The removal of renal carcinoma thrombus extending to the right atrium by means of extracorporeal circulation: report of a case]

A case of renal cell carcinoma with a tumor thrombus extending to the right atrium was reported. A 70-year-old woman was admitted with a diagnosis of right renal tumor which had been detected on a routine abdominal ultrasonography. MRI revealed a tumor thrombus extending into the right atrium through the inferior vena cava. A transesophageal echocardiogram confirmed that the tumor extended into the right atrium, and was not adherent to the inferior vena cava and the atrium. Right nephrectomy and removal of the tumor thrombus were performed using extracorporeal circulation. Temporary occlusion of portal venous and hepatic arterial inflow was effective in reducing blood loss. She has been doing well, and there has been no evidence of recurrence during 18 month postoperatively.     

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.     

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.     

Extension of renal cell carcinoma into the vena cava: clinical review and surgical approach

Between 1972 and 1983, 25 patients were treated for renal carcinoma with tumor extension into the vena cava but without other clinical evidence of disseminated disease. Of these patients 12 had vena caval tumor thrombus extension up to the level of the hepatic veins (group 1), 10 had extension into the intrahepatic vena cava (group 2) and 3 had tumor extending into the right atrium (group 3). A perioperative management plan and an anatomical surgical approach have been developed to allow safe en bloc removal of these extensive tumor thrombi without removal of the vena cava. Successful management is dependent upon preoperative evaluation to determine precisely the extent of the disease, prophylaxis against pulmonary embolism and a well planned surgical method. For patients without evidence of metastatic or perinephric disease, the 5-year actuarial survival rate of 33 per cent is comparable to that of other patients without thrombus. Complete resection was possible in 20 patients (80 per cent), with a 5-year actuarial survival rate of 36 per cent. While patients with metastatic tumor cannot be cured, short-term palliation can be achieved for patients who have an imminent risk of vena caval occlusion or pulmonary embolism by an en bloc removal of tumor and thrombus, even for those with intra-atrial extension. Over-all, operative intervention was successful, with 22 of 25 patients leaving the hospital alive.     

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.     

Tumor thrombectomy for endometrial stromal sarcoma extending into the inferior vena cava and the right atrium from the uterus

We report an extremely rare case of endometrial stromal sarcoma (ESS) extending into the inferior vena cava and the right atrium. A 65-year-old woman was admitted to our hospital due to lower-extremity edema. The chest-abdominal computed tomography (CT) showed tumor thrombus invading the inferior vena cava and right atrium with multiple lung metastasis. To prevent sudden death from pulmonary embolism, she underwent surgical removal the tumor thrombus with the use of cardiopulmonary bypass and deep hypothermic circulatory arrest. The pathological diagnosis of the tumor thrombus was low-grade ESS originating from the uterus. After thrombectomy, she underwent chemotherapy with carboplatin and paclitaxel. Surgical resection and chemotherapy to low-grade ESS achieved favourable prognosis.     

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.     

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.     

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.     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

Vascular control for resection of suprahepatic intracaval Wilms' tumor: technical considerations

The surgical resection of Wilms' tumor can be complicated by tumor thrombus extension into the inferior vena cava. In cases of suprahepatic Wilms' tumor thrombus that may extend into the right atrium, a median sternotomy and cardiopulmonary bypass (CPB) are used to facilitate tumor resection. However, if the tumor can be localized and controlled below the atrium, resection without the use of cardiopulmonary bypass may limit morbidity. The authors describe a novel approach to tumor thrombectomy for a Wilms' tumor extending to the suprahepatic vena cava without the use of CPB. The authors used transesophageal echocardiography to localize the tumor thrombus and detect any tumor or air embolization and a minimal lower sternotomy to obtain intrapericardial control of the inferior vena cava. This technique may be useful in selected cases of Wilms' tumor as an alternative to median sternotomy and use of cardiopulmonary bypass.     

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.     

Hepatocellular carcinoma with right atrial tumor thrombus: Report of a case

Hepatocellular carcinoma (HCC) with a tumor thrombus (TT) extending into the right atrium is generally regarded as a terminal-stage condition. We report a case of long-term survival following treatment of this complication with en bloc hepatectomy and resection of the thrombus under cardiopulmonary bypass. Our review of 19 similar cases reported in the literature found the following: that lung metastasis, the most critical prognostic factor, occurred in only 5 (27.8%) patients; that postoperative survival ranged from 18 days to 56 months, with a median survival of 11 months; and that 7 (38.9%) patients showed no signs of recurrence, with 4 (21.1%) surviving longer than 2 years. Thus, to prevent sudden death and extend the survival of patients with HCC and TT extending into the right atrium, we advocate simultaneous en bloc resection performed under cardiopulmonary bypass, provided distant metastasis and recurrence in the remnant liver are controlled.     

Thrombectomy before hepatic resection for hepatocellular carcinoma with a tumor thrombus extending to the inferior vena cava

Tumor thrombi of hepatocellular carcinoma occasionally invade into the inferior vena cava (IVC) through the hepatic vein. Once the tumor thrombus is dislodged, severe and lethal complications, such as pulmonary infarction, can develop. We successfully operated on a hepatocellular carcinoma (HCC) patient with a tumor thrombus extending to the IVC through the right hepatic vein. To avoid dislodging the thrombus during surgery, a thrombectomy using selective hepatic vascular exclusion was performed before a hepatic resection, which is the most dangerous procedure to dislodge the thrombus.     

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.     

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.     

Aggressive surgery for hepatocellular carcinoma in advanced stage and with recurrence]

Between July 1973 and September 1990, 160 patients with hepatocellular carcinoma underwent hepatic resection at Keio University Hospital. Hepatic resection was carried out for patients with advanced diseases as well as recurrence. The patients with advanced disease consisted of 5 patients with obstructive jaundice, 6 with tumor thrombi in the portal trunk, one with tumor thrombus in hepatic vein, inferior vena cava and right atrium, 8 with satellite nodules in both lobes. Nine (45%) of these patients survived more than 2 years. Seven patients underwent removal of recurrent tumors: 4 in the remnant liver, one each at the left adrenal gland, lung and chest wall. Two patients lived longer than 2 years with relief of pain.     

Tumor Thrombectomy Without Bypass for Low-Grade Malignant Tumors Extending into the Inferior Vena Cava: Report of Two Cases

Endometrial stromal sarcoma (ESS) rarely extends into the inferior vena cava (IVC). Two cases of ESS extending into the IVC were encountered. In the first case a low-grade sarcoma and cavography revealed the tumor thrombus to extend to just below the left renal vein from the right internal iliac vein, and the IVC was patent. A tumor thrombectomy was accomplished to prevent pulmonary embolism (PE) and to achieve a good prognosis. The second case was also a low-grade sarcoma. Abdominal computed tomography scanning revealed a large thrombus extending into the IVC just below the hepatic vein. A tumor thrombectomy with an IVC resection was performed. The postoperative course was uneventful for both cases. Aggressive surgical treatment is thus recommended to excise a tumor thrombus with or without an IVC resection in patients with ESS of low-grade malignancy extending into the IVC to prevent sudden death due to PE.     

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.     

Renal cell carcinoma with right atrial extension with associated atrial septal defect: a case report

We present a case of locally advanced renal cell carcinoma with tumor thrombus in the inferior vena-cava extending into the right atrium with associated atrial septal defect. Tumor removal posed a unique challenge in this patient as there was a risk of paradoxical embolism during the surgery.