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.     

Techniques for Avoidance of Sternotomy and Cardiopulmonary Bypass During Resection of Extensive Renal Cell Carcinoma with Vena Caval Tumor Thrombus Extension Above the Diaphragm

Abstract   Renal cell carcinoma (RCC) is a commonly encountered malignancy in urology. Extensive RCC may frequently invade the renal vein and the inferior vena cava (IVC). In advanced cases, this tumor thrombus may grow cephalad up to the level of the right atrium. The mainstay of surgical treatment for such lesions remains resection of all possible tumor burden. Current techniques for resection of supradiaphragmatic RCC tumor thrombus in the IVC incorporate cardiopulmonary bypass (CBP) with deep hypothermic circulatory arrest, especially in cases where the thrombus reaches the right atrium. We report a safe technique using a transabdominal approach to such lesions that allows exposure to the level of the intrapericardial IVC and right atrium permitting safe resection of the tumor thrombus without median sternotomy, CBP, or deep hypothermic circulatory arrest.     

Surgical resection of adrenal carcinoma extending into the vena cava, right atrium and ventricle: case report and review of the literature

A case of adrenal carcinoma with the tumor thrombus extending into the right atrium and right ventricle is reported. A 46-year-old man was admitted because of abdominal distention and back pain. Angiogram, venacavography, dynamic CT, cardio-echogram and determinations of blood concentration of hormones disclosed a huge non-functional right adrenal tumor and its thrombus having extended into the right atrium and ventricle via the right adrenal vein. Right adrenalectomy and nephrectomy were followed by simultaneous removal of the tumor thrombus. The resected tumor was 14 X 11 X 7 cm in size and 880 g. The thrombus was 90 g. Pathohistological diagnosis of sarcomatoid adrenocortical carcinoma was made. The patient was discharged three weeks after operation and had been remained asymptomatic for 5 months. He died of the recurrence of the tumor on the 206th postoperative day. In the review of English and Japanese literature, 61 cases of malignant tumors extending into the right atrium were analyzed, among which only one case was an adrenal tumor. From this survey, it seems that aggressive resection would provide better survival, and a surgical excision with a use of cardiopulmonary bypass is worth trying for such conditions.     

Renal angiomyolipoma with a tumor thrombus extending into the right atrium--a case report]

We present a case of spontaneous rupture of renal angiomyolipoma with a tumor thrombus extending from the right renal vein and inferior vena cava to the right atrium. A 41-year-old woman, previously in good health, was referred to our hospital with right flank pain. Computed tomography showed fat densities in both tumor and thrombus. Other imaging examinations also demonstrated a large right renal mass (18 cm in diameter), a long tumor thrombus (13 cm in length) and a small left renal tumor (1.5 cm in diameter). Right nephrectomy and en-bloc removal of the intra caval and intracardiac tumor thrombus were performed on cardiopulmonary bypass. It was pathologically diagnosed as an angiomyolipoma without tuberous sclerosis. At present, three years after surgery the patient is doing well, showing neither metastasis nor increase of the left renal angiomyolipoma. To our knowledge, our case seems to be the 3rd case report of renal angiomyolipoma with a tumor thrombus extending to the right atrium. We conclude that renal angiomyolipoma even with an intra cardiac tumor thrombus can be resected safely and successfully.     

Surgical treatment under extracorporeal circulation for renal cell carcinoma with tumor thrombus in inferior vena cava]

Three cases of renal cell carcinoma with tumor thrombus extending into the inferior vena cava are reported. Radical nephrectomy and thrombectomy were performed under extracorporeal circulation in all the cases. The level of tumor thrombus was preoperatively determined by computed tomography, magnetic resonance imaging or venacavography. The tumor thrombus extended into the right atrium in one, and above the hepatic vein in two cases. One patient whose thrombus reached the right atrium died of multiple metastasis of renal cell carcinoma 5 months after operation. Another patient with lung metastasis was given interferon-alpha and is alive 5 months after operation. The other patient is clinically free of disease and in good health 7 years after operation. We believe that extracorporeal circulation allows an opportunity to resect the tumor thrombus in a controlled situation, and makes the operation safer.     

Transesophageal echocardiography in the surgical management of renal cell carcinoma with intracardiac extension.

Renal cell carcinomas may extend into the vena cava and the tumor thrombus occasionally involves the right atrium. The operative approach depends upon precise preoperative and intraoperative staging and thrombus localization. We report a case of renal cell carcinoma with complete inferior vena caval and hepatic vein occlusion with tumor extension into the right atrium. Preoperatively, transesophageal echocardiography provided superior images of the tumor and its extension, and intraoperatively allowed continuous monitoring of cardiac function and the removal of tumor from the atrium and inferior vena cava. Its use obviated the need for more costly and invasive preoperative and intraoperative procedures.     

Renal cell carcinoma accompanied by venous invasion and inferior vena cava thrombus: classification and operative strategies for the vascular surgeon

Venous invasion is a common characteristic of renal cell carcinoma, manifesting as tumor thrombus with possible extension into the renal vein and, in extensive cases, the thrombus can reach from the renal vein to the right atrium. Currently, cytoreductive nephrectomy and tumor thrombectomy are the foundations for improving quality of life and survival in the treatment of renal cell carcinoma, and a role has emerged for a vascular specialist to become an integral part of operative planning and therapy.     

Pheochromocytoma with thrombus in cava

Pheochromocytoma, a paraganglioma of suprarenal location, is a catecholamine-secreting chromaffin cell tumour. Spread of these tumours to the vena cava is rare and the thrombus only reaches the right atrium in exceptional cases. We present the case of a patient who, without previous symptomatology, presented with a clinical picture of multiorganic dysfunction with primary manifestation of a suprarenal tumour with vascular spread to the right atrium affecting the right suprahepatic vein.     

Open heart surgery for posttraumatic inferior vena caval thrombosis.

A 40-year-old woman was diagnosed as intrahepatic hematoma after blunt abdominal trauma. One month later computed tomography (CT) revealed the inferior vena caval thrombus extending into the right atrium. Emergency thrombectomy was performed under cardiopulmonary bypass. We believe that the thrombus, which was derived from laceration of the hepatic vein, extended through the inferior vena cava into the right atrium, and was the eve of pulmonary embolization. CT study should be repeated, once the intrahepatic hematoma was recognized. We emphasize that we should recognize the existence of such complication to prevent the catastrophic result.     

Pulmonary thromboembolism with floating thrombus trapped in patent foramen ovale

A 39-year-old man was hospitalized with symptoms of acute deep vein thrombosis, and computed tomography showed that he had pulmonary thromboembolism. Transthoracic echocardiography showed a large, right atrial thrombus and transesophageal echocardiography showed migrating thrombus trapped in a patent foramen ovale and extending all the way up to the ascending aorta. He underwent surgical embolectomy under cardiopulmonary bypass. At the conclusion of the operation, repeat transesophageal echocardiography examination revealed fresh but small thrombus in the right atrium. This continued entry of thrombi into the heart was further managed with fluoroscopy-guided insertion of a retrievable inferior vena cava filter through the internal jugular vein in the operating room itself.     

Thyroid carcinoma with extensive tumor thrombus in the atrium

To our knowledge, only a few cases of thyroid carcinoma with an extensive tumor thrombus in the atrium have been reported in literature. We describe a unique case of papillary carcinoma of the thyroid with extensive tumor thrombus in the atrium. A 74-year-old man consulted our hospital because of thyroid carcinoma with an extensive tumor thrombus in the atrium. Computed tomography (CT) revealed a 2-cm tumor with extensive continuous tumor thrombus in the left jugular vein, innominate vein, superior vena cava, and atrium. The tumor was resected to reduce the risk of sudden death from tumor embolism into the pulmonary arteries. Histologically, the diagnosis was papillary carcinoma of the thyroid. Thyroid carcinoma, especially papillary carcinoma, rarely develops a macroscopic tumor thrombus. Patients with an extensive tumor thrombus generally have poor prognoses and high mortality. This patient has been followed for 7 months after successful operation without recurrence.     

Thrombus entrapped in a patent foramen ovale of the atrial septum

A 59-year-old women was referred to our hospital due to severe dyspnea and shock status 12 days after intracranial hematoma evacuation for the hypertensive right putaminal hemorrhage. Transthoracic echocardiography revealed right ventricular dilatation and floating structures in the right atrium. Transesophageal echocardiography demonstrated a large, snake-like structure crossing her foramen ovale of the interatrial septum, and impending paradoxical embolism was diagnosed. She did not receive any anticoagulation and surgery due to recent cerebral hemorrhage. Follow-up TEE showed complete disappearance of the thrombus in the atrium two weeks after the onset. Phlebogram of deep vein demonstrated several thrombus in her leg. She underwent placement of inferior vena cava filter and was discharged from our hospital without any symptom of paradoxical embolism.     

A case of tumor thrombus in the right atrium after multimodal treatment of testicular tumor

A case was reported concerning a successful removal of tumor thrombus extending into the right atrium through the left brachiocephalic vein and the superior vena cava. The patient was a 34-year-old man who underwent a left inguinal orchiectomy for immature teratoma of testis in June 1987. The operation was followed by another three operations for excision of lymph node metastases and five courses of cisplatin based combination chemotherapy. In December 1988, the chest CT scan film revealed filling defect in the superior vena cava and the right atrium. Thrombus was detected using echocardiography and angiography. He had no symptom, but multiple pulmonary infarcts were also detected. In February 1989, the operation was performed by means of cardio-pulmonary bypass. A soft yellowish thrombus attached to the left venous angle was removed with resection of the left brachiocephalic vein. Microscopic findings revealed that the thrombus was metastatic testicular teratoma. With further treatment after the operation, he has been disease-free for 14 months now. We conclude that in this case aggressive surgical management following chemotherapy had great value to control the disseminated testicular tumor.     

Left atrial thrombus in an 80-year-old woman scheduled to have an operation for uterus cancer; report of a case

An 80-year-old woman was scheduled to have an operation for uterus cancer. Echocardiography revealed a giant mobile mass in the left atrium with a stalk at posterior wall of the left atrium. There was no significant mitral disease. Due to the risks of sudden circulatory collapse and systemic emboli, an emergency operation was indicated. Right side of the left atrium was opened under cardiopulmonary bypass following median sternotomy. The mass was attached to the posterior wall, 1.5 cm medial to the right upper pulmonary vein, with a thin stalk as diagnosed preoperatively. The mass (4.2 x 3.4 x 3.4 cm) was removed very easily. Pathological analysis revealed that the mass was a thrombus mixed with fibrin. A possible cause would be paroxysmal atrial fibrillation and/or hypercoagulative status due to malignancy. Anti-coagulation therapy was initiated postoperatively to prevent recurrence of thrombus. The patient recovered and discharged uneventfully.     

Intravenous leiomyomatosis of the uterus with extension into the heart

A case was reported concerning a successful removal of a leiomyoma with extension into the right atrium through the right ovarian vein and the inferior vena cava. The patient was a 72 year-old woman who had suddenly suffered dyspnea and palpitation. She was hospitalized, and a mass in the right atrium and the inferior vena cava was discovered using echocardiography and magnetic resonance imaging. A myxoma in the right atrium with a thrombus in the inferior vena cava was diagnosed preoperatively. The operation was performed in July 1987 by means of cardio-pulmonary bypass. During atriotomy of the right atrium, a large sausage-shaped mass of milky-pinkish color was found. Though the root of the mass was centered beyond the periphery of the inferior vena cava, most of it was removed through the right atrium. Immediately after extirpation of the tumor, hypotension and abdominal distention occurred in the patient, and emergency laparotomy was carried out. Retroperitoneal bleeding from the right ovarian vein occurred and the similar tumors were observed in the right ovarian vein. Intravenous leiomyomatosis of the uterus with extension into the heart is very rare, this being only the seventeenth case reported in literature. To the best of our knowledge, this was also the oldest patient on record. The good surgical method for this tumor seems to be total removal using cardio-pulmonary bypass and laparotomy at the same time.     

Fiberoptic examination of the inferior vena cava during circulatory arrest for complete removal of renal cell carcinoma thrombus

Renal cell carcinoma is known to invade the inferior vena cava and may extend its entire length. Profound hypothermic circulatory arrest has been demonstrated to be a very effective technique to facilitate removal of tumor thrombus from the cava while limiting the amount of blood loss. We describe an innovative method of ensuring complete removal of tumor thrombus from the retrohepatic cava with a fiberoptic bronchoscope introduced through the right atrium during profound hypothermic circulatory arrest. Fiberoptic examination of the cava and hepatic vein orifices under these circumstances will prevent incomplete removal of tumor.     

Removal of intra-atrial tumor thrombus of renal cell carcinoma: report of a case

A case of left renal cell carcinoma with a tumor thrombus extending into the vena cava and the right atrium is reported. A 49-year-old female presented with a one month history of palpitation, dyspnea, and leg edema. CT-scanning and angiography revealed a left renal tumor with a tumor thrombus extending into the right atrium. Left nephrectomy and the removal of an intra-atrial tumor thrombus were performed under cardiopulmonary bypass. The postoperative course was unfavorable and the patient died on the 42nd day after the operation because of multiple organ failure in spite of repeated hemoperfusion. Operative procedure and prognosis of renal cell carcinoma with tumor thrombus extending into the right atrium are discussed.     

Intracardiac extension of chondroblastic osteosarcoma

Intravascular tumour extension invading the intracardiac space is rarely seen with osteosarcoma. We present a patient with a history of previously resected pelvic osteosarcoma who was later found to have a local recurrence with continuous intravascular extension from the right femoral vein to the right atrium. Preoperative imaging studies initially described extensive thrombus burden, and a multidisciplinary approach involving open and percutaneous thrombectomy was planned. Intraoperative inspection and pathological analysis revealed unresectable malignant solid tumour rather than thrombus. Though exceedingly rare, the possibility of metastatic tumour must be considered when planning treatment strategies for these patients.     

Adrenal cortical carcinoma: preoperative demonstration of right atrial extension by sonography and computerized tomography

We report a case of adrenal cortical carcinoma with tumor thrombus extending to the right atrium. Tumor extension was demonstrated preoperatively with sonography and computerized tomography. We recommend that both modalities be used when evaluating masses in the suprarenal space. The preoperative diagnosis of tumor extension via the adrenal vein into the inferior vena cava was confirmed at operation.     

Renal cell carcinoma extending into the right atrium; report of a case

A 62-year-old male was diagnosed through abdominal ultrasonography, with right renal cell carcinoma extending into the inferior vena cava. Surgery was performed because echocardiography revealed the tumor to have reached the right atrium. The portion of the tumor situated in the right atrium was resected under the extracorporeal circulation. Distal part of inferior vena cava was resected with the tumor included. The tumor remaining in the confluence of hepatic veins was removed from the incised end of the inferior vena cava and was detached from the venous wall. Postoperative abdominal echography revealed a small additional tumor mass in hepatic veins. Although this mass was considered to be a remnant of the intravenous tumor, an additional surgical procedure was judged to be impossible. In retrospect, an additional long-axis incision on the inferior vena cava might have enabled us to catch the remnant of the tumor thrombus in the hepatic vein.