Surgical treatment for transvenous tumor extension into the heart: four cases

Wide en-bloc thymectomy and venous axis reconstruction in Masaoka stage IIIB thymoma: a case report and literature review

Thymomas are rare tumors originating from thymic tissue and rarely metastasize. They can be diagnosed either incidentally or symptomatically when compressing or invading nearby structure. A 36-year-old man presented with significant high-grade fever, chest pain that worsens upon lying down, and dyspnea. A chest X-Ray and computed tomography followed by biopsy confirmed the diagnosis of thymoma. The management included chemotherapy cycles, followed by surgery. Pericardiectomy was performed with en-bloc thymectomy and partial resection of the infiltrating lung. Venous drainage was restored by 8/16 mm inverted bifurcated brachiocephalic-superior vena cava Dacron bypass. The pericardium was reconstructed by a synthetic Dacron patch, and the right diaphragm metastasis was resected. Neoadjuvant chemotherapy was initiated. After 3 months of follow-up, no recurrence was evidenced by computed tomography.

Inferior Vena Caval Tumor Thrombus in Giant Cell Tumor of Sacrum - An Unusual Complication Treated with Multimodality Management

INTRODUCTION

Giant cell tumor is the most common benign lesion encountered. It accounts for 5 % of all skeletal tumors. It mainly affects the epiphysis of long bones and rarely axial bones. In axial bones, sacrum is the most common site to be affected.

CASE REPORT

A 23 year old female with giant cell tumor of sacrum was treated initially with conservative treatment (serial angioembolisation and bisphosphonates). Later intralesional curettage was done as the patient started developing bladder and bowel disturbances after two sessions of angioembolisation. Six months later patient again presented with pain at the primary lesion site and bilateral limb swelling. Imaging revealed recurrence of the disease and tumor thrombus extending into the inferior vena cava up to the subhepatic region.

CONCLUSION

Treatment of sacral GCT (Giant Cell Tumor) poses a unique challenge to the treating surgeon because of the close proximity of vital neurovascular structures, viscera and associated complications related to the disease. Tumor thrombi are a very rare phenomenon associated with giant cell tumors of the bone. High index of suspicion and multimodality approach is the key in treating such challenging tumors and their complications.

One-stage complete resection of giant intracardiac leiomyomatosis with moderate hypothermia extracorporeal circulation and beating heart technique with 36 months follow-up-a case report

BACKGROUND

Intracardiac leiomyomatosis (ICL) is a rare benign neoplasm of the smooth muscle in the uterus extending into the heart. Complete resection is difficult because of the extensive range.

CASE PRESENTATION

We report a case of one-stage complete resection of a giant ICL with moderate hypothermia extracorporeal circulation and beating heart technique.

CONCLUSIONS

The outcome of 36 months follow-up was very good.

Intravenous leiomyomatosis with intracardiac extension - a review of diagnosis and management with an illustrative case

Intravenous leiomyomatosis with intracardiac extension is an uncommon pathologic progression of uterine leiomyomata. It is a histologically benign condition, however due to interfence with right sided cardiac function patients may present with marked cardiovascular compromise and present a diagnostic dilemma to clinicians who are unfamiliar with this condition. Given the rarity of this condition, experience in individual institutions is usually limited to a few cases. We present an illustrative case and provide a review of the clinical presentation, preoperative assessment, operative approach, pathology and postoperative issues. The importance of a multidisciplinary approach to diagnosis and management is highlighted. Operative management aims to completely resect all tumour in the safest manner for the patient, most commonly via single or two stage operation. Where complete resection is achieved, recurrence appears to be a rare event.

Intracaval and intracardiac extension of invasive thymoma complicated by superior and inferior vena cava syndrome

We present a case of an aged male with invasive thymoma that extended into the right atrium and led to superior and inferior vena cava syndrome. The patient initially presented with edema of the face and bilateral lower extremities. Echocardiography revealed a mass within the right atrium. Imaging studies demonstrated an anterior mediastinal tumor that continuously occupied the bilateral brachiocephalic veins, superior vena cava, and right atrium. Pathological diagnosis of the tumor biopsy was highly suspicious of thymoma. Due to the high risk of wide spread of the tumor, treatments including resection of the tumor were impossible. Several days later he died, and an autopsy was performed. The tumor was type B2 thymoma invading bilateral brachiocephalic veins, superior vena cava and right atrium. Multiple tumor emboli within the pulmonary arteries were identified. Direct cause of death was deemed to be tumor strangulation at the tricuspid orifice. In addition to the superior vena cava syndrome, inferior vena cava syndrome including ectasia of the intrahepatic vessels was confirmed along with pericarditis. To our knowledge, this is the first English report of an autopsy case of intracardiac thymoma extension, and a detailed literature review of similar cases is also presented.

Pulmonary artery extension of uterine leiomyoma

Intravenous leiomyomatosis is a rare tumor arising either from a uterine leiomyoma or from uterine vessel walls with extension into venous channels. Although intravenous leiomyomatosis is considered histologically "benign," intrusion to the cardiac chambers is almost malignant given its possibility for destruction of heart valves, extending into the pulmonary vasculature, and embolizing. We report a patient with an intravenous leiomyomatosis progressing through the left iliac vein, along the entire vena cava up to the right cardiac chambers and branches of pulmonary artery (PA), and review the literature on this subject.

Clear cell sarcoma of the kidney: a review

Clear cell sarcoma of the kidney (CCSK) is a rare renal tumour that is observed most often in children under 3years of age. Only a few large series of CCSK have been reported and patients with CCSK are often included among patients with other types of childhood renal tumours. The purpose of this paper is to review the published series and case reports of CCSK and to create an up-to-date overview of clinical and histological features, genetics, treatment, and outcome.

Strategy for management of retroperitoneal tumors with caval tumor thrombus

The surgical management of retroperitoneal tumors extending into the inferior vena cava (IVC) can be challenging. Although Wilms' tumor is the most common retroperitoneal tumor extending into the IVC, one must approach these tumors systematically as other diagnoses are possible. We present 4 consecutive cases of retroperitoneal tumors with IVC extension as a basis for a management strategy in approaching these patients. Despite similar presentations, these cases illustrate the nuances in surgical management and need for multidisciplinary care with the pediatric oncologists, pediatric surgeons, and pediatric cardiac surgeons.

Diagnostic and surgical issues in emergency presentation of a pelvic leiomyoma in the right heart

A computed tomography scan in a 43-year-old woman with a nonsignificant previous medical history demonstrated an inferior caval mass prolapsing through the right atrium and the tricuspid valve. The mass was misdiagnosed as a thrombus-in-transit, and heparin was started. The clinical picture suddenly evolved into cardiogenic shock, and the patient underwent an emergency resection of the intracardiac portion of the mass. Macroscopic and microscopic features were consistent with leiomyoma. In the presence of an inferior caval mass, historical elements and computed tomography imaging that do not corroborate the hypothesis of caval thrombosis should raise the suspicion of intracaval tumor originating from an abdominal or pelvic organ. The preferred treatment strategy is an elective combined thoracic and abdominal resection.

Clear cell sarcoma of the kidney with cavo-atrial tumor thrombus: complete resection in a child

Clear cell sarcoma is one of the rarely occurring renal tumors during childhood, and transvenous tumor extension into the right atrium is even more unusual. In this report, we describe the presentation, treatment, technique of complete resection, and outcome of a 23-month-old girl with clear cell sarcoma of the right kidney with cavo-atrial tumor thrombus.

Intracardiac Extension of Lung Cancer Demonstrated on PET Scanning

Intracardiac tumors are unusual and can originate within the heart or spread from other sites. This is a report of a patient who presented with a TIA, and during the subsequent stroke workup, a right hilar nonsmall cell lung carcinoma was discovered. The tumor had extended into the left atrium through a pulmonary vein. The hilar tumor as well as intracardiac extension were demonstrated by PET scanning using FDG.

Renal adenocarcinoma with intramyopericardial and right atrial metastasis, latter via coronary sinus: report of a case

Primary renal tumors with intracardiac metastasis are not infrequent. Most of the secondary spread is blood-borne and occurs via inferior vena cava. Patients with such a spread often present with cardiac symptoms. We presume that a metastatic spread in the right atrium through coronary sinus has never been reported in the literature according to the result of a Medline search at the time of writing this report.

Leiomyomatosis Metastatic to the Tricuspid Valve Complicated by Pelvic Hemorrhage

Metastatic leiomyomatosis is a rare but potentially life-threatening tumor of smooth muscle cells. Leiomyomas originate predominantly in the uterus and can spread to the lung and, rarely, the heart. We present a case of a 36-year-old woman with known pelvic leiomyomatosis with metastasis to the tricuspid valve. Tricuspid valve replacement was complicated by retroperitoneal hemorrhage from residual pelvic tumor. This potentially catastrophic occurrence should be considered when undertaking resection of intracardiac leiomyomatosis.

Resection of an intravenous leiomyoma with intracardiac extension with use of endovascular techniques

Intravenous leiomyoma with intracardiac extension is a rare entity that necessitates surgical excision to alleviate symptoms and prevent life-threatening complications. These procedures are generally performed under cardiopulmonary bypass, and review of the literature reveals an evolution in management of this disease from 2-stage to single-stage procedures. We report the case of a 45-year-old woman with an intravenous leiomyoma with intracardiac extension after presenting with syncopal symptoms. The intravenous tumor and its supradiaphragmatic extension were ultimately resected via laparotomy without the need for cardiopulmonary bypass. Distal control was achieved by passing an occluding balloon catheter above the tumor through a venotomy with fluoroscopic guidance and echocardiography, thus enabling protected tumor extraction through the intra-abdominal inferior vena cava. In selected patients, we believe use of endovascular techniques combined with proper preoperative imaging can safely permit single-stage resection of these tumors via laparotomy without cardiopulmonary bypass.

Pelvic leiomyomatosis with intracaval and intracardiac extension: a case report and review of the literature

BACKGROUND

Intravenous leiomyomatosis with intracaval and intracardiac extension has been rarely described in surgical, gynecological, and radiological literatures. Complete excision of the tumor is essential for a favorable outcome. Because of the uniqueness of this tumor having an absent or localized attachment site, its removal is feasible when assisted, prior to surgery, with appropriate imaging and planning.

CASE

The case was a 46-year-old woman, with intravenous leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium, with extensive intracaval attachment, diagnosed from the various preoperative studies and operated successfully through the single-stage approach using cardiopulmonary bypass.

CONCLUSION

We present an unusual case of intravenous leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium with extensive intracaval attachment. We include a brief review of the literatures.

Renal cell carcinoma with extension of tumor thrombus into the vena cava: surgical strategy and prognosis

PURPOSE

The outcome of patients who underwent radical resection of renal cell carcinoma extending into the vena cava was retrospectively analyzed, and risk factors for long-term survival were investigated.

METHODS

From 1983 to 1999, 33 patients who had renal cell carcinoma with inferior vena caval tumor extension underwent 34 surgical procedures. There were 27 men and six women with an average age of 60.1 years. Twenty-two cases (64.7%) were classified as stage III (T1-2 N1 M0 or T3 N0-1 M0), and 12 cases (35.3%) as stage IV (T4 or N2-3 or M1). Coexistent lung metastasis was found in seven cases (20.6%). The tumor thrombi invaded into the inferior vena cava below the hepatic hilum in 19 cases, below the orifice of hepatic veins in 12, and above the diaphragm in 3. Cardiopulmonary bypass graft was applied in 13 cases (38.2%). Inferior vena cava was reconstructed by direct suture (n = 19), polytetrafluoroethylene patch angioplasty (n = 13), or graft replacement (n = 2).

RESULTS

Two patients died during the early postoperative period because of retrohepatic caval injury and intraoperative pulmonary embolism. Late death occurred in 16 patients; the causes of death were tumor recurrence in 15 and acute pulmonary embolism as a result of graft thrombosis in 1. Overall 1-, 5-, and 10-year survival rates were 70%, 44%, and 26.4%, respectively. One- and 5-year survival rates were 81.3% and 52.9% for stage III and 50% and 31.2% for stage IV; a statistically significant correlation was found between surgical staging and survival (P =.049). Patients without lymph node metastasis had a significant survival advantage over those with lymph node metastasis (P =.022). There was no significant difference in survival on the basis of the presence or absence of synchronous lung metastasis (P =.291). The degree of local extension of the tumor or the level of tumor thrombus did not tend to influence survival.

CONCLUSIONS

Surgical prognosis in patients with renal cell carcinoma extending into the vena cava was determined by the staging of the tumor, especially lymph node status, and not by the level of tumor thrombus or the presence of concurrent lung metastasis. The use of cardiopulmonary bypass graft is recommended for the resection of tumor thrombus extending over the diaphragm.