Ann Thorac Surg 2012;93:e119-e121. doi:10.1016/j.athoracsur.2011.12.040
© 2012 The Society of Thoracic Surgeons
Case Reports
Novel Approach to Recurrent Cavoatrial Renal Cell Carcinoma
Jennifer L. Alejoa,
Timothy J. George, MDa,
Claude A. Beaty, MDa,
Mohamad E. Allaf, MDb,
James H. Black, III, MDc,
Ashish S. Shah, MDa,*
a Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
b Department of Urology, The Johns Hopkins Medical Institutions, Baltimore, Maryland
c Division of Vascular Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
Accepted for publication December 8, 2011.
* Address correspondence to Dr Shah, Division of Cardiac Surgery, The Johns Hopkins Medical Institutions, 600 N Wolfe St, Blalock 618, Baltimore, MD 21287 (Email: ashah29{at}jhmi.edu).
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Abstract
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Renal cell carcinoma (RCC) with cavoatrial extension is a rare and complex problem. Complete resection is difficult but correlates with favorable patient outcomes. We present 2 cases of successful reoperative resections of recurrent RCC in patients with level III-IV cavoatrial involvement. We used a thoracoabdominal approach, peripheral cannulation, and hypothermic circulatory arrest. We advocate this novel approach as a successful means of avoiding a more difficult reoperation.
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Introduction
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Level III-IV involvement of renal cell carcinoma (RCC) into the inferior vena cava (IVC) and right atrium (RA) frequently requires complex surgical intervention. There are a number of established surgical approaches to primary tumors. However patients with recurrent or residual caval or atrial tumors present a difficult problem and may not be offered surgical reintervention. We report 2 cases of successful resection of recurrent or residual RCC with IVC extension using a thoracoabdominal approach with peripheral cannulation and hypothermic circulatory arrest.
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Case Reports
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Patient 1
A 50-year-old man presented with recurrent RCC of the IVC at the level of the hepatic veins. Seven months previously he had undergone a left radical nephrectomy with IVC and RA thrombectomy through a median sternotomy and bilateral subcostal incision. Routine follow-up computed tomography (CT) showed tumor recurrence with recurrent invasion of the IVC and RA (Fig 1).
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Fig 1. Coronal computed tomography (CT) image demonstrating tumor in the inferior vena cava (IVC) (white arrow).
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The patient was placed in the left lateral decubitus position with his right hip abducted to facilitate a right thoracoabdominal exposure and peripheral cannulation through the right side of the groin. The right internal jugular vein was cannulated with a 15 French arterial cannula and the right femoral artery and vein were exposed. A thoracotomy was made in the eighth intercostal space and extended into the abdomen. After extensive adhesiolysis, the IVC was exposed along its length. The right side of the liver was mobilized to expose the entire right side of the retrohepatic vena cava. Transesophageal echocardiography revealed tumor in the RA (Fig 2). An 8-mm Hemashield (Boston Scientific) chimney graft was sewn to the femoral artery to facilitate arterial cannulation with a 23 French venous cannula in the right femoral vein. The patient was given heparin, placed on cardiopulmonary bypass with vacuum-assisted drainage, and cooled. At 22°C, circulation was arrested and the patient's blood was drained. The IVC was opened at the level of the hepatic veins, revealing a tumor that was densely adherent to the caval wall, necessitating an endarterectomy of the intima (Fig 3). All gross tumor was removed. The hepatic veins were well visualized. There were no hepatic or intracardiac adhesions. The IVC was reconstructed in 2 layers with running 4–0 Prolene (Ethicon, Somerville, NJ). Circulation was restarted and the patient was gradually rewarmed. The patient separated easily from bypass and was taken to the intensive care unit in stable condition. Cardiopulmonary bypass time was 170 minutes and hypothermic circulatory arrest time was 27 minutes. He was discharged uneventfully on postoperative day 5. The patient is currently without recurrence 2 years after resection.
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Fig 2. Intraoperative transesophageal echocardiogram demonstrating tumor of the right atrium (RA) (white arrow).
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Patient 2
A 55-year-old man presented with recurrent RCC 9 months after right radical nephrectomy and IVC and RA thrombectomy. CT showed recurrence of tumor thrombus with extension into the right hepatic vein as well as new thrombus of the infrarenal IVC, proximal left renal vein, right common iliac vein, right external iliac vein, and right common femoral vein (Fig 4).
The patient was placed in the left lateral decubitus position for a thoracoabdominal incision. A 15 French superior vena cava cannula was placed through the right internal jugular vein and the right side of the groin was exposed to facilitate peripheral cannulation. A thoracotomy was performed through the eighth intercostal space and deepened to open the chest and the abdomen. After extensive abdominal adhesiolysis and lateral incision of the diaphragm, the IVC was exposed along its length. The retrohepatic vena cava was exposed by mobilizing the right lobe of the liver and reflecting it to the left. After heparinization, the right common iliac artery was cannulated through an 8-mm Hemashield chimney graft anastomosed to the common iliac artery. The right femoral vein was cannulated with a 23 French venous cannula, and cardiopulmonary bypass with vacuum-assisted drainage was initiated. The patient was cooled to 18°C and circulation was arrested. The IVC was opened from the confluence of the hepatic veins down to the left renal vein and into the iliac veins to reveal the tumor. This was removed completely without any gross residual tumor. To facilitate closure, the IVC was transected below the left renal vein, and the cavotomy was closed with running 3–0 Prolene (Ethicon) in a single layer. Because of chronic thrombosis of the iliac veins and the lack of patient symptoms, the IVC was not reconstructed and the confluence of the iliac veins was oversewn. Circulation was restarted and the patient was rewarmed. Cardiopulmonary bypass time was 174 minutes, with 24 minutes of hypothermic circulatory arrest.
The patient was discharged uneventfully on postoperative day 11. Six months postoperatively, there is no evidence of local recurrence.
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Comment
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We present 2 cases of recurrent RCC with cavoatrial involvement after previous sternotomy. We resected the tumor through a thoracoabdominal incision with peripheral cannulation and hypothermic circulatory arrest. To our knowledge, the thoracoabdominal approach is a novel approach for this type of cancer [1–7]. Stage III and stage IV levels of disease present the greatest challenges in surgical resection of cavoatrial tumors because of the varying amounts of penetration into the walls of the IVC and cardiac structures [3]. There is no standard procedure for this operation in the literature, but we have found the approach we have described to be successful.
Since both patients had previous sternotomies, we used a thoracoabdominal incision to avoid redo sternotomy and the challenges of extensive adhesiolysis needed to access the retrohepatic vena cava. We also used peripheral cannulation to institute cardiopulmonary bypass with vacuum-assisted drainage. Circulatory arrest facilitates a bloodless field, optimizing visibility for complete resection [7]. Patients with recurrent tumors may be offered safe reoperative resection. Peripheral cannulation, hypothermic circulatory arrest, and a thoracoabdominal retrohepatic exposure allow for compete resection of tumor.
In conclusion, selected patients with recurrent RCC in the retrohepatic vena cava can be offered safe surgical reoperation.
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References
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- Dedeilias P, Koletsis E, Rousakis A, et al. Deep hypothermia and circulatory arrest in the surgical management of renal tumors with cavoatrial extension J Card Surg 2009;24:617-623.[Medline]
- Ciancio G, Shirodkar SP, Soloway MS, et al. Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass Ann Thorac Surg 2010;89:505-510.[Abstract/Free Full Text]
- Jibiki M, Iwai T, Inoue Y, et al. Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava J Vasc Surg 2004;29:829-835.
- Bustamante J, Garcia-Moran E, Bustamante E, Soto De Prado D, Florez S. Cardiac surgery in the treatment of renal cell carcinoma with extension into the vena cava Cir Esp 2010;87:182-184.[Medline]
- Kaoutzanis C, Evangelakis E, Kokkinos C, Kaotzanis G. Successful repair of injured hepatic veins and inferior vena cava following blunt traumatic injury, by using cardiopulmonary bypass and hypothermic circulatory arrest Interact Cardiovasc Thorac Surg 2011;12:84-86.[Abstract/Free Full Text]
- Fehrenbacker J, Siderys H, Terry C, Kuhn J, Corvera JS. Early and late results of descending thoracic and thoracoabdominal aortic aneurism open repair with deep hypothermia and circulatory arrest J Thorac Cardiovasc Surg 2010;140(6 suppl):154-160discussion S185–90.
- Chiappini B, Savini C, Marinelli G, et al. Cavoatrial tumor thrombus: single-stage surgical approach with profound hypothermia and circulatory arrest, including a review of the literature J Thorac Cardiovasc Surg 2002;124:684-688.[Abstract/Free Full Text]
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Abstract
Introduction
