon arriving at the operating room, she suffered a sudden onset of severe dyspnea and showed hemodynamic instability. Intraoperative TEE showed pulmonary embolization of a right atrial mass. Removal of the pulmonary artery mass and the intra-abdominal mass, and the cardiopulmonary bypass were performed without any complications.     

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.     

Treatment of renal cell carcinoma extending into the right atrium with extra-corporeal circulation using high-grade hypothermia: a case report

A 68-year-old woman underwent surgical treatment for renal cell carcinoma associated with tumor thrombus extending into the right atrium. Although the tumor thrombus reached the level of the right atrium, there were no other apparent metastases. Combination therapy with interferon alfa plus tegafur/uracil (UFT) was attempted with the expectation of reducing the tumor thrombus, but there was no change. Successful management was achieved with right radical nephrectomy, right auriculotomy, and partial cavectomy using cardiopulmonary bypass under high-grade hypothermia. After removal of the tumor and thrombus, blood loss was 13,900 ml during the patient's recovery. She had mild heart failure for about two weeks after the operation, but recovered. She was discharged on the 40th day after the operation. Proper preparation for blood transfusion is the key point of this operation.     

Anesthetic management of a patient with hepatocellular carcinoma with tumor thrombosis extending into the right atrium

We report a patient with hepatocellular carcinoma whose tumor thrombus was extending into the right atrium. A 55-year-old man underwent extended anterior segmental hepatectomy and removal of the tumor thrombus in the right atrium under cardiopulmonary bypass and general anesthesia using sevoflurane, nitrous oxide and oxygen. End-tidal carbon dioxide was closely monitored to detect pulmonary tumor emboli during the surgery. Intravenous fluid and blood transfusion in large volumes were necessary to avoid circulatory derangement.     

Less invasive surgical treatment of renal cell carcinomas extending into the right heart and pulmonary arteries: surgery for renal cell carcinoma

BACKGROUND: Radical resection using deep hypothermic circulatory arrest improves the survival of patients with transvenous intracardiac tumor extension of renal cell carcinomas. A less invasive surgical approach avoiding deep hypothermia, circulatory arrest, and cross-clamping of the aorta is presented. METHODS: Between 1987 and 1999, 12 patients (mean age 57+/-8 years) underwent resection of a renal cell carcinoma extending into the right atrium, right ventricle, or pulmonary arteries. After median sterno-laparotomy, normothermic cardiopulmonary bypass is used cannulating the ascending aorta, superior caval vein, and inferior caval vein below the renal veins. The tumor and the corresponding kidney are radically excised, including the renal vein. Tumor fragments from the inferior caval vein, the right heart, and pulmonary arteries are removed either on the fibrillating or beating heart. RESULTS: Operative mortality was 0%. Mean cardiopulmonary bypass time was 53+/-27 minutes (median 36; range 32-110 minutes). Mean blood loss per patient was 1200 mL. Mean duration of postoperative mechanical ventilation was 36+/-12 hours (median 36; range 30-77 hours), mean intensive care stay 5.5+/-5 days (median 3; range 1-48 days), and mean duration of hospitalization 22+/-12 days (median 21; range 10-58 days). All patients were discharged home. Patients with multiple tumor manifestations outside the cardiovascular systems died within 9 months after the operation. CONCLUSIONS: The use of normothermic cardiopulmonary bypass is a less invasive method for radical resection of renal cell carcinoma with intracardiac tumor extension. Radical resection does not improve survival in patients with multiple distant metastases.     

Anesthetic management of a patient with hepatocellular carcinoma with tumor thrombus extending into the right atrium

A 58 year-old male was scheduled for surgery of his hepatic cancer. Tumor invaded to the right atrium through the inferior vena cava. The operative method of removing the tumor in the right atrium was scheduled under extracorporeal circulation after the left lobe hepatectomy. Since there was a tumor in the right atrium, central venous pressure monitoring could not be reliable. Transesophageal echocardiography (TEE) was employed in order to detect the part of the tumor flowing into the pulmonary artery or occluding the tricuspid valve. Due to massive blood loss during hepatectomy, the capacity in the right atrium decreased and the tumor was often about to engage the tricuspid valve. After the rapid fluid therapy, the right atrium capacity increased preventing the engagement of the tumor. TEE was useful not only to observe the movement of the tumor in the right atrium but also to monitor the circulating blood volume.