SPINAL CORD INFARCTION FOLLOWING RADICAL NEPHRECTOMY USING EXTRACORPOREAL CIRCULATION FOR RENAL CELL CARCINOMA WITH TUMOR THROMBUS IN THE INFERIOR VENA CAVA AND RIGHT ATRIUM: A CASE REPORT

Aim: “To evaluate oncological and surgical outcomes of different levels of tumor thrombus and tumor characteristics secondary to renal cell carcinoma (RCC)”.Materials and Methods: Retrospective review from 2013 to 2020 of 34 patients who underwent radical nephrectomy with thrombectomy for RCC with tumor thrombus extending into the inferior vena cava (IVC) and right atrium (RA) at our center. Level I and most level II tumors were removed using straight forward occluding maneuvers with control of the contralateral renal vein. None of the patients had level III tumor extensions in our study group. For level IV thrombus, a beating heart surgery using a simplified cardiopulmonary bypass (CPB) technique was used for retrieval of thrombus from the right atrium. Results: “Of the 34 patients with thrombus”, 19 patients had level I, 12 patients had level II, none had level III, and three patients had level IV thrombus. Two patients required simplified CPB. Another patient with level IV thrombus CPB, was not attempted in view of refractory hypoten-sion intraoperatively. Pathological evaluation showed clear-cell carcinoma in 67.64%, papillary carcinoma in 17.64%, chromophobe in 5.8%, and squamous cell carcinoma in 8.8% of cases. Left side thrombectomy was difficult surgically, whereas right side thrombectomy did not have any sur-vival advantage. Mean blood loss during the procedure was 325 mL, ranging from 200 to 1000 mL, and mean operative time was 185 min, ranging from 215 to 345 min. The immediate postoperative mortality was 2.9%. Level I thrombus had better survival compared to level II thrombus. Conclusion: Radical nephrectomy with tumor thrombectomy remains the mainstay of treatment in RCC with inferior venacaval extension. The surgical approach and outcome depends on primary tumor size, location, level of thrombus, local invasion of IVC, any hepato-renal dysfunction or any associated comorbidities. The higher the level of thrombus, the greater is the need for prior optimization and the adoption of a multidis-ciplinary approach for a successful surgical outcome.

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Renal cell carcinoma with inferior vena cava thrombus extending to the right atrium diagnosed during pregnancy

Therapeutic Advances in Urology ◽

10.1177/1756287217701378 ◽

2017 ◽

Vol 9 (6) ◽

pp. 155-159 ◽

Cited By ~ 3

Author(s):

Efe C. Ghanney ◽

Jaime A. Cavallo ◽

Matthew A. Levin ◽

Ramachandra Reddy ◽

Jeffrey Bander ◽

...

Keyword(s):

Renal Cell Carcinoma ◽

Inferior Vena Cava ◽

Right Atrium ◽

Renal Cell ◽

Lupus Anticoagulant ◽

Tumor Thrombus ◽

Inferior Vena ◽

Vena Cava ◽

Ivc Tumor ◽

The Right

Only one case of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus diagnosed and treated during pregnancy has been reported in the literature. In that report, the tumor thrombus extended to the infrahepatic IVC (level II tumor thrombus). In the present case, a 37-year-old woman with lupus anticoagulant antibodies was diagnosed with RCC and IVC tumor thrombus extending to the right atrium (level IV tumor thrombus) at 24 weeks of pregnancy. The fetus was safely delivered by cesarean section at 30 weeks of gestation. At 4 days later, an open right radical nephrectomy and IVC and right atrial thrombectomy were performed on cardiopulmonary bypass (CPB) once the patient’s hemodynamic status had been optimized. Fetal and maternal concerns included the risk of a thromboembolic event (due to increased hypercoagulability from pregnancy, active malignancy, and lupus anticoagulant), intraoperative hemorrhage risk (due to extensive venous collaterals and anticoagulation), and fetal morbidity and mortality (due to fetal lung immaturity). Standardized guidelines for treatment of RCC with or without IVC tumor thrombus during pregnancy are unavailable due to the infrequency of such cases. Treatment decisions are therefore individualized and this case report may inform the management of future patients diagnosed with RCC with level IV tumor thrombus during pregnancy.

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