Indian Journal of Urology Users online:532  
IJU
Home Current Issue Ahead of print Editorial Board Archives Symposia Guidelines Subscriptions Login 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size


 
RESEARCH ARTICLE
Year : 2004  |  Volume : 20  |  Issue : 2  |  Page : 90-94
 

Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience


Department of Urology & Renal Transplantation, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow, India

Correspondence Address:
Aneesh Srivastava
Department of Urology & Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow - 226 014
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


Rights and PermissionsRights and Permissions

 
   Abstract 

Objectives : Renal cell carcinoma with tumor thrombus extension to inferior vena cava is found in 4-10% of pa­tients. We evaluated the surgical techniques of thrombec­tomy for different levels of the tumor thrombus in inferior vena cava and overall surgical outcome in these patients.
Methods : We retrospectively reviewed the records of 17 patients operated between 1994 and 2001. Eleven pa­tients had Infrahepatic (level I) thrombus, retrohepatic (level II) thrombus in two patients and four had supra­diaphragmatic (level III) thrombus without intra-a trial extension. All patients underwent radical nephrectomy and vena caval thrombectomy. The retrohepatic and supradia­phragmatic thrombectomies were done under venovenous bypass.
Results : The patients with infrahepatic and retrohepatic thrombectomies recovered without any major post opera­tive complication. Two patients with supradiaphragmatic thrombectomy died in postoperative period. The overall 2-year and 5-year survivals were 64.9% and 29.5% respectively.
Conclusions: Radical nephrectomy and vena caval thrombectomy is the best treatment option in renal call carcinoma with tumor thrombus extending to inferior vena cava. The retrohepatic and supradiaphragmatic thrombec­tomies can be done with the help of venovenous bypass in select group of patients.


Keywords: Renal cell carcinoma, thrombus, venovenous bypass.


How to cite this article:
Singh V, Zaman W, Kumar A, Kapoor R, Srivastava A. Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience. Indian J Urol 2004;20:90-4

How to cite this URL:
Singh V, Zaman W, Kumar A, Kapoor R, Srivastava A. Renal cell carcinoma with tumor thrombus extension to inferior vena cava: SGPGIMS experience. Indian J Urol [serial online] 2004 [cited 2019 Jun 18];20:90-4. Available from: http://www.indianjurol.com/text.asp?2004/20/2/90/21519



   Introduction Top


Renal cell carcinoma has an unique feature of intracaval extension of tumor thrombus without involvement of vena cava wall in majority of the cases. [1],[2],[3],[4],[5] The vena caval ex­tension of thrombus is seen in 4 to 10 per cent of cases. [1],[2],[3],[4],[5],[6] It is a locoregional disease and has no bearing on distant spread or survival. [6],[8] In the absence of alternative effec­tive treatment, radical nephrectomy and vena caval thrombectomy is the only hope for a potential cure in pa­tients who do not have metastasis. [9],[10]

The distal end of the tumor thrombus is the basis of classification for the level of thrombus. [1],[2],[3],[4],[5],[8],[10] The level I thrombus is defined as when the distal end of thrombus lying below the liver (infrahepatic), level II thrombus are those lying behind the liver (retrohepatic) and level III thrombus are supradiaphragmatic with or without exten­sion to the right atrium. [1],[2],[3],[4],[5],[6],[11],[12] Preoperative determination of the cephalad extension of the tumor thrombus is essen­tial because the surgical techniques for thrombectomy is determined by the distal end of thrombus which may affect the immediate surgical outcome. [7],[11],[12],[13] This study presents the clinical utility of preoperative determination of the distal end of thrombus, its impact on surgical tech­niques for thrombectomy and overall surgical outcome in these patients.


   Patients and Methods Top


Between 1994 and 2001, 17 patients of renal cell carci­noma with vena cava extension of tumor thrombus were seen at our centre. All were male patients and mean age was 55 years.The tumor was seen on right side in 11 pa­tients and left side in 6 patients.The painless hematuria was the commonest presentation seen in 10 patients, flank pain in 8 cases, renal lump in 7 cases, anorexia and weight loss in 3 patients and varicocele on the tumor side in 2 patients.The triad of pain, hematuria and lump was seen in 3 patients. All patients had routine hemogram, renal function tests, urinalysis, urine culture, liver function tests, chest X-ray and ultrasound abdomen.The diagnosis of re­nal tumor with tumor thrombus in IVC was accomplished by CECT scan in all patients. The cephalad extension of thrombus was clearly delineated by CT scan in 9 patients [Figure - 1]. In 6 patients MRI abdomen and thorax was needed to confirm the distal end of tumor thrombus [Figure - 2]. In two patients apart from CT scan and MRI, color doppler ultrasound was required to determine exactly the distal end of tumor thrombus as well as to confirm the patency of the hepatic veins.Both these cases had retrohepatic tumor thrombus.The cephalad extension of the tumor thrombus was infrahepatic in 11 patients, retrohepatic in 2 patients (in both cases the thrombus ex­tended up to the hepatic veins) and supradiaphragmatic thrombus in 4 patients. All patients had negative preopera­tive metastatic work-up.


   Surgical Techniques of Thrombectomy Top


Infrahepatic Thrombectomy (n=11). The primary tumor mass was approached either by chevron or mid­line incision. Thrombectomy in these cases need no com­plex manuevers.The IVC was isolated and conventional vascular controls taken both above and below the throm­bus and of the opposite renal vein. After extraction of tumor thrombus the cavotomy was repaired by 4/0 polypropylene.

Retrohepatic Thrombectomy (n=2). The surgical ap­proach in these patients was right thoracoabdominal incision.The right lobe of the liver was mobilised and lifted anteriorly after incising the right triangular and coronary ligaments to expose the retrohepatic IVC. The caudate lobe vein was ligated and cut. The porta hepatis was mobilised and control was taken over porta hepatis. The distal and proximal controls were taken by mobilising the intrapericardial IVC and the infrarenal vena cava. The venovenous bypass was instituted at this stage to divert the blood from infrarenal vena cava to the right atrium. The porta hepatis was clamped to stop the return from IVC and hepatic veins. Now the vena cava was opened and tumor thrombus was removed. In one case who had right renal tumor, the left renal vein and porta hepatis were not clamped and the hepatic venous backflow and venous blood from left renal vein were drained separately by two sump suction drain and was returned to right atrium after the filtration.

Supradiaphragmatic Thrombectomy (n=4). These cases were done by instituting venovenous bypass, thus diverting blood from infrarenal IVC to right atrium. The porta hepatis was clamped for 10 to 15 minutes in all cases during cavotomy and thrombectomy. The surgical ap­proach was thoracoabdominal in two cases and median sternotomy in another two cases. None of the patients had intra-atrial thrombus extension. However the cardiovas­cular surgeons were involved in all these cases with the readiness to go for total cardipulmonary bypass and cir­culatory arrest. The IVC reconstruction by longitudinal pericardial patch was done in 2 cases where tumor was adherent to the vena caval wall.

The survivals were calculated from the time of sur­gery to the last follow-up and subsequently analysed by Kaplan-Meier method [Figure - 3]


   Results Top


Eleven patients had infrahepatic (level I) thrombus, retrohepatic (level II) thrombus in two cases and four pa­tients had supradiaphragmatic (level III) thrombus. None of the level III thrombus had intra-atrial extension.The thrombectomy was done successfully in all cases. There was no operative mortality, intraoperative tumor embo­lism or major exsanguination.The average blood loss was 600 ml (400 -2000 ml). Six patients required blood trans­fusion and mean transfusion requirement was 4 units.The mean operative time was 210 minutes (150 - 300 min­utes). The IVC reconstruction by longitudinal pericardial patch was done in 2 cases where tumor was adherent to the vena caval wall. There was no evidence of microscopic invasion of the vena caval wall by tumor on histopatho­logical examination. Two patients with level III thrombec­tomy died in postoperative period. One patient developed severe jaundice and hepatic encephalopathy due to hemo­lytic reaction and died on tenth postoperative day. Other patient who had solitary kidney with renal failure was on maintenance hemodialysis. He had severe hematemesis on 12th postoperative day and died within hours inspite of intensive resuscitation. The survivals were calculated from the time of surgery to the last follow-up and subse­quently analysed by Kaplan-Meier survival curve [Fig­ure 3].The mean follow-up of the patient is 48 months. Two patients with supradiaphragmatic thrombectomy died in post operative period.The patients who were lost to fol­low-up after recurrences and did not respond to our letters were considered as dead. Three patients with infrahepatic thrombectomy and one patient with retrohepatic thrombec­tomy died in follow-up.The survival of the patients are shown in the table. The overall 2-year and 5-year survivals are 64.9% and 29.5% respectively [Table - 1].


   Discussion Top


An aggressive approach is needed in RCC with throm­bus extension to IVC without distant metastatis [1],[2],[5] . The prognosis of patients with resectable IVC extension with­out unresectable vena caval wall invasion or lymph node metastasis approaches that of stage I disease [2],[6],[6] . The Spi­ral CT scan can diagnose the tumor thrombus in the IVC. [1],[2],[3],[4],[6] Sosa and colleagues reported no survivors at the end of one year leaving the tumor thrombus in the IVC after nephrectomy. [9] The distal end of tumor thrombus in IVC is , important because the surgical techniques for thrombec­tomy is determined by the distal end of thrombus. [1],[2],[3],[4],[7],[10] The preoperative determination of the distal end of throm­bus can be done traditionally by vena cavography [7] but transesophageal echocardiography [7] and color doppler ul­trasound [11] can diagnose it also. However, MRI is the best technique for the exact determination of the distal end of thrombus. [12],[13] Thrombectomy for infrahepatic thrombus do not require any complex maneuvers. [1],[2],[5],[8] For retro­hepatic thrombectomy, venovenous bypass and occlusion of porta hepatis and opposite renal vein are required to achieve the bloodless operative field. [8],[15],[16] In the present study, one retrohepatic thrombectomy was done without putting clamps on the porta hepatis and the opposite renal vein. [18] Level III thrombus extending in to the right atrium requires full cardiopulmonary bypass, hypothermia and circulatory arrest. [10],[14],[16] However, if the thrombus is lying just below the right atrium, thrombectomy can be done on venovenous bypass [14],[16] and temporary occlusion of porta hepatis. [14],[15],[16] Cardiopulmonary bypass and circulatory ar­rest is ideal for level III thrombectomy as the entire sur­gery is done in a bloodless field without much mobilization of IVC. [14],[16] The major problem in using cardiopulmonary bypass with hypothermia and circulatory arrest is bleed­ing diathesis [8],[14],[15],[16] seen in 5% cases which can be profuse and secondary to the heparinization and hyperfibrinosis leading to platelet dysfunction. [20] The advantage of veno­venous bypass is that full heparinization is not always needed. [14],[15],[16],[17] In the present study full heparinization was done in all the venovenous bypass. Burt et al has strongly recommended the use of blood retrieval system because by retrieving, filtering, washing and returning the autolo­gous blood, the volume of transfused banked blood will be reduced. [14] The disadvantage of this procedure is the possibility of disseminating tumor emboli from the oper­ated site. [16],[18] However, literature suggests that there is no increase in metastasis with autotransfusion. [19] Venovenous bypass is simple to institute and uses less priming fluid resulting in much less hemodilution. [16] The extended ac­cess to IVC with a greately reduced blood loss, minimal or no heparinization and prevention from hypotension are the distinct advantages of venovenous bypass. [14],[15],[16],[18] In the present study all level II and level III thrombectomies were done on venovenous bypass because of our limitations to use cardiopulmonary bypass, circulatory arrest and hypo­thermia. The authors strongly feel that in a select group of patients without atrial thrombus extension, venovenous bypass can be a resonable alternative to total cardiopul­monary bypass and hypothermia. If we compare the ex­penditure of consumables and post operative intensive care monitoring of the patients who have had cardiopulmonary bypass, circulatory arrest and hypothermia then it would be rupees fifty thousand more than in venovenous bypass. Thus venovenous bypass is cost-saving in the context of Indian scenario. In the present study all 4 patients with level III thrombus had tumor thrombus lying below the right atrium which were diagnosed accurately preopera­tively. These cases were operated successfully on veno­venous bypass without major blood loss and intraoperative tumor embolism. Our 2 patients with level III thrombec­tomy died in postoperative period but the cause of death was not related to the surgical technique and the type of bypass.


   Conclusions Top


In renal cell carcinoma with vena caval thrombus, radi­cal nephrectomy and vena caval thrombectomy provides satisfactory surgical outcome in select groups of patients. Prior knowledge of cephalad extension of the tumor thrombus helps in deciding the technique for thrombec­tomy. The venovenous bypass is a reasonable alternative for cardiopulmonary bypass and circulatory arrest for the supradiaphragmatic thrombus without right atrial exten­sion. One or more imaging modalities should be consid­ered preoperatively to know accurately the cephalad extension of tumor thrombus. With improvement in op­erative technique and perioperative care, we advocate an aggressive, optimistic approach for those patients with clinically confined tumor with isolated caval thrombus extension.

 
   References Top

1.Sateesh CB, Tim M. Shah PM, Goyal A, Choudhary M, Eshghi M et al. Malignant Renal Tumors with Extension to the Inferior Vena Cava. The Am J Surg1998; 176: 137-139.  Back to cited text no. 1    
2.Skinner DG, Pritchett TR, Lieskovsky G et al. Vena cava involve­ment by renal cell carcinoma: Surgical resection provides mean­ingful long-term survival. Ann Surg 1989; 210: 387-394.  Back to cited text no. 2    
3.Neves RJ, Zinck H. Surgical treatment of renal cancer with vena cava extension. Br J Urol 1987; 59: 390-395.  Back to cited text no. 3    
4.O'Donohue MK, Flanagan F, Fitzpatrick JM. Smith JM. Surgical approach to inferior vena cava extension of renal carcinoma. Br J Urol 1987; 60: 492-496.  Back to cited text no. 4    
5.Hemant BT, Dandekar NP, Dalal AV, Kulkarni IN, Kamat MR. Renal Cell Carcinoma Extending to the Renal Vein and Inferior Vena Cava: Results of Surgical Treatment and Prognostic Factors. J Surg Oncol 1995; 59: 94-100.  Back to cited text no. 5    
6.Skinner DB, Pfister RF, Colvin R. Extension of renal cell carci­noma into vena cava.The rationale for aggressive surgical manage­ment. J Urol 1972: 107: 711-716.  Back to cited text no. 6    
7.Abraham Glazer and Andrew C. Novick. Preoperative Teanseso­phageal Echocardiography For Assessment Of Vena Caval Tumor Thrombi. A Comparative Study with Venacavography and Mag­netic Resonence Imaging. Urology 1997; 49: 32-34.  Back to cited text no. 7    
8.Marcus L. Duck, John P. Stein and Donald G. Skinner. Surgical Approaches to Venous tumor Thrombus. Semin Urol Oncol 2001; 19: 88-96.  Back to cited text no. 8    
9.Sosa ER, Muecke EC, Vaughan DE Jr, McCarron Jp Jr.Renal cell carcinoma extending into inferior vena cava:The prognostic signifi­cance of the level of vena caval involvement. J Urol 1984; 132: 1097­-1100.  Back to cited text no. 9    
10.John AB, Levinson ME,. Pae WE. Complete Radical Nephrec­tomy and Vena Caval Thrombectomy During Circulatory Arrest. J Urol 2000; 163: 434-436.  Back to cited text no. 10    
11.Hubsch P, Schurawitzke H, Susani M et al. Color Doppler Imaging of the inferior vena cava: indentification of tumor thrombus. J Ul­trasound Med 1992; 11: 639-645.  Back to cited text no. 11    
12.Pritchett TR, Raval JK, Benson RC et al. Preoperative magnetic resonance imaging of vena caval tumor thrombi. Experience with 5 cases. J Urol 1987; 138: 1220-1222.  Back to cited text no. 12    
13.Myneni L, Hricak H. Carrol PR. Magnetic resonance imaging of renal carcinoma with extension into the vena cava: Staging accu­racy and recent advances. Br J Urol 1991; 68: 571-578.  Back to cited text no. 13    
14.Burt M. Inferior Vena Caval Involvement by Renal Cell carcinoma. Use of Venovenous Bypass as adjunct during resection. Urol Clin North Am 1991; 18(3): 437-444.  Back to cited text no. 14    
15.Moggio RA, Praeger PI, Sarabu MR. Use of the Centrifugal Fugal Pump for Vena Caval Shunting. Ann Thorac Surg 1990; 50: 146­-148.  Back to cited text no. 15    
16.Attwood S, Lang DM, Goiti J and Grant J. Venous Bypass for Sur­gical Resection of Renal Carcinoma Involving the Vena Cava: A New Approach. Br J Urol 1988: 61: 402-405.  Back to cited text no. 16    
17.David IB, Diehl JT. Benak A, et al: Resection of retrohepatic infe­rior vena caval tumors: A new technique using the Biomedicus pump. Can J Surg 1988; 31: 219-220  Back to cited text no. 17    
18.Mishra V K, Kapoor R and Mittal P. Removal of Vena Caval Throm­bus in Renal Cell Carcinoma: Technique 11 -A Modified Venoatrial Bypass: Ind J Urol 1992; 8: 108-110.  Back to cited text no. 18    
19.Klimberg 1, Sirois R, Wajsman Z and Baker J. Intraoperative auto­transfusions in urologic oncology. Arch Surg 1986: 12: 1326-1331.  Back to cited text no. 19    
20.Beutler E, Lichtman MA, Coller BS, JK Thomas and Seligsohn U. Acquired qualitative platelet disorders due to disease, drugs and foods. In William's Hematology, 5th Edition 1995, Chapter 120: 1586-1587.  Back to cited text no. 20    


    Figures

  [Figure - 1], [Figure - 2], [Figure - 3]
 
 
    Tables

  [Table - 1]



 

Top
Print this article  Email this article
Previous article Next article

    

 
   Search
 
   Next article
   Previous article 
   Table of Contents
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    [PDF Not available] *
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
    Introduction
    Patients and Methods
    Surgical Techniq...
    Results
    Discussion
    Conclusions
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed5344    
    Printed98    
    Emailed3    
    PDF Downloaded0    
    Comments [Add]    

Recommend this journal

HEALTHWARE INDIA