Surgical Outcome of Renal Cell Carcinoma with Tumor Thrombus Extension into Inferior Vena Cava and Right Atrium (Beating Heart Removal of Level 4 Thrombus): A Challenging Scenario

Main Article Content

Abdul Khawaja
Khalid Sofi
Yasir Dar
Muzaain Khateeb
Javeed Magray
Abdul Waheed
Sajad Malik
Arif Hamid Bhat
Mohd. Saleem Wani
Akbar Bhat

Keywords

Abstract

Aim: “To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”.
Materials and Methods: Retrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium.


Results: “Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypoten-sion intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any sur-vival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus.


Conclusion: Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidis-ciplinary approach for a successful surgical outcome.


 

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References

1. Rini BI, Wilding G, Hudges G, Stadler WM, Kim S, Tarazi J, et  al. Phase II study of axitinib in sorafenib-refractory meta-static renal cell carcinoma. J Clinical Oncol. 2009;27(27):4462–8. http://dx.doi.org/10.1200/JCO.2008.21.7034
2. Novick AC, Kaye MC, Cosgrove DM, Angermeier K, Pontes JE, Montie JE, et al. Experience with cardiopul-monary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena caval thrombi. Ann Surg. 1990;212(4):472–6. http://dx.doi. org/10.1097/00000658-199010000-00010
3. Gastro GJ, Mckiernan JM. Epidemiology, clinical staging, and presentation of renal cell carcinoma Urol Clin North America-2008 35(4):581–92. http://dx.doi.org/10.1016/j. ucl.2008.07-005.
4. Skinner DG, Pritchett TR, Lieskovsky G, Boyd SD, Stiles QR. Vena caval involvement by renal cell carcinoma. Surgical resection pro-vides meaningful long-term survival. Ann Surg. 1989;210(3):387– 92. http://dx.doi.org/10.1097/00000658-198909000-00014
5. Nesbitt JC, Soltero ER, Walsh GL, Schrump DS, Swanson DA, Pisters LL, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg. 1997;63(6):1592–600. http://dx.doi.org/10.1016/ S0003-4975(97)00329-9
6. Neves RJ, Zincke H. Surgical treatment of renal cancer with vena cava extension. Br J Urol. 1987;59(5):390–5. http://dx.doi. org/10.1111/j.1464-410X.1987.tb04832.x
7. Glazer AA, Novick AC. Long-term followup after surgical treatment for renal cell carcinoma extending into the right atrium. J Urol. 1996;155(2):448–50. http://dx.doi.org/10.1016/ S0022-5347(01)66415-2
8. Yamashita C, Ataka K, Azami T, Nakagiri K, Wakiyama H, Okada M. Usefulness of cardiopulmonary bypass in recon-struction of inferior vena cava occupied by renal cell carci-noma tumor thromb. Angiology. 1999;50(1):47–53. http://dx.doi. org/10.1177/000331979905000106
9. Montie JE, el Ammar R, Pontes JE, Medendorp SV, Novick AC, Streem SB, et al. Renal cell carcinoma with inferior vena cava tumor thrombi. Surg Gynecol Obstet. 1991;173(2):107–15.
10. Gallucci M, Borzomati D, Flammia G, Alcini A, Albino  G, Caricato M, et al. Liver harvesting surgical technique for the treatment of retrohepatic caval thrombosis concomitant to renal cell carcinoma: Perioperative and long-term results in 15 patients without mortality. Eur Urol. 2004;45(2):194–202. http:// dx.doi.org/10.1016/j.eururo.2003.09.004
11. Marshall FF, Reitz BA, Diamond DA. A new technique for management of renal cell carcinoma involving the right atrium: Hypothermia and cardiac arrest. J Urol. 1984;131(1):103–7. http://dx.doi.org/10.1016/S0022-5347(17)50221-9
12. Krane RJ, de Vere White R, Davis Z, Sterling R, Dobnik DB, McCormick JR. Removal of renal cell carcinoma extending into the right atrium using cardiopulmonary bypass, profound hypo-thermia and circulatory arrest. J Urol. 1984;131(5):945–7. http:// dx.doi.org/10.1016/S0022-5347(17)50722-3
13. Okita Y, Takamoto S, Ando M, Morota T, Matsukawa R, Kawashima Y. Mortality and cerebral outcome in patients who underwent aortic arch operations using deep hypothermic circulatory arrest with retrograde cerebral perfusion: No relation of early death, stroke, and delirium to the duration of circulatory arrest. J Thorac Cardiovasc Surg. 1998;115(1):129–38. http://dx. doi.org/10.1016/S0022-5223(98)70451-9
14. Ergin MA, Galla JD, Lansman L, Quintana C, Bodian C, Griepp RB. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of operative mortality and neurologic outcom. Thorac Cardiovasc Surg. 1994;107(3):788– 97. http://dx.doi.org/10.1016/S0022-5223(94)70334-5
15. Svensson LG, Crawford ES, Hess KR, Coselli JS, Raskin S, Shenaq SA, et al. Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients. J Thoraccardiovasc Surg. 1993;106(1):19–28.
16. Glazer A, Novick AC. Preoperative transesophageal echocardiography for assessment of vena caval tumor thrombi: A com-parative study with venacavography and magnetic resonance imaging. Urology. 1997;49(1):32–4. http://dx.doi.org/10.1016/ S0090-4295(96)00374-3
17. Sigman DB, Hasnain JU, Del Pizzo JJ, Sklar GN. Real-time transesophageal echocardiography for intraoperative surveil-lance of patients with renal cell carcinoma and vena caval extension undergoing radical nephrectomy. J Urol. 1999;161(1):36–8. http://dx.doi.org/10.1016/S0022-5347(01)62054-8