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.     

16 肝细胞癌合并脉管系统癌栓的外科治疗

目的:探讨肝细胞癌（HCC）合并脉管系统癌栓的外科治疗效果。方法:回顾性分析1993年1月—2002年1月采用肝切除和癌栓取出术治疗HCC合并脉管系统癌栓68例的临床资料，其中门静脉癌栓63例，肝左静脉癌栓1例，肝中静脉癌栓合并门静脉左支癌栓1例，肝右静脉、下腔静脉合并门静脉右支癌栓1例，下腔静脉癌栓2例。HCC合并门静脉癌栓患者中6例术后行门静脉化疗。结果:6例术后3个月内死于肝肾功能衰竭， HCC合并脉管系统癌栓患者术后1，3，5年生存率分别为41.7%，20.8%，4.1%。结论:肝切除并癌栓取出术是HCC合并脉管系统癌栓有效的治疗方法，术后辅助治疗能提高治疗的效果。     

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.     

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.     

Surgical techniques for treating a renal neoplasm invading the inferior vena cava

PURPOSE: Historically inferior vena caval thrombus associated with renal cell carcinoma was a deterrent to surgery. During the last 3 decades there has been steady improvement in surgical techniques and perioperative care, which has dramatically improved the ability to resect safely these tumors. We acknowledge these improvements in chronological order. MATERIALS AND METHODS: A comprehensive literature review of the different techniques used for resecting renal cell carcinoma with inferior vena caval involvement was performed using MEDLINE. Data focused on surgical techniques, including various incisions, exposures, adjuncts to surgery and outcomes. RESULTS: Tumor thrombus associated with renal cell carcinoma is no longer considered to have a detrimental impact on survival. Patients who are acceptable surgical candidates have survival rates as high as 68%. Although there is a great deal of emphasis on the importance of an aggressive surgical approach, a uniform operative strategy based on the level of the tumor thrombus has not been established. Surgical techniques derived from liver transplant surgery and cardiac arrest with cardiopulmonary bypass have drastically decreased operative complications associated with extensive involvement of the inferior vena cava with tumor thrombus. CONCLUSIONS: The only curative approach to renal cell carcinoma is surgery. An aggressive approach is warranted when tumor involves the renal vein and inferior vena cava. Surgical strategy depends on the level of the inferior vena caval thrombus. Patients with extension of the thrombus above the diaphragm are a greater technical challenge. Hypothermic circulatory arrest should be considered when treating vena caval-atrial tumor thrombus. Surgeons familiar with liver mobilization can greatly facilitate the exposure needed for safely operating in these cases.     

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。     

腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

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.     

Renal cell carcinoma with extension of tumor thrombus into the vena cava: surgical strategy and prognosis

PURPOSE: The outcome of patients who underwent radical resection of renal cell carcinoma extending into the vena cava was retrospectively analyzed, and risk factors for long-term survival were investigated. METHODS: From 1983 to 1999, 33 patients who had renal cell carcinoma with inferior vena caval tumor extension underwent 34 surgical procedures. There were 27 men and six women with an average age of 60.1 years. Twenty-two cases (64.7%) were classified as stage III (T1-2 N1 M0 or T3 N0-1 M0), and 12 cases (35.3%) as stage IV (T4 or N2-3 or M1). Coexistent lung metastasis was found in seven cases (20.6%). The tumor thrombi invaded into the inferior vena cava below the hepatic hilum in 19 cases, below the orifice of hepatic veins in 12, and above the diaphragm in 3. Cardiopulmonary bypass graft was applied in 13 cases (38.2%). Inferior vena cava was reconstructed by direct suture (n = 19), polytetrafluoroethylene patch angioplasty (n = 13), or graft replacement (n = 2). RESULTS: Two patients died during the early postoperative period because of retrohepatic caval injury and intraoperative pulmonary embolism. Late death occurred in 16 patients; the causes of death were tumor recurrence in 15 and acute pulmonary embolism as a result of graft thrombosis in 1. Overall 1-, 5-, and 10-year survival rates were 70%, 44%, and 26.4%, respectively. One- and 5-year survival rates were 81.3% and 52.9% for stage III and 50% and 31.2% for stage IV; a statistically significant correlation was found between surgical staging and survival (P =.049). Patients without lymph node metastasis had a significant survival advantage over those with lymph node metastasis (P =.022). There was no significant difference in survival on the basis of the presence or absence of synchronous lung metastasis (P =.291). The degree of local extension of the tumor or the level of tumor thrombus did not tend to influence survival. CONCLUSIONS: Surgical prognosis in patients with renal cell carcinoma extending into the vena cava was determined by the staging of the tumor, especially lymph node status, and not by the level of tumor thrombus or the presence of concurrent lung metastasis. The use of cardiopulmonary bypass graft is recommended for the resection of tumor thrombus extending over the diaphragm.     

Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava

OBJECTIVE: A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS: We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS: One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION: Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.     

肝癌合并下腔静脉癌栓的外科治疗

目的总结7例肝癌合并下腔静脉（inferior vena cava,IVC）癌栓患者的手术方法及治疗经验。方法自2003年7月至2005年5月,我们为7例肝癌合并IVC癌栓的患者实施了肝癌切除及右心房和（或）IVC切开取栓手术。所有患者均采用全肝血流阻断来控制IVC血流。根据癌栓上极位置的不同,分别采用5种不同术式：（1）静脉转流,心脏停搏,右心房及下腔静脉切开取栓1例;（2）静脉转流,心脏不停搏,心包内高位阻断下腔静脉,右心房和（或）下腔静脉切开取栓2例;（3）经腹部切口切开膈肌,心包内高位阻断下腔静脉,下腔静脉切开取栓1例;（4）经腹部切口,经膈肌腔静脉裂孔小切口,心包外高位阻断肝上下腔静脉,下腔静脉切开取栓1例;（5）经腹部切口,肝上阻断下腔静脉,下腔静脉切开取栓2例。结果所有手术均获成功,术后并发症包括胸腔积液2例,右膈下积液1例,切口感染1例。7例患者的生存时间为2周～26个月,平均9．8个月。已死亡的6例患者术后生存时间分别为13、9、11、2、17个月和2周,尚生存的1例患者已无瘤生存26个月。结论对合适病例实施肝癌切除和IVC切开取栓手术是安全可行的。手术治疗可以避免右心流人道阻塞和肺动脉栓塞造成的猝死,并有可能获得相对提高的生存时间和生活质量。     

Renal cell carcinoma with inferior vena caval involvement

Renal cell carcinoma extends into the lumen of the inferior vena cava in approximately 4% of patients at the time of diagnosis. Surgical removal of the intracaval tumor thrombus with radical nephrectomy is the preferred treatment for this malignancy. From January 1977 to June 1990, 31 such patients were examined for combined problems of renal carcinoma and intracaval tumor extension. Twenty-six of these patients underwent radical nephrectomy and vena caval thrombectomy. Ten patients had tumor thrombus confined to the infrahepatic vena cava, 11 had retrohepatic caval involvement, and 5 had extension to the level of the diaphragm or into the right atrium. Surgical approach was dictated by the level of caval involvement. Control of the suprahepatic vena cava plus temporary occlusion of hepatic arterial and portal venous inflow were necessary in some cases; cardiopulmonary bypass was required for transatrial removal of more extensive tumors. Five of the 26 patients had evidence before operation of distant metastatic disease; none of these survived beyond 12 months. The 5-year actuarial survival rate of the 21 patients without known preoperative metastatic disease was 57%. Complete surgical excision of all gross tumor appears to be critical for long-term survival in these patients.     

Kidney cancers with supra-diaphragmatic invasion. Surgical treatment using extracorporal circulation with heart arrest

STUDY AIM: The study aim was to report results of nephrectomy with resection of cavo atrial thrombus in 6 patients with a renal carcinoma and supra-diaphragmatic vena cava extension and to discuss limits of the surgical indications. PATIENTS AND METHOD: Six patients, five adults (mean age: 57 +/- 10 years) and a four-year old girl, were operated on for a renal cell carcinoma with supra-diaphragmatic vena cava extension. The venous extension was detected in all cases by abdominal ultrasonography. The superior extent of the thrombus was effectively visualized by CT scan in three cases, and by ultrasonography and magnetic resonance imaging in all cases. All the patients were operated on, using cardio-pulmonary bypass, without circulatory arrest, four in normothermia, two in moderate hypothermia at 28 degrees C. RESULTS: Hospital mortality was 0%. Average intensive care unit stay was 3.8 days. During the following period, all the patients developed metastatic disease. Mean survival rate of the five adult patients who had loco-regional invasion was 9.4 months (range: 6 to 19). The young girl underwent a wedge excision of two pulmonary metastases one year later and was still alive 7 years later. CONCLUSIONS: With cardio-pulmonary bypass, surgical resection of cavo-atrial thrombi may be performed with a low mortality and morbidity rate but late results were disappointing. Surgery should be limited to patients without loco-regional invasion or distant metastatic disease, and therefore accurate preoperative staging is mandatory.     

Strategy for hepatoblastoma with major vascular involvement: A guide for surgical decision-making

BackgroundSurgical management of tumor thrombus extending to the major vascular system for children with hepatoblastoma is challenging and insufficiently discussed.MethodsWe conducted a retrospective review of hepatoblastoma with tumor thrombus extending to the major vascular system (inferior vena cava, 3 hepatic veins, and portal vein trunk) treated at our center between May 2010 and June 2021. We describe our preoperative assessment, surgical strategies, and outcomes.ResultsWe identified 9 patients (median age at the diagnosis: 3.4 years). All patients received chemotherapy before liver surgery. At the time of the diagnosis, tumor thrombus extended to the portal vein trunk (n = 6), inferior vena cava (n = 3), and 3 hepatic veins (n = 2). Among the 9 patients, 4 underwent liver resection. Liver transplantation was performed in 5 patients. The inferior vena cava wall was circumferentially resected for tumor removal in 1 patient and partially resected in 2 patients. One patient underwent liver transplantation using veno-venous bypass. Patients with tumor thrombus extending to the portal vein trunk were more likely to be managed by liver transplantation in comparison to those with tumor thrombus spreading to the inferior vena cava. The median follow-up period was 5.5 years. One patient underwent transhepatic balloon dilatation for biliary stricture after liver resection. Tumor recurrence was seen in 3 patients (33.3%; lung, n = 2; lymph node and liver, n = 1). No patients died during the follow-up period.ConclusionSurgical intervention for pediatric hepatoblastoma with tumor thrombus extending into the major vascular system is safe, feasible, and achieves excellent outcomes.     

Surgical Treatment of Renal Neoplasmatic Thrombi Extending into the Inferior Vena Cava

Renal cell carcinoma produces neoplasmatic thrombus that usually invades and progressively grows into the endorenal veins. The thrombus may extend into the ipsilateral renal vein or the inferior vena cava in 15-20% and 8-15% of cases, respectively. These tumors are classified into four categories (I, II, III, and IV) according to the level of cephalad extension of thrombus into the inferior vena cava. The purpose of this study was to assess the surgical strategy for cases of renal tumor thrombus invading the vena cava. We retrospectively reviewed the records of 10 patients with renal cell carcinoma, who underwent in our institution radical nephrectomy and resection of vena cava thrombus between January 1997 and December 2004. Four patients were classified as level I, four were level II, and two were level III. In all cases, the thrombus was removed through a small cavotomy without cardiopulmonary bypass and the cavotomy was closed primarily. Pringle’s maneuver was performed in the two level III cases. There were no perioperative pulmonary embolisms or deaths, and the mean hospital stay was 8 ± 1.1 days. The mean survival was 21.8 ± 8 months, and the vena cava remained patent for this period. Tumor thrombectomy improves the prognosis and the quality of life of these patients, and in most of cases the surgical technique, although challenging, carries a low morbidity and mortality rate.     

Management of renal cell carcinoma with inferior vena cava tumor thrombus

OBJECTIVE: The prognostic implication of radical nephrectomy with inferior vena cava tumor thrombectomy for renal cell carcinoma is still controversial. We investigated the type of renal cell carcinoma with vena cava tumor thrombus for which surgical resection was beneficial. MATERIALS AND METHODS: We retrospectively reviewed the records of 16 patients with renal cell carcinoma and inferior vena cava tumor thrombus. Of these, 10 received surgical treatment and 6 did not. We evaluated the association between the pretreatment serum C-reactive protein (CRP) level and the efficacy of surgery. RESULTS: Among the 8 patients with an elevated pretreatment serum CRP level (CRP > or = 1.0 ng/ml), there was no significant difference of the median disease-specific survival between those who did (20.2 months) and did not undergo surgery (8.2 months; p = 0.1946). On the other hand, among the 8 patients who had a pretreatment serum CRP level within normal limits (CRP < 1.0 ng/ml), the median disease-specific survival of those who did not undergo surgery (80.6 months) was significantly better than that of those who did (50.2 months; p = 0.0136). CONCLUSION: This study suggested that conservative treatment can be recommended for patients with renal cell carcinoma and inferior vena cava tumor thrombus when the pretreatment serum CRP level is normal because tumor progression is usually slow and surgical treatment may actually worsen the prognosis.     

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.     

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.     

Caval extension of renal cell carcinoma. Results of surgical treatment

Twenty-eight patients with renal cell carcinoma extending to the vena cava underwent surgical treatment consisting of radical nephrectomy and removal of tumor thrombus, which was at the level of the renal veins in 23 cases, the hepatic veins in 4, and extending above the diaphragm in 1 case. In 7 patients lymph nodes were invaded, and 8 had both positive nodes and extrarenal tumor diffusion discovered at surgery. The mean survival was 41.7 months for patients with only venous extension of the tumor, 16 months for patients with positive nodes, and 10.2 months for those with both nodal and extrarenal tumor diffusion.     

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.