Transesophageal echocardiography in renal cell carcinoma: an accurate diagnostic technique for intracaval neoplastic extension

Between 4 and 10% of patients with renal cell carcinoma have tumor involving the inferior vena cava and many of these patients have suprahepatic extension. In patients with intracaval neoplastic extension precise definition of the superior aspect of the tumor thrombus is critical. Transabdominal ultrasonography, computerized tomography (CT), magnetic resonance imaging (MRI) and inferior venacavography are all currently used to evaluate the inferior vena cava in these patients. Intraoperative transesophageal echocardiography was used to image the inferior vena cava in 5 patients with renal cell carcinoma and intracaval neoplastic extension. In each patient transesophageal echocardiography correctly revealed the superior extent of tumor thrombus. In 3 patients tumor thrombus was found at a higher level by transesophageal echocardiography than by CT, MRI and inferior venacavography. In all patients tumor imaging by transesophageal echocardiography correlated well with the gross appearance and extent of tumor found at operation. Echocardiography also documented the absence of residual gross tumor after resection. Transesophageal echocardiography was also useful to assess left ventricular function. Although each of these patients had a pulmonary artery catheter as well transesophageal echocardiography can be useful in situations when right atrial tumor thrombus prevents right heart catheterization. This small series demonstrates that intraoperative transesophageal echocardiography can accurately evaluate the extent of tumor thrombus and provides a means to assess myocardial function complementary to the pulmonary artery catheter.     

Real-time transesophageal echocardiography for intraoperative surveillance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy

PURPOSE: Vena caval tumor thrombus associated with renal cell carcinoma occurs in 4 to 10% of all renal tumors. There is significant operative morbidity and mortality in removing these tumors. We investigate the use of real-time transesophageal echocardiography intraoperatively and to identify tumor thrombus migration and air embolus, which are 2 potentially fatal complications of this procedure. MATERIALS AND METHODS: A total of 13 consecutive patients with renal masses and vena caval extension underwent extirpative surgery monitored with real-time transesophageal echocardiography. RESULTS: In 11 cases the involved kidney and tumor thrombus were removed without morbidity and no evidence of tumor migration or air embolus. Transesophageal echocardiography revealed a 5 cm. tumor thrombus in the right atrium which was removed by immediate atriotomy in 1 of the remaining 2 cases, and a large volume of air in the right atrium that was percutaneously evacuated in the other. These intraoperative complications were unsuspected and only recognized due to the use of transesophageal echocardiography. CONCLUSIONS: Real-time transesophageal echocardiography is a useful adjunct to surgery in patients with renal cell carcinoma and vena caval extension. Transesophageal echocardiography facilitates identification of tumor thrombus migration and air embolization, which are potentially fatal complications, and allows for immediate intraoperative intervention.     

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.     

The usefulness of intraoperative TEE monitoring in a patient with renal cell carcinoma

A 55-year-old man was admitted to our hospital for treatment of renal cell carcinoma. Preoperative MRI showed infradiaphragmatic extension of the tumor thrombus. However, intraoperative transesophageal echocardiography (TEE) revealed intracardiac extension of the thrombus. Therefore, the tumor thrombus was extirpated under cardiopulmonary bypass. The patient recovered without any complications. Intraoperative TEE monitoring is useful not only for the evaluation of cardiac functions but also for intraoperative diagnosis of a tumor thrombus during the operation for renal cell carcinoma.     

Inferior vena caval involvement by adrenal cortical carcinoma

A case of preoperative demonstration of inferior vena caval extension of tumor thrombus from adrenal cortical carcinoma is presented. Surgery showed that extension had occurred via the adrenal vein rather than by direct invasion. A search of the literature failed to uncover either any mention of preoperative attention to the possibility of caval involvement or of this particular mode of extension. Review of our experience with 17 adrenal cortical carcinomas suggested that carcinoma of the right adrenal gland involves the vena cava more commonly than does carcinoma of the left. We recommend that cavography be performed in the evaluation of adrenal carcinoma.     

Adrenal cortical carcinoma with vena cava tumor thrombus requiring cardiopulmonary bypass for resection

We believe this is the fifteenth case report of adrenal cortical carcinoma with tumor thrombus to the vena cava, and the fourth reported case of a left-side tumor propagating thrombus to the vena cava. The patient underwent successful resection which required cardiopulmonary bypass. The caval tumor thrombus was very friable and gelatinous, unlike many renal cell thrombi, and required special surgical considerations.     

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.     

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.     

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.     

Management of primary nonrenal parenchymal malignancies with vena caval thrombus

We report our experience with the management of 7 primary nonrenal parenchymal malignancies with vena caval tumor thrombus. Included are 3 cases of adrenal cortical carcinoma and 1 each of transitional cell carcinoma, embryonal cell testicular carcinoma, pheochromocytoma and primary small cell carcinoma of the lung with metastases to the kidney. Surgical treatment and followup are presented, as well as a review of the literature. An aggressive surgical approach is warranted because prolonged survivals free of disease are possible.     

功能性肾上腺皮质癌的诊断和治疗

目的：探讨功能性肾上腺皮质癌的诊断和治疗方法。方法：加顾性分析８例本病患者的临床资料。结果：均经手术和病理证实。本病具有典型的临床表现,如库兴综合征、原发性醛固酮增多症或性征异常,血和尿醇、醛固酮,１７－羟类固醇、尿１７－酮类固的测定及Ｂ超和ＣＴ检查均有助于诊断。结论：手术是唯一有效的治疗方法,术后辅以放疗和化疗有助于提高疗效。本病早期诊断困难。因而预后差。     

Preoperative magnetic resonance imaging of vena caval tumor thrombi: experience with 5 cases

Magnetic resonance scans were performed preoperatively in 5 patients who underwent surgical removal of renal or adrenal tumors with direct extension of the tumor into the vena cava. Of the patients 4 had renal cell carcinoma and 1 had adrenocortical carcinoma. Magnetic resonance imaging staged correctly the level of vena caval tumor thrombus involvement in 4 patients and missed the presence of right atrial tumor extension in 1. This noninvasive imaging modality can be used instead of contrast venography in most patients to assess the presence and extent of vena caval tumor involvement by renal cell carcinoma. Contrast venography should be used for those patients with suspected cardiac involvement and for those whose tumor thrombus extent remains unclear after magnetic resonance imaging.     

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma

BACKGROUND: We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). METHODS: Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. RESULTS: In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. CONCLUSIONS: Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.     

Renal cell carcinoma with thrombus in the inferior vena cava: extracorporeal circulation and deep hypothermia without open-chest surgery

INTRODUCTION: Renal cell carcinoma with thrombus in the inferior vena cava and no apparent metastasis requires immediate surgical treatment. Over the last few years, extracorporeal circulation with deep hypothermia and total circulatory arrest have played an increasingly important role in the treatment of diseases not associated with primary cardiovascular disorders, such as cavoatrial tumor thrombus in uterine tumors, adrenal tumors, Wilms' tumor, as well as renal cell carcinoma. CASE REPORT: A 78-year-old patient with renal cell carcinoma and tumoral thrombus in the inferior vena cava and above the supra-hepatic veins underwent right radical nephrectomy and removal of the thrombus from the vena cava with extracorporeal circulation and deep hypothermia with total circulatory arrest without opening the chest. The patient presented good post-operative evolution.     

Unrecognized left ventricular thrombus during reoperative coronary artery bypass grafting

Left ventricular thrombus after myocardial infarction is relatively common but rarely threatening enough to warrant surgical removal at the time of coronary revascularization. The rare cases of ventricular thrombectomy described in the literature involve a pedunculated thrombus. We describe an urgent coronary revascularization procedure in a patient who had unrecognized left ventricular thrombus. The large clot was detected by transesophageal echocardiography after decannulation in a hemodynamically unstable patient. The thrombus was removed after placing the patient back on cardiopulmonary bypass emergently. He recovered and was discharged with no neurologic sequelae. Aggressive removal of clot using cardiopulmonary bypass is warranted even for the critically ill patient.     

肾上腺皮质癌诊治方法的探讨

目的 探讨肾上腺皮质癌的诊断和治疗方法。方法 回顾１９７８－１９９８年收治的１５例肾上腺皮质癌,其中有内分泌功能８例,无内分泌功能７例,均经手术和病理证实。结果 有内分泌功能性上肾上腺皮质癌具有典型肾上腺皮质功能增强的临床表现,如库兴综合征、原发性醛固酮增多症或性征异常;无内分泌功能性肿瘤为腺外表现;如急性腹痛、高血压等,尿１７－羟、１７－酮和血、尿皮质醇、醛固酮的测定及ＣＴ和Ｂ超检查均有助于诊断     

Organized thrombus of the tricuspid valve mimicking valvular tumor

We report on a case of organized thrombus of the tricuspid valve mimicking a valve tumor. Preoperative transesophageal echocardiography showed the mass to have originated from the septal leaflet of the tricuspid valve. A pouch of the tricuspid valve and a ventricular septal defect were observed perioperatively, with the mass attached to the septal leaflet. Histologic examination revealed the mass to be an organized thrombus without tumor components.     

Adrenocortical carcinoma: report of a case]

A 24-year-old man visited our hospital complaining of hypertension and headache. Endocrinological findings revealed no abnormalities except for a slight decrease in serum adrenocorticotropic hormone (ACTH), a slight increase in urine 17-ketosteroid (17-KS), and a marked increase in serum pregnenolone. Computed tomography and magnetic resonance imaging revealed a 3 x 3 cm mass in the right adrenal area and I131-aldosterol scintigraphy demonstrated a high absorption of the isotope in the right adrenal area. Vena cavography suggested a 2 x 2 cm tumor thrombus originating in the right adrenal. Under the diagnosis of the right adrenocortical carcinoma, adrenalectomy and removal of the tumor thrombus were performed. Both serum pregnenolone and urine 17-KS returned to the normal level within a week after the operation and blood pressure was well controlled without any medication 3 months after the operation. Thus, the tumor seemed to be endocrinologically active.     

Rare case of left adrenal cortical carcinoma with level 3 inferior vena cava thrombus via adrenal vein

Introduction

Adrenocortical carcinoma (ACC) is a rare malignancy with an incidence of 0.7–2.0 cases/million habitants/year. It shows a bimodal pattern of age distribution with a higher incidence in the first decade and then between 40 and 50 years. Women are most frequently affected (55–60%).

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.