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Möbius A, Grieshaber P, Turra J, Riesterer D, Zaradzki M, Soso P, Hatiboglu G, Hohenfellner M, Warnecke G, Tochtermann U. Cavoatrial hypernephroma resection on cardiopulmonary bypass: Mild/normo-versus moderate hypothermia. Perfusion 2023; 38:1644-1651. [PMID: 36125270 PMCID: PMC10612369 DOI: 10.1177/02676591221128143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCION Renal cell carcinoma (RCC) is one of the most prevalent malignant tumors. It extends up into the systemic veins and right atrium. Surgical extraction of such extensions is usually carried out using cardiopulmonary bypass (CPB) with moderate hypothermic (MH) being frequently applied in order to obtain a clear surgical field. However, due to obvious disadvantages of hypothermia, approaches with mild/normothermia (NT) during CPB have also been established. The current study aims to compare the outcomes of patients undergoing RCC tumor and extensions resection using MH versus NT. MATERIAL AND METHODS This is a retrospective, non-randomized study. All patients who underwent RCC tumor and extensions resection for stage III or IV (Staehler) RCC in a single center between 2006 and 2020 were included. During surgery, MH or NT were applied. CPB was realized using aortic and bicaval cannulation. We compared the procedural times, transfusion requirements and postoperative outcomes, respectively between the MH and NT groups. RESULTS A total of 24 consecutive patients (n(NT) = 12, n(MH) = 12) were included in the study (median age NT 68.5 and MH 66.5). The study only showed a significant difference in heart-lung machine times (median CPB time NT 45.5 min and MH 110.0 min, p = 0.004). All other results, loss of drainage, administration of blood products, as well as the postoperative course and mortality were comparable in both groups. CONCLUSION The results showed a high perioperative and long-term mortality. The perioperative course was similar after surgery with NT or MH. Therefore, NT which minimizes potential complications of MH should be preferred.
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Affiliation(s)
- Andreas Möbius
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Philippe Grieshaber
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Jan Turra
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - David Riesterer
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Petar Soso
- Department of Cardiothoracic Surgery, Hospital Passau, Passau, Germany
| | - Gencay Hatiboglu
- Department of Urology, SLK Hospital Group Heilbronn, Heilbronn, Germany
| | | | - Gregor Warnecke
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Ursula Tochtermann
- Department of Cardiothoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Sidiropoulos T, Parasyris S, Ntella V, Margaris I, Christodoulou S, Theodoraki K, Vassiliu P, Smyrniotis V, Arkadopoulos N. En-Bloc Resection of Renal Cell Carcinoma With Tumor Thrombus Propagating Into the Intrapericardial Inferior Vena Cava: Efficacy and Safety of Transabdominal Approach. Cureus 2023; 15:e42394. [PMID: 37621783 PMCID: PMC10446507 DOI: 10.7759/cureus.42394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Renal cell carcinoma (RCC) is the most common primary kidney cancer. In up to 4-10% of patients, the tumor is complicated with a malignant thrombus extending to the inferior vena cava (IVC). Complete surgical excision of the RCC and the neoplastic thrombus can be curative. We aim to present a safe and feasible alternative transabdominal operative technique with the omission of thoracotomy, as applied in six patients diagnosed with RCC and IVC thrombus extending over the diaphragm. METHODS This case series study was conducted in a tertiary university hospital in Athens, Greece. All six patients, who were operated on for RCC and a malignant thrombus exceeding in the intrapericardial IVC in our department from January 2009 until March 2020, were screened. Intraoperatively, the infrarenal and intrapericardial IVC were clamped simultaneously with the renal and liver blood inflow. Access to the intrapericardial IVC was obtained via the central tendon of the diaphragm. Intrathoracic extension of the tumor was confirmed by transesophageal or intraoperative ultrasonography. The intrathoracic IVC was exposed to direct vision and two finger palpation was applied to secure the clamping of the IVC above the tip of the thrombus. The tumor was resected through a longitudinal venotomy and the operation was completed on a standard radical nephrectomy. RESULTS During the study period six patients presented with RCC and intrapericardial IVC thrombus. All patients, five female and one male, underwent radical nephrectomy combined with IVC thrombectomy, without the need for a thoracotomy. The mean age was 66 years old and the mean operative time was 122.5 minutes. Mean blood loss was 338 ml and only four of the patients were transfused with two units of RBC. Operative and hospital mortality was 0%. The hospital stay was seven (six to nine) days. Only one patient required readmission and reoperation 30 days later, due to intrapericardial herniation. CONCLUSIONS The proposed surgical technique may be curative in patients with advanced intracaval thrombus and helps reduce the associated morbidity, mortality, and the overall cost of more extended operations.
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Affiliation(s)
- Theodoros Sidiropoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Stavros Parasyris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassiliki Ntella
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Ioannis Margaris
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Spyridon Christodoulou
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Kassiani Theodoraki
- 1st Department of Anesthesiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Panteleimon Vassiliu
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Vassilios Smyrniotis
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
| | - Nikolaos Arkadopoulos
- 4th Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, GRC
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Voit A, Commander SJ, Williams Z. Partial Inferior Vena Cava Reconstruction with Cryopreserved Aortic Homograft Following Resection for Malignancy. Vasc Endovascular Surg 2022; 57:79-82. [DOI: 10.1177/15385744221124297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Malignant invasion of the inferior vena cava (IVC) often necessitates complete tumor thrombectomy and IVC reconstruction. Bovine pericardial xenografts and prosthetic grafts are frequently used for partial or entire IVC reconstruction with adequate subsequent patency and freedom from thrombosis. Cryopreserved aortic homografts represent an alternative conduit for vena cava replacement with resistance to infection in contaminated fields or following extensive retroperitoneal dissection. Specific reports of aortic homograft use for IVC reconstruction are scarce. Described are 2 cases of cryopreserved aortoiliac artery allograft use for long segment cava patch repair while avoiding extensive caval reconstruction, mobilization and the need for renal vein and hepatic vein re-implantation.
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Affiliation(s)
- Antanina Voit
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sarah Jane Commander
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
| | - Zachary Williams
- Division of Vascular and Endovascular Surgery, Duke University Medical Center, Durham, NC, USA
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Cai X, Huang J, Yao X, Qian H, Zhang J, Kong W, Wu X, Huang Y, Chen Y, Xue W. Cognitive Function after Cardiopulmonary Bypass and Deep Hypothermic Circulatory Arrest in Management of Renal Cell Carcinoma with Vena Caval Thrombus. Urology 2022; 167:144-151. [DOI: 10.1016/j.urology.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 10/18/2022]
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Liu Z, Li Y, Zhang Y, Zhao X, Ge L, Tang S, Hong P, Zhang S, Tian X, Wang S, Liu C, Zhang H, Ma L. PUTH Grading System for Urinary Tumor With Supradiaphragmatic Tumor Thrombus: Different Surgical Techniques for Different Tumor Characteristics. Front Oncol 2022; 11:735145. [PMID: 35070959 PMCID: PMC8770268 DOI: 10.3389/fonc.2021.735145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/09/2021] [Indexed: 01/11/2023] Open
Abstract
Purpose To explore the different treatment strategies for urinary tumors with Mayo IV thrombus. Materials and Methods We retrospectively analyzed the patients with Mayo IV thrombus in Peking University Third Hospital from January 2014 to April 2021. We used the Peking University Third Hospital (PUTH) grading system to classify urinary tumors with supradiaphragmatic thrombus. PUTH-A referred to the filled thrombus whose tip just reached above the diaphragm, or the thrombus entering the right atrium (< 2cm). PUTH-B referred to the filled thrombus entering the right atrium (> 2cm), or the thrombus invading the wall of the inferior pericardial vena cava. Detailed techniques were described for various scenarios. Clinicopathological data and perioperative outcomes were reported. Group difference statistical analysis was performed. Results A total of 26 cases of urinary tumors with supradiaphragmatic IVC thrombus (Mayo grade IV) underwent treatment were enrolled in this study. 19 patients in the PUTH-A group received the open approach without sternotomy and cardiopulmonary bypass. Seven patients in the PUTH-B group received open thoracotomy assisted by cardiopulmonary bypass. No intraoperative death occurred. After 56 months of follow-up, 46.2% (12 of 26) patients died of all causes. Estimated 1-year, 2-year, and 3-year overall survival were 72.0% (95% CI, 54.4%-89.6%), 58.2% (95% CI, 38.0%-78.4%), and 52.4% (95% CI, 31.2%-73.6%), respectively. Conclusions We introduced the PUTH grading system for the characteristics of urinary tumors with supradiaphragmatic tumor thrombus, and selected different surgical techniques according to different classifications. This grading system was relatively feasible and effective.
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Affiliation(s)
- Zhuo Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yuxuan Li
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yu Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xun Zhao
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Liyuan Ge
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shiying Tang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Peng Hong
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shudong Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xiaojun Tian
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Shumin Wang
- Department of Ultrasound, Peking University Third Hospital, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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Surgical treatment of renal cell carcinoma with inferior vena cava tumor thrombus. Surg Today 2022; 52:1125-1133. [PMID: 34977987 DOI: 10.1007/s00595-021-02429-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE The present report discusses the indications of cardiopulmonary bypass (CPB) in open nephrectomy and surgical outcomes of conventional and minimally invasive surgical techniques for treating advanced renal cell carcinoma with inferior vena cava tumor thrombus. METHODS The present study involved a comprehensive retrieval of pertinent literature from the most recent two decades. RESULTS Comparisons between radical nephrectomy procedures in terms of open, laparoscopic and robotic-assisted surgeries revealed that open surgery had more blood loss, a longer operation time and higher mortality rates than laparoscopic and robotic-assisted surgeries. Furthermore, surgery with CPB was associated with more blood loss than non-CPB surgery. Rates of early and late deaths were much higher in patients with CPB than in those without CPB. CONCLUSIONS Different surgical techniques had different indications in terms of levels of inferior vena cava tumor thrombus. The laparoscopic, robotic-assisted, open surgical techniques and CPB with deep hypothermic circulatory arrest were indicated for Levels I, II, III and III-IV inferior vena cava tumor thrombus, respectively. Laparoscopic and robotic-assisted surgeries cause less trauma than open surgery but require more complicated equipments to support the procedure. CPB should be avoided in radical nephrectomy whenever possible. The increased application of laparoscopic and robotic techniques in the future is anticipated.
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Multidisciplinary surgical approach for renal cell carcinoma with inferior vena cava tumor thrombus. Surg Today 2021; 52:1016-1022. [PMID: 34786640 DOI: 10.1007/s00595-021-02415-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022]
Abstract
PURPOSES The optimal surgical management of renal cell carcinoma with tumor thrombus within the inferior vena cava (IVC) remains to be clarified. METHODS Sixteen consecutive cases were reviewed. Incision, the IVC clamping position, and the venous drainage procedure were modified according to the tumor thrombus extension level: level I or II (below the hepatic vein, n = 8), level III (above the hepatic vein but below the right atrium, n = 5), and level IV (extending into the right atrium, n = 3). RESULTS For level I or II, resection could be simply achieved by clamping the IVC below the hepatic vein, without hemodynamic collapse. For level III, clamping the IVC above the hepatic vein and the hepatoduodenal ligament was required. Venous drainage from the lower body (cannulation to distal IVC) and portal system (cannulation to ileocolic vein) were applied. When opening the IVC, the significant backflow was controlled using cardiopulmonary bypass with drop-in suckers. For level IV, median sternotomy, exposure of the right atrium, and cardiopulmonary bypass were mandatory. With the combination of these approaches, the perioperative mortality rate was 0% and the 5-year overall survival rate was 52%. CONCLUSIONS A multidisciplinary surgical approach is essential, especially for level III and IV cases.
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Surgical Resection of Tumors Invading the Inferior Vena Cava at the Hepatic Vein and Thoracic Levels. World J Surg 2021; 45:3174-3182. [PMID: 34218311 DOI: 10.1007/s00268-021-06227-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Our aim was to describe the results of our program of surgical resection of tumors invading the inferior vena cava (IVC) at the hepatic and thoracic levels. We hypothesized that similar surgical outcomes may be obtained compared to tumor resection below the hepatic vein level if the liver function was preserved. METHODS We performed a single-center retrospective study of 72 consecutive patients who underwent surgical resection from 1996 to 2019 for tumors invading the IVC. We compared two groups based on tumor location below (group I/II) or above (group III/IV) the inferior limit of hepatic veins. RESULTS Tumor histology was similarly distributed between groups. In group III/IV (n = 35), sterno-laparotomy was used in 83% of patients, cardiopulmonary bypass in 77%, and deep hypothermic circulatory arrest in 17%; 23% underwent liver resection. Corresponding proportions in group I/II were 3%, 0%, 0%, and 8%. In group III/IV, 4 patients required emergency resection. Mortality on day 30 was 17% (n = 6) in group III/IV and 0% in group I/II (P = 0.01). There was no liver failure among the 66 postoperative survivors and 5 out of 6 patients who died postoperatively presented a preoperative or postoperative liver failure (P < 0.001). Overall survival was not significantly different between groups with a median follow-up of 15.1 months. R0 resection was achieved in 66% of group I/II and 49% of group III/IV patients (P = 0.03). CONCLUSION Surgical resection of tumors invading the inferior vena cava at hepatic vein and thoracic levels should be reserved to carefully selected patients without preoperative liver failure to minimize postoperative mortality.
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Wang G, Bi H, Ye J, Zhang H, Hou X, Liu C, Qiu M, Tian Y, Kaushik D, Ma L. Transabdominal approach for renal cell carcinoma with supradiaphragmatic tumor thrombus: description of a modified technique and indications for treatment. J Int Med Res 2021; 48:300060520962288. [PMID: 33143510 PMCID: PMC7645515 DOI: 10.1177/0300060520962288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective We investigated the safety and effectiveness of a modified transabdominal approach for renal cell carcinoma (RCC) with a supradiaphragmatic inferior vena cava (IVC) tumor thrombus (TT). Methods Eight patients underwent radical nephrectomy with removal of a supradiaphragmatic IVC-TT through an abdominal incision using a transdiaphragmatic approach in Peking University Third Hospital from April 2015 to January 2018. We modified this technique using a Foley catheter balloon to avoid piggyback liver mobilization. Results All patients underwent successful operations. The median operative time was 7 hours 23 minutes. The median estimated blood loss was 2963 mL. All patients received a blood transfusion with a median blood infusion volume of 2162 mL. Two patients with Budd–Chiari syndrome developed postoperative ascites and hydrothorax due to non-watertight repair of the diaphragm. During a follow-up of 11 to 44 months, only one patient died of liver metastasis and four patients developed distant metastasis without recurrence in the IVC. Conclusions The modified transabdominal approach described herein has an encouraging safety profile and provides a surgical option for treatment of RCC with a supradiaphragmatic IVC-TT. More evidence concerning the beneficial role of this procedure will be elucidated in further studies.
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Affiliation(s)
- Guoliang Wang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hai Bi
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Jianfei Ye
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Hongxian Zhang
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Xiaofei Hou
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Cheng Liu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Min Qiu
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Yu Tian
- Department of Urology, Peking University Third Hospital, Beijing, China
| | - Dharam Kaushik
- Division of Urologic Oncology, Department of Urology, University Texas Health Science Center, San Antonio, TX, USA
| | - Lulin Ma
- Department of Urology, Peking University Third Hospital, Beijing, China
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Shen D, Du S, Huang Q, Gao Y, Fan Y, Gu L, Liu K, Peng C, Xuan Y, Li P, Li H, Ma X, Zhang X, Wang B. A modified sequential vascular control strategy in robot-assisted level III-IV inferior vena cava thrombectomy: initial series mimicking the open 'milking' technique principle. BJU Int 2020; 126:447-456. [PMID: 32330369 DOI: 10.1111/bju.15094] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To introduce a modified sequential vascular control strategy, mimicking the open 'milking' technique principle, for the early release of the first porta hepatis (FPH) and to stop cardiopulmonary bypass (CPB) in level III-IV robot-assisted inferior vena cava (IVC) thrombectomy (RA-IVCTE). PATIENTS AND METHODS From November 2014 to June 2019, 27 patients with a level III-IV IVC tumour thrombus (IVCTT) underwent RA-IVCTE in our department. The modified sequential control strategy was used in 12 cases. Previously, we released the FPH after the thrombus was resected and the IVC was closed completely, and CPB was stopped at the end of surgery (15 patients). Presently, using our modified strategy, we place another tourniquet inferior to the second porta hepatis (SPH) once the proximal thrombus is removed from the IVC below the SPH. Then, we suture the right atrium and perform early release of the FPH, and stop CPB. Finally, tumour thrombectomy, vascular reconstruction, and radical nephrectomy are performed. RESULTS Compared with the previous strategy, the modified steps resulted in a shorter median FPH clamping (19 vs 47 min, P < 0.001) and CPB times (60 vs 87 min, P < 0.05); a lower rate of Grade II-IV perioperative complications (25% vs 60%, P < 0.05); and better postoperative hepatorenal and coagulation function, including better median serum alanine aminotransferase (172.7 vs 465.4 U/L, P < 0.001), aspartate aminotransferase (282.4 vs 759.8 U/L, P < 0.001), creatinine (113.4 vs 295 μmol/L, P < 0.01), blood urea nitrogen (7.3 vs 16.7 mmol/L, P < 0.01), and D-dimer (5.9 vs 20 mg/L, P < 0.001) levels. CONCLUSION With the early release of the FPH and stopping CPB, the modified sequential vascular control strategy in level III-IV RA-IVCTE reduced the perioperative risk for selected patients and improved the feasibility and safety of the surgery. We would recommend this approach to other centres that plan to develop robotic surgery for renal cell carcinoma with level III-IV IVCTT in the future.
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Affiliation(s)
- Donglai Shen
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Songliang Du
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China.,School of Medicine, Nankai University, Tianjin, China
| | - Qingbo Huang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yu Gao
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Yang Fan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Kan Liu
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Cheng Peng
- Department of Urology, The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yundong Xuan
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Pin Li
- Department of Pediatric Urology, Bayi Children's Hospital Affiliated to The Seventh Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, The First Medical Center of Chinese PLA General Hospital/Medical School of Chinese PLA, Beijing, China
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The Onco-cardiologist Dilemma: to Implant, to Defer, or to Avoid Transcatheter Aortic Valve Replacement in Cancer Patients with Aortic Stenosis? Curr Cardiol Rep 2019; 21:83. [DOI: 10.1007/s11886-019-1166-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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González J, Gaynor JJ, Martínez-Salamanca JI, Capitanio U, Tilki D, Carballido JA, Chantada V, Daneshmand S, Evans CP, Gasch C, Gontero P, Haferkamp A, Huang WC, Espinós EL, Master VA, McKiernan JM, Montorsi F, Pahernik S, Palou J, Pruthi RS, Rodriguez-Faba O, Russo P, Scherr DS, Shariat SF, Spahn M, Terrone C, Vera-Donoso C, Zigeuner R, Hohenfellner M, Libertino JA, Ciancio G. Association of an organ transplant-based approach with a dramatic reduction in postoperative complications following radical nephrectomy and tumor thrombectomy in renal cell carcinoma. Eur J Surg Oncol 2019; 45:1983-1992. [PMID: 31155470 DOI: 10.1016/j.ejso.2019.05.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 03/06/2019] [Accepted: 05/08/2019] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Our aim was to determine whether using an organ transplant-based(TB) approach reduces postoperative complications(PCs) following radical nephrectomy(RN) and tumor thrombectomy(TT) in renal cell carcinoma(RCC) patients with level II-IV thrombi. METHODS A total of 390(292 non-TB/98 TB) IRCC-VT Consortium patients who received no preoperative embolization/IVC filter were included. Stepwise linear/logistic regression analyses were performed to determine significant multivariable predictors of intraoperative estimated blood loss(IEBL), number blood transfusions received, and overall/major PC development within 30days following surgery. Propensity to receive the TB approach was controlled. RESULTS The TB approach was clearly superior in limiting IEBL, blood transfusions, and PC development, even after controlling for other significant prognosticators/propensity score(P < .000001 in each case). Median IEBL for non-TB/TB approaches was 1000 cc/300 cc and 1500 cc/500 cc for tumor thrombus Level II-III patients, respectively, with no notable differences for Level IV patients(2000 cc each). In comparing PC outcomes between non-TB/TB patients with a non-Right-Atrium Cranial Limit, the observed percentage developing a: i) PC was 65.8%(133/202) vs. 4.3%(3/69) for ECOG Performance Status(ECOG-PS) 0-1, and 84.8%(28/33) vs. 25.0%(4/16) for ECOG-PS 2-4, and ii) major PC was 16.8%(34/202) vs. 1.4%(1/69) for ECOG-PS 0-1, and 27.3%(9/33) vs. 12.5%(2/16) for ECOG-PS 2-4. Major study limitation was the fact that all TB patients were treated by a single, experienced, high volume surgeon from one center (non-TB patients were treated by various surgeons at 13 other centers). CONCLUSIONS Despite this major study limitation, the observed dramatic differences in PC outcomes suggest that the TB approach offers a major breakthrough in limiting operative morbidity in RCC patients receiving RN and TT.
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Affiliation(s)
- Javier González
- Department of Urolorgy, Hospital General Universitario Gregorio Marañón, Madrid, Spain.
| | - Jeffrey J Gaynor
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
| | | | - Umberto Capitanio
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy.
| | - Derya Tilki
- Department of Urology, University of California, Davis, School of Medicine, Sacramento, CA, USA.
| | - Joaquín A Carballido
- Servicio de Urología, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain.
| | - Venancio Chantada
- Servicio de Urología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | | | - Christopher P Evans
- Department of Urology, University of California, Davis, School of Medicine, Sacramento, CA, USA.
| | - Claudia Gasch
- Department of Urology, University of Heidelberg, Heidelberg, Germany.
| | - Paolo Gontero
- Department of Urology, A.O.U. San Giovanni Battista, University of Turin, Turin, Italy.
| | - Axel Haferkamp
- Department of Urology and Pediatric Urology, Mainz University Medical Center, Mainz, Germany.
| | - William C Huang
- Department of Urology, New York University Langone School of Medicine, New York, USA.
| | | | - Viraj A Master
- Department of Urology, Emory University, Atlanta, GA, USA.
| | - James M McKiernan
- Department of Urology, Columbia University College of Physicians and Surgeons, New York, USA.
| | - Francesco Montorsi
- Department of Urology, Hospital San Raffaele, University Vita-Salute, Milano, Italy.
| | - Sascha Pahernik
- Department of Urology, Paracelsus University Hospital (PMU), Nürnberg, Germany.
| | - Juan Palou
- Department of Urology, Fundació Puigvert, Barcelona, Spain.
| | - Raj S Pruthi
- Department of Urology, UNC at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Paul Russo
- Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Douglas S Scherr
- Department of Urology, Weill Cornell Medical Center, New York, USA.
| | - Shahrokh F Shariat
- Department of Urology, Medical University of Vienna, Vienna General Hospital, Vienna, Austria.
| | - Martin Spahn
- Department of Urology, Center of Urology/Prostate Cancer Center Hirslanden, Zürich, Switzerland.
| | - Carlo Terrone
- Division of Urology, Maggiore della Carita Hospital, University of Eastern Piedmont, Novara, Italy.
| | | | - Richard Zigeuner
- Department of Urology, Medical University of Graz, Graz, Austria.
| | | | - John A Libertino
- Department of Urology, Emerson Hospital-MGH Cancer Center, Boston, MA, USA.
| | - Gaetano Ciancio
- The Lillian Jean Kaplan Renal Transplant Center and the Miami Transplant Institute, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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13
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Master VA, Ethun CG, Kooby DA, Staley CA, Maithel SK. The value of a cross-discipline team-based approach for resection of renal cell carcinoma with IVC tumor thrombus: A report of a large, contemporary, single-institution experience. J Surg Oncol 2018; 118:1219-1226. [PMID: 30332513 DOI: 10.1002/jso.25271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 09/18/2018] [Indexed: 12/14/2022]
Abstract
INTRODUCTION We report the evolution of the largest, contemporary, single-institution experience with this complex procedure to highlight the value of a cross-discipline, team-based approach. METHODS Patients from a prospectively maintained database who underwent resection of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus from 2005 to 2016 at a single-institution were included for analysis. RESULTS Of 140 patients, 102 (73%) had tumor thrombus below the level of the hepatic vein confluence, and 96 (69%) were performed for curative-intent, while 43 (31%) were cytoreductive procedures for clinical trial consideration. Median overall survival (OS) of the entire cohort was 43.8 months (5-year OS:43%), and 73.6 months (5-year OS:59%) for those without metastatic disease. Fifty-one patients underwent resection from 2005 to 2010 and 89 from 2011 to 2016. All procedures since 2011 were performed by the same cross-discipline dedicated team of two surgeons, composed of a surgical and urological oncologist. When comparing the two time-periods, the team-approach after 2011 had shorter operative-times (5.3 vs 6.7 hours; P = 0.009), decreased ICU-utilization (25% vs 72%; P < 0.001), and decreased ICU length-of-stay (0.4 vs 2.2 days; P = 0.001). This group also trended towards less blood loss (1.2 vs 1.8 L), shorter average hospital length-of-stay (10 vs 11 days), and decreased 90-day mortality (6% vs 10%). CONCLUSION Resection of RCC with IVC tumor thrombus yields long-term survival. A dedicated, cross-discipline, and team-based approach optimizes patient outcomes and may improve value of care by reducing utilization of expensive hospital resources.
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Affiliation(s)
- Viraj A Master
- Department of Urology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Charles A Staley
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, Georgia
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Gu L, Li H, Wang Z, Wang B, Huang Q, Lyu X, Shen D, Gao Y, Fan Y, Li X, Xie Y, Du S, Liu K, Tang L, Peng C, Ma X, Zhang X. A systematic review and meta-analysis of clinicopathologic factors linked to oncologic outcomes for renal cell carcinoma with tumor thrombus treated by radical nephrectomy with thrombectomy. Cancer Treat Rev 2018; 69:112-120. [PMID: 29960124 DOI: 10.1016/j.ctrv.2018.06.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND There remain discrepancies over the factors that influence oncologic outcomes after radical nephrectomy with thrombectomy (RNTE). To assess significant predictors of oncologic outcomes after RNTE from a systematic review and meta-analysis. METHODS A comprehensive search of PubMed, Embase, Cochrane Library and Web of Science was performed to identify eligible studies. The endpoints included cancer-specific survival (CSS), overall survival (OS), and recurrence-free survival (RFS). A formal meta-analysis was performed for studies containing non-metastatic and metastatic tumors. Additionally, a sensitivity analysis including the subgroup of studies containing non-metastatic tumors only was conducted. Cumulative analyses of hazard ratios (HRs) and their corresponding 95% confidence intervals (CIs) were conducted. RESULTS Overall, 35 retrospective studies of low to moderate risk of bias including 11,929 patients were included. The results indicated that large tumor size, high Fuhrman grade, tumor necrosis, positive lymph node, and metastasis at surgery were adverse significant predictors for both CSS and OS. Also, IVC tumor thrombus, sarcomatoid differentiation, perinephretic fat invasion, and adrenal gland invasion were associated with poor CSS. In the subset of non-metastatic patients, the significant predictors were clinical symptom, thrombus level, Fuhrman grade and adrenal gland invasion for CSS; thrombus consistency, Fuhrman grade and tumor necrosis for OS; tumor size, Fuhrman grade and perinephretic fat invasion for RFS. CONCLUSIONS A meta-analysis of available data identified significant prognostic factors of CSS, OS and RFS that should be systematically evaluated to propose a risk-adapted approach to postoperative patient counseling, risk stratification, and therapy selection.
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Affiliation(s)
- Liangyou Gu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Hongzhao Li
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Zihuan Wang
- Institute of Occupational Health, Beijing Center for Disease Control and Prevention, Beijing, China
| | - Baojun Wang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Qingbo Huang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xiangjun Lyu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Dan Shen
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yu Gao
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Yang Fan
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xintao Li
- Department of Urology, Chinese Air Force General Hospital, Beijing, China
| | - Yongpeng Xie
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Songliang Du
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Kan Liu
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Lu Tang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Cheng Peng
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China
| | - Xin Ma
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
| | - Xu Zhang
- Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital/PLA Medical School, Beijing, China.
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15
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González J, Gaynor JJ, Alameddine M, Esteban M, Ciancio G. Indications, complications, and outcomes following surgical management of locally advanced and metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2018; 18:237-250. [PMID: 29353520 DOI: 10.1080/14737140.2018.1431530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Surgery may set the basis for a potential cure or would provide the best achievable quality of life in locally advanced or metastatic renal cell carcinoma (mRCC). However, survival extension with this approach would be scarce and not exempt from adverse events, thus preventing its recommendation in an already frail patient. An evidence based analysis on the role of surgery in each of the possible clinical scenarios involved under this heading may provide a clear picture on this issue and would be of value in the decision making process. Areas covered: Current literature was queried in PubMed/Medline in a systematic fashion. Manuscripts included were selected according to the quality of the data provided. A narrative review strategy was adopted to summarize the evidence acquired. Expert commentary: A surgery-based multimodal treatment approach should be strongly considered after adequate counseling in locally advanced and mRCC, since it may provide for additional benefits in terms of survival. However, a critical reevaluation of its adequacy, optimal timing, and selection of ideal candidates is currently ongoing.
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Affiliation(s)
- Javier González
- a Servicio de Urología , Hospital Central de la Cruz Roja San José y Santa Adela , Madrid , Spain
| | - Jeffrey J Gaynor
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Mahmoud Alameddine
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
| | - Manuel Esteban
- c Servicio de Urología , Hospital Nacional de Parapléjicos , Toledo , Spain
| | - Gaetano Ciancio
- b Department of Surgery (Division of Transplantation), Department of Urology and the Miami Transplant Institute , University of Miami Miller School of Medicine, Jackson Memorial Hospital , Miami , FL , USA
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16
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Gologorsky E, Fukazawa K, Ciancio G. Perioperative management of patients with renal cell carcinoma with high level of IVC tumor thrombus invasion revisited. J Clin Anesth 2017; 39:23-24. [PMID: 28494899 DOI: 10.1016/j.jclinane.2017.03.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/07/2017] [Indexed: 11/25/2022]
Affiliation(s)
- Edward Gologorsky
- Temple University School of Medicine, Department of Anesthesiology, CVT and Liver Transplant Divisions, Allegheny General Hospital, Pittsburgh, PA, United States.
| | - Kyota Fukazawa
- Dept. of Anesthesiology and Pain Medicine, Univ. of Washington School of Medicine, Seattle, WA, United States
| | - Gaetano Ciancio
- Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, FL, United States
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17
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Hofer L, Gasch C, Hatiboglu G, Motsch J, Grüllich C, Duensing S, Hohenfellner M. [Level IV inferior vena cava tumor thrombus : A rare diagnosis in patients with renal cell carcinoma]. Urologe A 2017; 56:868-875. [PMID: 28349189 DOI: 10.1007/s00120-017-0369-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Renal cell carcinoma in combination with a supradiaphragmatic tumor thrombus is a rare tumor entity. Radical surgery including nephrectomy and thrombectomy is still considered standard treatment. The extent of the tumor thrombus should be preoperatively evaluated by MRI and TEE. An interdisciplinary team is important for surgery planning and realization. Despite the known risks of an operation, a longer overall survival is achieved.
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Affiliation(s)
- L Hofer
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
| | - C Gasch
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - G Hatiboglu
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - J Motsch
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Grüllich
- Klinik für Medizinische Onkologie, Nationales Zentrum für Tumorerkrankungen, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Duensing
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
| | - M Hohenfellner
- Urologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland
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Spelde A, Steinberg T, Patel PA, Garcia H, Kukafka JD, MacKay E, Gutsche JT, Frogel J, Fabbro M, Raiten JM, Augoustides JGT. Successful Team-Based Management of Renal Cell Carcinoma With Caval Extension of Tumor Thrombus Above the Diaphragm. J Cardiothorac Vasc Anesth 2017; 31:1883-1893. [PMID: 28502456 DOI: 10.1053/j.jvca.2017.02.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Indexed: 12/24/2022]
Affiliation(s)
- Audrey Spelde
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Toby Steinberg
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Harry Garcia
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeremy D Kukafka
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Jessie M Raiten
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Gagné-Loranger M, Lacombe L, Pouliot F, Fradet V, Dagenais F. Renal cell carcinoma with thrombus extending to the hepatic veins or right atrium: operative strategies based on 41 consecutive patients. Eur J Cardiothorac Surg 2016; 50:317-21. [PMID: 27016196 DOI: 10.1093/ejcts/ezw023] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/12/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The natural history of renal cell carcinoma (RCC) with tumour thrombus extending at or above the hepatic veins is dismal. Different surgical approaches have been described including cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest. We here report our experience in terms of surgical techniques and outcomes on 41 consecutive patients presenting an RCC extending to the hepatic veins or the right atrium. A surgical decision-making algorithm is discussed. METHODS Retrospective review of 41 patients operated for RCC extending in the retrohepatic vena cava (extent level III-IV) between 2000 and 2015. Patients were operated by a dedicated urology/cardiac surgery team. RESULTS The mean age was 62.6 ± 10.4 years; 39% were female. Surgery was emergent in 7.3% of patients, 2.4% of patients had preoperative dialysis, 4.9% required a redo sternotomy and 19.5% had coronary artery disease. Tumour thrombus extended above the diaphragm in 23 patients (level IV) and to the level of hepatic veins (level III) in 18 patients. CPB was used in 38 patients. Arterial cannulation was in the aorta or femoral artery in 14 patients during the initial experience. In the current era, the axillary artery and the innominate artery were used in 12 patients each. Mean CPB, cross-clamp and circulatory arrest times were, respectively, 96.5 ± 42.9, 21.1 ± 16.4 and 10.2 ± 8.2 min (mean temperature of 25.7 ± 4.9°C). Hepatic exclusion without the use of CPB was performed to excise the thrombus in 3 patients. A right nephrectomy was performed in 25 patients, a left in 15 patients and a bilateral nephrectomy in 1 patient. Five patients had a partial inferior vena cava (IVC) resection, with 4 patients requiring a patch reconstruction of the IVC. Three patients had an infrarenal IVC ligation. One patient suffered a cerebrovascular accident in the postoperative period. One in-hospital death occurred (in-hospital mortality 2.4%). The mean follow-up was 1.9 ± 2.0 years. Twenty-three patients died during follow-up; 21 were disease-related. Three-year survival rate was 37.1%. CONCLUSION High-level RCC tumour thrombus is a rare clinical entity, the treatment of which is complex and requires dedicated operative teams. The operative technique should be tailored according to the level of extension and the extent of vena cava obstruction/occlusion of the tumour thrombus. Contemporary operative techniques may be conducted with excellent results. Mid-term survival is limited, supporting the necessity to pursue research efforts towards establishing effective adjunct therapies.
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Affiliation(s)
- Maude Gagné-Loranger
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
| | - Louis Lacombe
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Frédéric Pouliot
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - Vincent Fradet
- Department of Urology, Hôtel-Dieu de Québec, Centre Hospitalier Universitaire de Québec, Laval University, Québec, Canada
| | - François Dagenais
- Department of Cardiovascular Surgery, Quebec Heart and Lung Institute, Laval University, Sainte-Foy, Canada
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20
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Shah R, Gutsche JT, Patel PA, Fabbro M, Ochroch EA, Valentine EA, Augoustides JGT. CASE 6-2016Cardiopulmonary Bypass as a Bridge to Clinical Recovery From Cardiovascular Collapse During Graft Reperfusion in Liver Transplantation. J Cardiothorac Vasc Anesth 2015; 30:809-15. [PMID: 26738978 DOI: 10.1053/j.jvca.2015.08.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Indexed: 02/07/2023]
Affiliation(s)
- Ronak Shah
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Fabbro
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Edward A Ochroch
- Liver Transplant Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth A Valentine
- Liver Transplant Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - John G T Augoustides
- Cardiovascular and Thoracic Section Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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