Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal circulation and beating heart

Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal... Formation of tumor thrombus is an occasional manifestation of renal cell carcinoma (RCC). Intravascular invasion of the renal vein and thereafter the inferior vena cava (IVC) might in very rare cases extend into the cardiac chambers. The subtle course and symptoms of such cases alongside with the engagement of vital anatomical structures marks them as a diagnos- tic and therapeutic challenge. Aggressive surgical intervention has proven to be critical for survival rates in such cases; how- ever total synchronous resection remains a challenge for the surgical team and a debate for the medical community. Following we report the case of a 66-year-old male who was diagnosed with a RCC of the right kidney accompanied by a tumor thrombus extending into the right atrium, after he suffered a presyncope episode. The patient underwent a radical en bloc nephrectomy and tumor thrombectomy under extracorporeal circulation with beating heart. INTRODUCTION [3]. Average survival without any kind of surgical intervention is 5 Renal cell carcinoma (RCC) is characterized by its high metastatic months [4]. Surgical removal launches 5-year survival from 40 to 60% [4]. Due to the rarity of such patients there are still many index and its propensity to invade intravascular and generate tumor thrombi. Approximately 15% of all RCCs will invade the controversies regarding the most appropriate surgical technique. The aim is to limit complication and mortality rates thus improv- inferior vena cava (IVC) but only 1% of them will extend supra- diaphragmatic into the right atrium, classified as a Level IV tumor ing prognosis. Precise tumor staging studies, collaboration of an experienced multidisciplinary team and patient’sconsent arepre- thrombus according to the Neves and Zincke system [1, 2]. Total surgical resection is the gold standard of therapy in these patients requisites for therapeutic planning. Received: January 19, 2018. Accepted: April 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 E. Mavrigiannaki et al. CASE REPORT DISCUSSION A 66-year-old male, former smoker with a history of hyperten- A radical nephrectomy and thrombectomy provides the only sion, chronic obstructive pulmonary disease and glaucoma was perspective for a favorable prognosis in patients with RCC and delivered to the emergency department after a presyncope epi- tumor thrombus of any level as recorded in survival rates [5]. sode. The patient mentioned episodes of diarrheic melaenas The effect of the thrombus level to overall survival is debatable, over the last 2 weeks, a progressively worsening dysthymia yet is referred to as an independent prognostic factor in most over the last 2 months and a constant pain of the right lower studies [1, 5, 6]. A level IV extension sets an anatomical conun- lumbar region of more than five months that was diagnosed as drum that renders surgical approach more complex and riskier a hernia. ECG showed sinus rhythm with frequent atrial ecto- [4] and even in high performance centers is associated with pics. The clinical examination was without special findings and major complications and higher perioperative mortality and malaena was not clinically confirmed. Vital signs were mea- morbidity [1, 3, 4]. Gaudino et al. reported an inhospital mortal- sured within normal limits. Laboratories revealed anemia (Hct ity of up to 40% and major complications in up to 47%. Abel 30.4%, Hb 9.8%), mild elevation of liver enzymes (gGT 197, ALP et al. reported a four-fold higher risk of major complications 186) and CRP (14.1 mg%). Cardiac markers and fecal occult with supradiaphragmatic thrombus and Protopapas et al. blood test were negative. An abdominal ultrasound revealed a reported 64% morbidity for level IV thrombi against 36% for heterogenous mass (6.8 × 6.7 cm ) on the upper pole of the right level III and mortality 15 and 10%, respectively. Increasing age, kidney and a tumor thrombus extending to the IVC. The CT elevated aspartate aminotranferase and alkaline phospate, scan of the abdomen and the thorax confirmed the diagnosis of hypoalbuminemia and systemic symptoms are also related to renal mass with cavoatrial tumor thrombus. Pre-surgical sta- complication rates and mortality [3, 4, 6]. Thromboembolism, ging with MRI and angiography revealed no other sites of path- hemorrhage, ileus and sepsis are the most common complica- ology or metastasis (Fig. 1). tions with any kind of surgery [3, 4, 7]. The rarity of level IV The patient underwent a radical en bloc nephrectomy and RCC makes prospective trials of different surgical techniques thrombectomy under extracorporeal circulation in normother- impossible [3]. A Chevron, midline or subcostal incision is mia and beating heart. The patient remained on ICU for 7 days reported by most authors as preferable to assess the peritoneal and on the fourth day, following oedema of the right lower leg, cavity, achieve complete exposure of the IVC and perform the a femoral and iliac vein thrombus was discovered. This was nephrectomy [4, 6, 8]. This is followed by or extended to a corrected surgically and no other complications were incurred. median sternotomy when bypass techniques are performed. To He was discharged on Day 19. Two years postsurgery a possible the presented case a Chevron/Kocher incision was performed retroperitoneal tumor was detected and removed by a median first to allow mobilization of the liver and the right kidney and laparotomy. Histology did not reveal any features of malig- exposure of the IVC, followed by a separate median sternot- nancy. The patient, 4 years after initial surgery, is under onco- omy. CPB with or without DHCA is the traditional approach to logical follow-up, receives targeted therapy and no other sites obtain a bloodless field for thrombectomy in patients with of metastasis have been found yet. atrial involvement [2, 5]. DHCA was questioned due to longer operative times, higher postoperative coagulopathy, renal fail- ure and retroperitoneal hemorrhage but a recent review of the literature demonstrated no significant difference to the out- come with or without hypothermia [1]. The non-CPB techni- ques reported in various studies produce satisfactory outcomes but remain controversial due to higher risk of intraoperative tumor embolization with manipulation, uncertainty of tumor burden clearance because of compromised visualization, lim- ited patient sample and limited application with a larger intra- atrial thrombus [1, 8]. Advances in anesthetic and surgical care have eliminated controversies among the techniques, and the availability of CPB in the operating room as an alternative is considered necessary. CPB was considered preferable to this case due to the sizable mass that was blocking almost all of the IVC width. Formation of such intravascular thrombus is documented as fast evolving, thus it is essential to obtain radiological imaging no longer than 14 days prior to surgery [4, 6, 9]. An additional principle reported in most studies and performed to this case is early ligation of the renal artery, in order to limit collateral cir- culation and thus potential blood loss [4, 10]. Metastasis is con- sidered a negative prognostic factor for survival but selected patients may undergo surgery with promising survival rates [3, 5]. Absence of metastasis, although random, was an add- itional positive predictor to our case. The most essential aspect for a prompt outcome is tailoring the therapy to the patients profile, the available technology to use and the experience of the operating team. The optimum cooperation of a multidiscip- linary team preoperatively, perioperatively and postoperatively Figure 1: MRI imaging displaying the cavoatrial tumor thrombus. was the key in our case as well. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Synchronous nephrectomy and cavoatrial tumor thrombectomy 3 4. Haidar GM, Hicks TD, El-Sayed HF, Davies MG. Treatment CONFLICT OF INTEREST STATEMENT options and outcomes for caval thrombectomy and resection The authors declare no conflict of interest. for renal cell carcinoma. J Vasc Surg Venous Lymphat Disord 2017;5:430–6. 5. Hatakeyama S, Yoneyama T, Hamano I, Murasawa H, FUNDING Narita T, et al. Prognostic benefit of surgical management The authors declare no funding interests. in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center. BMC Urol 2013;13:47. GUARANTOR 6. Psutka SP, Leibovich BC. Management of inferior vena cava Mavrigiannaki Eleftheria. tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015;7:216–29. 7. Wotkowicz C, Libertino JA, Sorcini A, Mourtzinos A. REFERENCES Management of renal cell carcinoma with vena cava and 1. Gaudino M, Lau C, Cammertoni F, Vargiu V, Gambardella I, atrial thrombus: minimal access vs median sternotomy Massetti M, et al. Surgical treatment of renal cell carcinoma with circulatory arrest. BJU Int 2006;98:289–97. with cavoatrial involvement: a systematic review of the lit- 8. Gagné-Loranger M, Lacombe L, Pouliot F, Fradet V, Dagenais erature. Ann Thorac Surg 2016;101:1213–21. F. Renal cell carcinoma with thrombus extending to the 2. Protopapas AD, Ashrafian H, Athanasiou T. Tumour throm- hepatic veins or right atrium: operative strategies based on bi in the suprahepatic inferior vena cava: the cardiothor- 41 consecutive patients. Eur J Cardio-Thoracic Surg 2016;50: acic surgeons’ view. ISRN Vasc Med 2013;2013:Article ID 317–21. 546709. 9. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The 3. Abel EJ, Thompson RH, Margulis V, Heckman JE, Merril MM, Mayo Clinic experience with surgical management, complica- Darwish OM, et al. Perioperative outcomes following surgi- tions and outcome for patients with renal cell carcinoma and cal resection of renal cell carcinoma with inferior vena cava venous tumour thrombus. BJU Int 2004;94:33–41. thrombus extending above the hepatic veins: a contempor- 10. González J. Update on surgical management of renal cell car- ary multicenter experience. Eur Urol 2014;66:584–92. cinoma with venous extension. Curr Urol Rep 2012;13:8–15. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

Synchronous nephrectomy and cavoatrial tumor thrombectomy under normothermic extracorporeal circulation and beating heart

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Abstract

Formation of tumor thrombus is an occasional manifestation of renal cell carcinoma (RCC). Intravascular invasion of the renal vein and thereafter the inferior vena cava (IVC) might in very rare cases extend into the cardiac chambers. The subtle course and symptoms of such cases alongside with the engagement of vital anatomical structures marks them as a diagnos- tic and therapeutic challenge. Aggressive surgical intervention has proven to be critical for survival rates in such cases; how- ever total synchronous resection remains a challenge for the surgical team and a debate for the medical community. Following we report the case of a 66-year-old male who was diagnosed with a RCC of the right kidney accompanied by a tumor thrombus extending into the right atrium, after he suffered a presyncope episode. The patient underwent a radical en bloc nephrectomy and tumor thrombectomy under extracorporeal circulation with beating heart. INTRODUCTION [3]. Average survival without any kind of surgical intervention is 5 Renal cell carcinoma (RCC) is characterized by its high metastatic months [4]. Surgical removal launches 5-year survival from 40 to 60% [4]. Due to the rarity of such patients there are still many index and its propensity to invade intravascular and generate tumor thrombi. Approximately 15% of all RCCs will invade the controversies regarding the most appropriate surgical technique. The aim is to limit complication and mortality rates thus improv- inferior vena cava (IVC) but only 1% of them will extend supra- diaphragmatic into the right atrium, classified as a Level IV tumor ing prognosis. Precise tumor staging studies, collaboration of an experienced multidisciplinary team and patient’sconsent arepre- thrombus according to the Neves and Zincke system [1, 2]. Total surgical resection is the gold standard of therapy in these patients requisites for therapeutic planning. Received: January 19, 2018. Accepted: April 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 E. Mavrigiannaki et al. CASE REPORT DISCUSSION A 66-year-old male, former smoker with a history of hyperten- A radical nephrectomy and thrombectomy provides the only sion, chronic obstructive pulmonary disease and glaucoma was perspective for a favorable prognosis in patients with RCC and delivered to the emergency department after a presyncope epi- tumor thrombus of any level as recorded in survival rates [5]. sode. The patient mentioned episodes of diarrheic melaenas The effect of the thrombus level to overall survival is debatable, over the last 2 weeks, a progressively worsening dysthymia yet is referred to as an independent prognostic factor in most over the last 2 months and a constant pain of the right lower studies [1, 5, 6]. A level IV extension sets an anatomical conun- lumbar region of more than five months that was diagnosed as drum that renders surgical approach more complex and riskier a hernia. ECG showed sinus rhythm with frequent atrial ecto- [4] and even in high performance centers is associated with pics. The clinical examination was without special findings and major complications and higher perioperative mortality and malaena was not clinically confirmed. Vital signs were mea- morbidity [1, 3, 4]. Gaudino et al. reported an inhospital mortal- sured within normal limits. Laboratories revealed anemia (Hct ity of up to 40% and major complications in up to 47%. Abel 30.4%, Hb 9.8%), mild elevation of liver enzymes (gGT 197, ALP et al. reported a four-fold higher risk of major complications 186) and CRP (14.1 mg%). Cardiac markers and fecal occult with supradiaphragmatic thrombus and Protopapas et al. blood test were negative. An abdominal ultrasound revealed a reported 64% morbidity for level IV thrombi against 36% for heterogenous mass (6.8 × 6.7 cm ) on the upper pole of the right level III and mortality 15 and 10%, respectively. Increasing age, kidney and a tumor thrombus extending to the IVC. The CT elevated aspartate aminotranferase and alkaline phospate, scan of the abdomen and the thorax confirmed the diagnosis of hypoalbuminemia and systemic symptoms are also related to renal mass with cavoatrial tumor thrombus. Pre-surgical sta- complication rates and mortality [3, 4, 6]. Thromboembolism, ging with MRI and angiography revealed no other sites of path- hemorrhage, ileus and sepsis are the most common complica- ology or metastasis (Fig. 1). tions with any kind of surgery [3, 4, 7]. The rarity of level IV The patient underwent a radical en bloc nephrectomy and RCC makes prospective trials of different surgical techniques thrombectomy under extracorporeal circulation in normother- impossible [3]. A Chevron, midline or subcostal incision is mia and beating heart. The patient remained on ICU for 7 days reported by most authors as preferable to assess the peritoneal and on the fourth day, following oedema of the right lower leg, cavity, achieve complete exposure of the IVC and perform the a femoral and iliac vein thrombus was discovered. This was nephrectomy [4, 6, 8]. This is followed by or extended to a corrected surgically and no other complications were incurred. median sternotomy when bypass techniques are performed. To He was discharged on Day 19. Two years postsurgery a possible the presented case a Chevron/Kocher incision was performed retroperitoneal tumor was detected and removed by a median first to allow mobilization of the liver and the right kidney and laparotomy. Histology did not reveal any features of malig- exposure of the IVC, followed by a separate median sternot- nancy. The patient, 4 years after initial surgery, is under onco- omy. CPB with or without DHCA is the traditional approach to logical follow-up, receives targeted therapy and no other sites obtain a bloodless field for thrombectomy in patients with of metastasis have been found yet. atrial involvement [2, 5]. DHCA was questioned due to longer operative times, higher postoperative coagulopathy, renal fail- ure and retroperitoneal hemorrhage but a recent review of the literature demonstrated no significant difference to the out- come with or without hypothermia [1]. The non-CPB techni- ques reported in various studies produce satisfactory outcomes but remain controversial due to higher risk of intraoperative tumor embolization with manipulation, uncertainty of tumor burden clearance because of compromised visualization, lim- ited patient sample and limited application with a larger intra- atrial thrombus [1, 8]. Advances in anesthetic and surgical care have eliminated controversies among the techniques, and the availability of CPB in the operating room as an alternative is considered necessary. CPB was considered preferable to this case due to the sizable mass that was blocking almost all of the IVC width. Formation of such intravascular thrombus is documented as fast evolving, thus it is essential to obtain radiological imaging no longer than 14 days prior to surgery [4, 6, 9]. An additional principle reported in most studies and performed to this case is early ligation of the renal artery, in order to limit collateral cir- culation and thus potential blood loss [4, 10]. Metastasis is con- sidered a negative prognostic factor for survival but selected patients may undergo surgery with promising survival rates [3, 5]. Absence of metastasis, although random, was an add- itional positive predictor to our case. The most essential aspect for a prompt outcome is tailoring the therapy to the patients profile, the available technology to use and the experience of the operating team. The optimum cooperation of a multidiscip- linary team preoperatively, perioperatively and postoperatively Figure 1: MRI imaging displaying the cavoatrial tumor thrombus. was the key in our case as well. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Synchronous nephrectomy and cavoatrial tumor thrombectomy 3 4. Haidar GM, Hicks TD, El-Sayed HF, Davies MG. Treatment CONFLICT OF INTEREST STATEMENT options and outcomes for caval thrombectomy and resection The authors declare no conflict of interest. for renal cell carcinoma. J Vasc Surg Venous Lymphat Disord 2017;5:430–6. 5. Hatakeyama S, Yoneyama T, Hamano I, Murasawa H, FUNDING Narita T, et al. Prognostic benefit of surgical management The authors declare no funding interests. in renal cell carcinoma patients with thrombus extending to the renal vein and inferior vena cava: 17-year experience at a single center. BMC Urol 2013;13:47. GUARANTOR 6. Psutka SP, Leibovich BC. Management of inferior vena cava Mavrigiannaki Eleftheria. tumor thrombus in locally advanced renal cell carcinoma. Ther Adv Urol 2015;7:216–29. 7. Wotkowicz C, Libertino JA, Sorcini A, Mourtzinos A. REFERENCES Management of renal cell carcinoma with vena cava and 1. Gaudino M, Lau C, Cammertoni F, Vargiu V, Gambardella I, atrial thrombus: minimal access vs median sternotomy Massetti M, et al. Surgical treatment of renal cell carcinoma with circulatory arrest. BJU Int 2006;98:289–97. with cavoatrial involvement: a systematic review of the lit- 8. Gagné-Loranger M, Lacombe L, Pouliot F, Fradet V, Dagenais erature. Ann Thorac Surg 2016;101:1213–21. F. Renal cell carcinoma with thrombus extending to the 2. Protopapas AD, Ashrafian H, Athanasiou T. Tumour throm- hepatic veins or right atrium: operative strategies based on bi in the suprahepatic inferior vena cava: the cardiothor- 41 consecutive patients. Eur J Cardio-Thoracic Surg 2016;50: acic surgeons’ view. ISRN Vasc Med 2013;2013:Article ID 317–21. 546709. 9. Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The 3. Abel EJ, Thompson RH, Margulis V, Heckman JE, Merril MM, Mayo Clinic experience with surgical management, complica- Darwish OM, et al. Perioperative outcomes following surgi- tions and outcome for patients with renal cell carcinoma and cal resection of renal cell carcinoma with inferior vena cava venous tumour thrombus. BJU Int 2004;94:33–41. thrombus extending above the hepatic veins: a contempor- 10. González J. Update on surgical management of renal cell car- ary multicenter experience. Eur Urol 2014;66:584–92. cinoma with venous extension. Curr Urol Rep 2012;13:8–15. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy095/4996197 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 15, 2018

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