IVC filter limb penetration of the caval wall during retroperitoneal surgery/lymph node dissection

Optional inferior vena cava (IVC) filters are being increasingly used for protection against pulmonary embolism in patients with deep vein thrombosis where anticoagulation is contraindicated. We describe two cases during retroperitoneal surgery where the IVC filters were found to have perforated the cava wall and were subsequently removed intra‐operatively. Cava wall penetration by filter limbs poses a significant danger during retroperitoneal lymph node dissection and filters should be removed preoperatively.     

Primary adrenal leiomyosarcoma with inferior vena cava thrombosis

We report a primary adrenal leiomyosarcoma in a 59-year-old man. Computed tomography demonstrated a poorly enhanced mass, measuring 10cm, between the left kidney and the normal left adrenal gland, with tumor thrombus in the inferior vena cava (IVC). The patient underwent left radical nephroadrenalectomy with IVC thrombectomy. The histological diagnosis was adrenal leiomyosarcoma. Adrenal leiomyosarcomas are extremely rare. Only seven cases have been reported previously in the English-language literature.     

Primary leiomyosarcoma of the inferior vena cava: a case report and review of the literature

Sixty-six cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported. We present another case and review the characteristics and treatment of this rare tumor. IVC leiomyosarcomas spread by extension into adjacent tissue planes. Direct extension into the heart is known, but not into the kidneys, adrenals, or bowel. IVC leiomyosarcomas arising below the renal vein cause pain in the right-lower quadrant, back, and flank, and varying degrees of lower extremity edema; those arising in the middle caval segment cause right-upper-quadrant pain and sometimes renovascular hypertension; those arising above the hepatic vein cause varying manifestations of the Budd-Chiari syndrome. A reasonable approach to early diagnosis involves oral and intravenous contrast studies followed by computed tomography, angiography, and vena cavography. Aggressive surgical treatment is optimal in light of the tumor's slow growth pattern and relatively low malignant potential. (Metastases have been reported in fewer than 50% of cases). Tumors involving the lower IVC are most amenable to surgery; extensive collateral venous drainage of the left kidney preserves renal function during resection of middle caval tumors. Upper caval leiomyosarcomas are the least amenable to complete removal. Postoperative survival of all patients has ranged from a few weeks to eight years.     

Resection and reconstruction of retrohepatic vena cava without venous graft during major hepatectomies

BACKGROUND: Progress in liver surgery has enabled hepatectomy with concomitant venous resection for liver malignancies involving the inferior vena cava (IVC). The authors describe an alternative technique for IVC reconstruction without the need of graft. METHODS: Parenchymal transection is performed from anterior surface of the liver down to the anterior or left lateral surface of the IVC using combination of two techniques reported elsewhere. IVC is clamped above and below the tumor and the liver in continuity with an invaded segment of IVC is removed en bloc. A transverse anastomosis of IVC is performed starting with running suture on the posterior wall followed by the anterior wall. RESULTS: This approach has been successfully employed in eight consecutive patients with IVC involvement. The procedures performed were 5 right hepatectomies, 1 right posterior sectionectomy, 1 right trisectionectomy, and 1 left trisectionectomy. Two patients needed total vascular exclusion (TVE) for 11 and 10 min, respectively. Blood transfusion was necessary in three patients. Pathologic surgical margins were free in all cases. No postoperative mortality was observed. CONCLUSION: This technique of IVC reconstruction precludes the use of graft and minimizes the use of TVE decreasing ischemic damage to the remnant liver.     

Xeno‐pericardial patch repair of the inferior vena cava for radical resection of renal cell carcinoma with tumor thrombus

Background and Objectives

For tumor thrombus in the inferior vena cava (IVC) complicated with kidney cancer, we built a surgical team to achieve (1) en bloc tumor resection; (2) xeno‐pericardial patch IVC repair; and (3) minimum organ damages. We reviewed outcome of the case series to verify rationale of this approach.

Methods

A consecutive series of 12 patients having the IVC tumor thrombus by renal cell carcinoma in the last 3 years was enrolled. Minimum kidney ischemia was induced in five cases (Procedure I), whereas liver and kidney ischemia was induced in five cases (Procedure II). Mild hypothermic extracorporeal circulation was used in two cases (Procedure III).

Results

There was no mortality or severe morbidities related to the surgery. Postoperative recovery was most prompt by the Procedure I. Liver and kidney ischemic time was longer in the Procedure III than the Procedure II, whereas organ function was not substantially impaired in either series. The resected IVC margin was free from the cancer in all cases, while local recurrence was not seen in any cases.

Conclusions

En bloc resection with xeno‐pericardial patch repair of the IVC was successfully performed in the tumor thrombus complicated with kidney cancer with minimum organ damage.     

肾癌下腔静脉癌栓的诊断和手术方法的探讨--附6例临床分析并文献复习

背景与目的:肾癌下腔静脉癌栓临床处理困难,肾癌根治性切除的同时再切除肾静脉癌栓和取出下腔静脉癌栓,预后仍然良好。术前明确诊断,特别是对癌栓延伸范围的判断,对手术方式的选择十分重要。本研究结合我们的经验,进一步探讨肾癌下腔静脉癌栓的诊断和手术治疗。方法:回顾性分析我院2000～2004年收治的6例肾癌并发下腔静脉癌栓患者的临床资料,包括诊断方法、手术治疗和预后。结果:6例患者术前均经B超、CT和MRI明确诊断,肾静脉型1例,肝下型3例,肝内型2例;1例肝内型患者术中死亡,余5例均手术成功。术后随访3～30个月,1例肝下型和1例肝内型患者分别于术后9个月、3个月死于远处转移,其余3例仍存活。结论:CT、MRI是目前无创诊断肾癌伴下腔静脉癌栓的最佳方法;对无淋巴结和远处转移的患者,应积极手术治疗;手术方式的选择取决于癌栓的延伸范围以及是否侵犯下腔静脉壁。     

5例下腔静脉平滑肌肉瘤的外科治疗分析

目的探讨下腔静脉平滑肌肉瘤的外科处理方法及临床疗效。方法回顾性分析5例患者临床资料,结合既往腹膜后肿瘤的手术经验,综合文献资料,分析下腔静脉平滑肌肉瘤的治疗要点。结果肿瘤来源于下腔静脉中段的3例,上段和下段各1例。4例按术前计划切除了肿瘤,其中2例达RO切除,分别随访20个月和22个月无复发,1例R1切除术后6个月复发而再次手术,后随访24个月未复发,1例有肝转移行R2切除,术后存活8个月,1例在术中发现肿瘤延及右心房且浸润血管而仅行活检,术后生存仅2个月。3例下腔静脉切除以后未重建,术后无肾功能衰竭等严重并发症。结论术前CT/MRI联合检查,主要进行肿瘤定位,评估手术切除的可能性;造影检查可以明确下腔静脉的走行、通畅程度以及侧支循环情况,可减少术中盲目探查引起的静脉性失血,同时指导下腔静脉切除以后是否需要重建;RO根治性切除是减少复发、延长生存时间的主要手段;术后有短暂的肾功能不全者可以通过血滤很快恢复;术后局部复发的患者可以再次手术,可明显延长生存时间。     

Intrapericardial isolation of the inferior vena cava through a transdiaphragmatic pericardial window for tumor resection without sternotomy or thoracotomy.

AIMS: The prognosis for patients with advanced tumors invading the inferior vena cava (IVC) is dismal and surgical treatments for these tumors are challenging. A surgical approach that avoids sternotomy and thoracotomy for tumors invading the IVC even to the level of the hepatocaval junction would be extremely helpful. METHODS: The intrapericardial IVC was isolated via a transdiaphragmatic pericardial window using a transabdominal approach. Hepatectomy was then applied via an anterior approach until the IVC was seen. Total hepatic vascular exclusion was achieved by clamping the portal triad, intrapericardial IVC and infrahepatic IVC. We removed the primary tumor, the liver portion involved and the tumor thrombi, with segmental resection of the IVC. Vascular continuity was reestablished using a 20-mm-diameter polytetrafluoroethylene graft. RESULTS: Four patients with tumors invading the IVC were treated with this method. All underwent gross en-bloc tumor resections and all survived. CONCLUSION: This method for the resection of IVC tumors could avoid emboli dislodging from the tumor thrombi, prevent the complications of sternotomy, cardiopulmonary bypass and shorten operative times.     

Cardiac metastasis from renal cell carcinoma without inferior vena involvement: a review of the literature based on a case report. Two different patterns of spread?

We report the case of a 59-year-old man with advanced renal cell carcinoma (RCC), without inferior vena cava (IVC) involvement, treated with radical nephrectomy, palliative radiotherapy for bone metastasis, and medical therapy for bone and lung metastases. The patient died of cardiac arrest after evidence of massive malignant pericardial effusion. At autopsy, massive myocardial and pericardial neoplastic invasion was found. Heart involvement via the IVC is a well-known phenomenon during RCC progression, while in the absence of IVC involvement, clinically evident cardiac involvement is exceptional, with few cases reported in the worldwide literature. Analysis of prior reports and of the present case provides evidence on how the cardiac metastasis may have two distinct origins and clinical features. The first is hematogenous, via the IVC, even in the absence of renal vein involvement; it is generally circumscribed and has a good prognosis after surgery. The second is through the intrathoracic lymphatic system, in the presence of disseminated disease, especially pulmonary metastasis, and this type has a very poor prognosis.     

Primary leiomyosarcoma of inferior vena cava,a rare entity: Imaging features

Leiomyosarcoma of the inferior vena cava (IVC) is an uncommon neoplasm, most frequently seen in the sixth decade with a female predominance. Imaging modalities allow an early and accurate preoperative diagnosis resulting in a higher rate of surgical resection and improved survival. Imaging findings in a 65‐year‐old woman with leiomyosarcoma of IVC are described. Computed tomography and MRI typically showed a non‐fatty, necrotic intraluminal IVC mass with extension to retroperitoneal compartments. Cavography was useful to evaluate the collateral circulation associated with the extensive intraluminal mass. The lesion was biopsied under ultrasound guidance.     

Hepatocellular carcinoma with intra-atrial tumor thrombi. A report of three cases responsive to thalidomide treatment and literature review

BACKGROUND: In patients with advanced hepatocellular carcinoma (HCC), inferior vena cava/intra-right atrial (IVC/RA) tumor thrombi are not uncommon findings and are usually associated with extremely poor outcome. Surgical interventions as well as nonsurgical approaches, such as transcatheter arterial chemoembolization and radiotherapy, have been used in the treatment of patients with symptomatic IVC/RA tumor thrombi. However, such therapeutic modalities are usually not feasible when a patient shows poor general performance, the presence of metastatic disease, and underlying hepatic dysfunction. Such patients show limited survival. MATERIAL AND METHODS: Herein we describe 3 patients with advanced-stage HCC whose IVC/RA tumor thrombi and primary tumors regressed remarkably after low-dose thalidomide (200-400 mg/day) therapy. An Entrez PUBMED search of English Literature articles was performed to identify other cases of RA tumor thrombi in HCC who had received various treatments. RESULTS: Two of our patients survived for more than 15 months after the diagnosis of IVC/RA tumor thrombi, while the other had effective symptomatic palliation associated with a drastic fall of AFP serum levels and significant tumor regression within 4 weeks of thalidomide therapy. A literature review suggested that the survival of our patients is comparable with that of occasional patients who had received aggressive surgical intervention. CONCLUSIONS: Our results suggest that, despite the low tumor response rate in earlier studies, thalidomide therapy may sometimes provide effective palliation for patients with far advanced HCC with symptomatic IVC/RA tumor thrombi and who are not candidates for alternative treatment options.     

A case of huge colon carcinoma and right renal angiomyolipoma accompanied by proximal deep venous thrombosis, pulmonary embolism and tumor thrombus in the renal vein

A preoperative inferior vena cava (IVC) filter is reported to be effective in surgical cases with proximal deep venous thrombosis (DVT) or in which pulmonary embolism (PE) has already developed, and considered to be at high risk of developing secondary fatal PE during or after surgery. However, guidelines for using an IVC filter have yet to be established. The patient in the present report had two huge tumors, ascending colon cancer and renal angiomyolipoma, which occupied the entire right half of the abdomen, coexisting PE, DVT and tumor thrombus in the right renal vein. Secondary PE is fatal in the perioperative period, therefore, the vena cava filters were preoperatively inserted into the supra- and the infrarenal IVC. We successfully removed the tumors without complications. The patient is alive without tumor recurrence and PE or recurrent DVT 1 year and 6 months after surgery. The coexistence of two huge abdominal tumors as potential causes of PE and DVT is extremely rare, and we could have safely undergone the operation, using two vena cava filters in the supra- and infrarenal IVC.     

Inferior vena cava filters in the cancer patient: current use and indications

Deep venous thrombosis and thromboembolism are significant health risks, with high rates of morbidity and mortality. Chronically ill and hospitalized patients, particularly those with cancer, have a high risk for developing these conditions. Mechanical inferior vena cava (IVC) filtration has been standard care for patients with these conditions in whom anticoagulation therapy is contraindicated or has failed. This article reviews caval filters and the current indications for using mechanical IVC filters, including retrievable versus permanent filters, focusing on their use in treating venous thromboembolism in cancer patients.     

Stenting in malignant and benign vena caval obstruction

Expandable metallic stents have been used with considerable success for the palliation of malignant vena caval obstruction. The role of stenting in vena caval obstruction of benign aetiology is less well defined. A review of 11 patients stented for vena caval obstruction and a review of recent series in the literature is presented. Of the 11 patients, seven patients had involvement of the superior vena cava (SVC), and four patients had inferior vena caval (IVC) obstruction. Seven cases had malignant vena caval obstruction, with a benign aetiology (SVC n = 3; IVC n= 1) in the other four cases. All seven patients treated with SVC stents experienced complete resolution or significant improvement in symptoms with no recurrence over the duration of available follow-up, over an average of 4.3 months (range: 1 week-12 months). Only one of four IVC lesions stented resulted in a good clinical response. All four patients with vena caval obstruction of benign aetiology had a good outcome. One patient experienced a small pulmonary embolus following SVC stent insertion without further sequelae. No other serious complications were encountered. Stenting can provide prompt relief of vena caval obstruction with low morbidity, and high patency rates in both benign and malignant vena caval lesions.     

Intraluminal tumour thrombus of a mixed non-seminomatous germ cell tumour of testis within the inferior vena cava

BACKGROUND: Intracaval tumour thrombus developed per continuitatem from a primary testicular tumour is rare. CASE REPORT: A patient with metastatic mixed non-seminomatous germ cell tumour of the testis extending into the inferior vena cava (IVC) is presented. He belonged to the intermediate-risk group according to the IGCCCG (International Germ Cell Cancer Collaborative Group) classification. The 26-year-old man underwent right inguinal orchiectomy. Computed tomography revealed the tumour thrombus as filling defect in the IVC extending nearly to the right renal vein. Duplex sonography detected a partial thrombosis of the IVC. Combination chemotherapy led to regression of pulmonal metastases and the intraluminal tumour thrombus. 5 months later, retroperitoneal lymphadenectomy was performed and the intraluminal thrombus was extracted by cavotomy. The thrombus originated from the ostium of the right testicularis vein in the IVC. Histological examination revealed no vital tumour tissue. CONCLUSION: In patients with testicular cancer information about pathological processes of the IVC is important for therapeutic management. Testicular tumours seldom extend up the IVC.     

Temporary placement of inferior vena cava filter prior to transcatheter arterial embolization (TAE) for hepatocellular carcinoma with IVC tumor thrombus--prevention of pulmonary tumor emboli after TAE]

A 66-year-old-man with a right huge hepatocellular carcinoma (HCC) extending into both the right portal vein and the right atrium underwent transcatheter arterial embolization (TAE) via the right hepatic artery. Prior to the TAE, a temporary inferior vena cava (IVC) filter was placed suprarenally for prevention of pulmonary tumor emboli. When we replaced the temporary IVC filter with a new one 7 days after the TAE, the filter which was pulled out of the IVC captured a fragment of the tumor thrombus. A histopathological specimen demonstrated only ghost cells. The patient has been followed at our outpatient clinic without any tumor thrombus or pulmonary infarction for 13 months after this procedure.     

Surgical treatment for recurrent hepatocellular carcinoma with tumor thrombi in right atrium: using cardiopulmonary bypass and deep hypothermic circulatory arrest

Tumor in the right atrium creates a life-threatening condition and should be removed immediately. A cirrhotic patient who had recurrent hepatocellular carcinoma (HCC) over remnant liver with tumor thrombi extending to inferior vena cava (IVC) and right atrium presented with impending congestive heart failure. The recurrent tumor and its thrombi were successfully resected en-bloc using cardiopulmonary bypass and hypothermic circulatory arrest. Although the patient's disease-free and actual survival time were only 6 months and 14 months, respectively, he was rescued from heart failure. This aggressive surgical strategy creates further possibility to treat such advanced HCC cases. Further investigations regarding adjuvant therapies in these circumstances, however, are necessary.     

En bloc caudate lobe and partial vena cava resection using a Gott shunt for retrohepatic caval bypass.

A technique of retrohepatic inferior vena cava bypass is described, useful for resection of the hepatic caudate lobe. A 77 year old female developed a solitary metastatic tumor mass in the caudate lobe compressing the Inferior Vena Cava (IVC), with cavography showing the IVC to be compressed, but patent. Without evidence of other metastatic disease radical resection of this tumor was performed. Successful resection was accomplished using a Gott shunt and porta hepatus compression for hepatic vascular isolation. No pump was used to avoid heparinization. Postoperative imaging confirmed IVC patency. The serum carcinoembryonic antigen (CEA) level fell to normal and remained so for 18 postoperative months. This introduces a new use of an atriocaval shunt for hepatic isolation during resection.     

宫颈癌全段腹主动脉旁淋巴结转移的解剖分布和CTV边界

目的 明确宫颈癌全段腹主动脉旁淋巴结转移的解剖学分布,探讨临床靶区（CTV）的勾画边界。方法 回顾分析86例宫颈癌转移至腹主动脉旁淋巴结的患者。应用CT增强影像、淋巴结与周围结构的三维重建图像,明确腹主动脉旁转移淋巴结的解剖学边界。结果 86例左肾静脉以下腹主动脉旁转移淋巴结,位于腹主动脉分叉处至左肾静脉上缘之间,沿腹主动脉和下腔静脉周围分布,在十二指肠出现后,下腔静脉右前方未发现肿大淋巴结。所有转移淋巴结均位于双侧卵巢血管和输尿管内侧,肠系膜下静脉紧邻其左前方;自上而下位于肾静脉、十二指肠、肠系膜血管后方;位于腰椎体和腰大肌前方。27例左肾静脉以上腹主动脉旁转移淋巴结,位于双侧膈脚后方,在腹主动脉后方沿奇静脉、半奇静脉上行,25/27例位于食管贲门交界水平（平第11胸椎）之下,5/27例伴有下腔静脉后内侧和右侧膈脚之间转移淋巴结,上界至腹腔干水平。结论 推荐全段腹主动脉旁淋巴结CTV勾画边界：上界,平第11胸椎（食管贲门交界水平）;左肾静脉以下侧界,肠系膜下静脉、卵巢血管和输尿管的内侧缘;左肾静脉以上侧界,双侧膈脚;前界,肾静脉以上腹主动脉的侧后壁、肾静脉、十二指肠、肠系膜血管的后缘;后界,腰椎体和腰大肌的前缘。     

The Clinical Presentation,Survival Outcomes,and Management of Patients With Renal Cell Carcinoma and Cardiac Metastasis Without Inferior Vena Cava Involvement: Results From a Pooled Clinical Trial Database and Systematic Review of Reported Cases

Background

Cardiac metastases from renal cell carcinoma (RCC) are uncommon and there are limited data regarding the presentation and outcomes of this population. The objective of this study was to evaluate the characteristics and outcomes of patients with RCC with cardiac metastasis without inferior vena cava (IVC) involvement.