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Ann Thorac Surg 2008;85:1145. doi:10.1016/j.athoracsur.2007.06.020
© 2008 The Society of Thoracic Surgeons
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Correspondence

Removal of Renal Cell Carcinoma and Thrombectomy With Intraatrial Tumor Without Cardiopulmonary Bypass

Gaetano Ciancio, MDa, Tomas A. Salerno, MDb

a Department of Surgery (Division of Transplantation) and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, East Tower 3072 (R-114), Miami, FL 33136
b Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, 1611 NW 12th Ave, East Tower 3072 (R-114), Miami, FL 33136

To the Editor:

The authors report their surgical experience of renal cell carcinoma with tumor thrombus extending into the atrium [1]. They reported a novel technique of tumor thrombectomy using cardiopulmonary bypass (CPB) and mild hypothermia, and intermittent cross-clamping of the supraceliac intra-abdominal aorta. The authors mentioned in their discussion that "non-CPB approaches are plagued by problems of profound intraoperative hypotension, suboptimal thrombectomy, risk of tumor embolization within the right atrium and pulmonary tree, disruption, the risk of unpredictable bleeding, and warm ischemic injury to the liver and kidneys." They referred to one of our articles (Reference 17) [2], and we would like to clarify our experience with these operations.

During the past 12 years at the University of Miami Miller School of Medicine and Jackson Memorial Hospital, we have used liver transplant techniques (ie, conventional or piggyback style mobilization) [2–10] to gain adequate exposure of the upper abdomen when dealing with urological tumors with caval involvement [2–4]. These techniques have been previously described in detail [3–5]. We have also tried to control the intrapericardial inferior vena cava transabdominally [2–10]. We have also described a new classification for level III (retrohepatic and suprahepatic portion of the inferior vena cava, not extending into the atrium but above the diaphragm) tumor thrombus and the surgical approach for each of the different levels [4]. In this article there were 23 patients who were classified as level III and who underwent surgical resection using liver transplant techniques for mobilization of the liver off of the inferior vena cava (ie, piggyback mobilization). None of the patients required a thoracoabominal approach, cardiopulmonary bypass, or veno-venous bypass. In 3 patients, the intrapericardial inferior vena cava was controlled without the use of a sternotomy [4]. This experience now extends to 40 patients with a level III classification. Moreover, we described a technique to avoid veno-venous bypass during these difficult cases [6] and how to deal with renal cell carcinoma with inferior vena cava tumor thrombus causing Budd-Chairi syndrome [5].

We reported our experience removing an adherent [2] and nonadherent [7] level IV (intra-atrial thrombus) tumor thrombus without a thoracoabdominal approach, median sternotomy, or cardiopulmonary bypass, or a combination thereof. More recently we reported the University of Miami Miller School of Medicine and Jackson Memorial Hospital experiences in dealing with renal cell carcinoma with caval tumor thrombus. All tumors were resected using liver transplant techniques, including 5 patients with tumor thrombus into the right atrium and 4 patients with a level III classification that were supradiaphragmatic without using CPB [10]. Finally, we also described the use of liver transplant techniques dealing with adrenal tumors with inferior vena cava tumor thrombus extending above the diaphragm [11, 12].

The University of Miami Miller School of Medicine and Jackson Memorial Hospital’s experience with these difficult tumors, which may extend into the atrium, indicates that CPB can be avoided for the majority of cases, thereby simplifying the operation.


   References
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 References
 

  1. Chowdhury UK, Mishra AK, Seth A, et al. Novel techniques for tumor thrombectomy for renal cell carcinoma with intra-atrial tumor thrombus Ann Thorac Surg 2007;83:1731-1736.[Abstract/Free Full Text]
  2. Cerwicka WH, Ciancio G, Salerno TA, Soloway M. Renal cell cancer with invasive atrial tumor thrombus excised off-pump Urology 2005;66:1318e9–11.
  3. Ciancio G, Hawke C, Soloway M. The use of liver transplant techniques to aid in the surgical management of urological tumors J Urol 2000;164:655-672.
  4. Ciancio G, Vaidya A, Savoie M, Soloway M. Management of renal cell carcinoma with level III thrombus in the inferior vena cava J Urol 2002;168:1374-1377.[Medline]
  5. Ciancio G, Soloway M. Renal cell carcinoma invading the hepatic veins Cancer 2001;92:1836-1842.[Medline]
  6. Ciancio G, Soloway M. The use of natural veno-venous bypass during surgical treatment of renal cell carcinoma with inferior vena cava thrombus Am Surg 2002;68:488-490.[Medline]
  7. Ciancio G, Soloway M. Renal cell carcinoma with tumor thrombus extending above the diaphragm: avoiding cardiopulmonary bypass Urology 2005;66:266-270.[Medline]
  8. Ciancio G, Soloway M. Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumor thrombus BJU Int 2005;96:815-818.[Medline]
  9. Cerwicka WH, Ciancio G, Salerno TA, Soloway M. Renal cell cancer with invasive atrial tumor thrombus excised off-pump Urology 2005;66:1318e9–11.
  10. Ciancio G, Livingstone AS, Soloway M. Surgical management of renal cell carcinoma with thrombus in the inferior vena cava: The University of Miami experience in using liver transplant techniques Eur Urol 2007;51:988-995.[Medline]
  11. Reyes M, Ciancio G, Singal R, Manoharan M. Adrenocortical carcinoma with tumor thrombus in the right hepatic vein: case report Intern J Urol 2006;13:1233-1235.
  12. Ekici S, Ciancio G. Surgical management of large adrenal masses without or with thrombus extending into the inferior vena cava J Urology 2004;172:2340-2343.[Medline]

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Reply
Ujjwal K. Chowdhury and Amlesh Seth
Ann. Thorac. Surg. 2008 85: 1145-1146. [Extract] [Full Text] [PDF]



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U. K. Chowdhury and A. Seth
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Ann. Thorac. Surg., March 1, 2008; 85(3): 1145 - 1146.
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