Modified Vein Clamping Technique for Renal Cell Carcinoma Complicated With Level I-II IVC Thrombus: A Study At A Single Center

Objectives To share our initial experience with modified vein clamping technique for the treatment of renal cell carcinoma complicated with the level I-II IVC thrombus Methods From March 2018 to April 2021, 11 patients with renal cell carcinoma (RCC) involving the IVC tumor thrombus were admitted to our hospital. Then, they all underwent laparoscopic radical nephrectomy and IVC thrombectomy (LRN-IVCTE) using modified vein clamping technique. Results All procedures were successfully completed without conversion to open surgery. The median operative time was 185 min (range 125–229 min); the median estimated blood loss was 200 ml (range 150–300 ml), and four patients received an intraoperative transfusion. Besides, the median IVC clamping time was 18 min (range 10–24 min); the median postoperative hospital stay was 6 days (range 4–8 days), while the median follow-up period was 28 months (range 2–36 months). Conclusions Modified vein clamping technique for the treatment of renal cell carcinoma complicated with the level I-II IVC thrombus may be a safe and technically feasible alternative technic.

Successful IVC thrombus extraction with the AngioVac device following five vessel coronary artery bypass graft: a case report

Background Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are unable to be anticoagulated. In this case, we present a 65-year-old male who underwent IVC filter placement and open-heart surgery who later developed extensive femoral and iliocaval thrombosis leading to right heart failure, which required thrombus extraction with an AngioVac suction device. Case presentation We present a 65-year-old male who presented with bilateral pulmonary emboli with extensive right lower extremity deep vein thrombosis. Upon investigation he had ischemic heart disease and underwent a five-vessel coronary artery bypass for which he had an IVC filter placed preoperatively. On post operative day 3 to 4, he was decompensated and was diagnosed with an IVC thrombus. He progressed to right heart failure and worsening cardiogenic shock despite therapeutic anticoagulation and was taken for a suction thrombectomy using the AngioVac (AngioDynamics, Latham, NY) aspiration thrombectomy device. The thrombectomy was successful and he was able to recover and was discharged from the hospital. Conclusion Despite being a rare complication, IVC thrombosis can have detrimental effects. This case is an example of how IVC thrombus in the post-operative setting can lead to mortality. The gold standard is therapeutic anticoagulation but despite that, this patient continued to have worsening cardiogenic shock. Other therapies have been described but because of its rarity, they are only described in case reports. This case shows that the AngioVac device is a successful treatment option for IVC thrombus and can have the possibility of future use.

Wilms’ Tumor in Adults—Conventional and Unconventional Presentations of a Rare Entity with a Review of Literature

Wilms’ tumor (WT) in adults is a rare neoplasm. Only a few reports are available in the literature. The tumor often masquerades as renal cell carcinoma (RCC). For accurate reporting, histopathological examination (HPE) plays a vital role in early diagnosis and prompt administration of multimodality treatment helps to improve the prognosis.We comprehensively analyzed five cases of adult WT presenting in the third to fifth decade with flank pain, hematuria, fever, and palpable lump. After complete clinical, biochemical, radiological, and HPE evaluation, tumor was staged and treatment was planned accordingly.Patients with low-stage WT were treated with open radical nephrectomy and chemotherapy. One of the patients diagnosed with inferior vena cava (IVC) thrombus apart from the above treatment also underwent IVC thrombectomy. Another young male presenting with distant metastasis (stage IV) and focal anaplasia on histology received preoperative chemotherapy and then planned for surgery. Unfortunately, the tumor being unresectable, second-line chemotherapy was given but he ultimately succumbed to death. All other patients are on regular follow-up and disease-free.Adult nephroblastoma is a rare clinical entity with hostile behavior. The presence of IVC thrombus is not a contraindication to surgery. Although the management strategy as per pediatric protocol by the inclusion of multimodality approach improves survival, still the overall prognosis in adults is dismal. There is a need for a standardized treatment protocol to encourage a homogenous approach for this rare disease and thereby improve survival.

CTCs detection from intraoperative salvaged blood in RCC–IVC thrombus patients by negative enrichment and iFISH identification: a preliminary study

Background Intra-operative cell salvage (IOCS) and leukocyte-depleted filter (LDF) are widely used and effective in saving blood. However, the safety issue concerning reinfusion of IOCS–LDF processed blood to renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus were inconclusive for fear of increased risk of cancer metastases. This study intends to analyze the circulating tumor cell (CTC) eliminating effect of IOCS–LDF in 5 RCC–IVC thrombus patients. Methods A novel strategy integrating negative enrichment by immunomagnetic beads and immunostaining-fluorescence in situ hybridization with probes identifying aneuploid of 8 and/or 7 were used to detect CTCs from salvages blood. Blood samples were collected from 4 stages in each patient. Results Of the 5 RCC patients, the number of CTCs decreased (from 3, 4, 10, 7, 3, respectively, to all zero) after IOCS–LDF treatment. The triploid of chromosome 7 and/or chromosome 8 were most common karyotype for RCC patients with IVC thrombus. Tetraploid of chromosome 8 occurred in only one sample and no polypoid (number of chromosome > 4) were found. Conclusion IOCS–LDF might be a promising way of reducing of allogeneic product transfusion based on current preliminary outcome. More convincing conclusions are to be drawn with enlarged sample size and long-term follow-up for patients prognosis.

Survival Benefits After Surgery of Renal Cell Carcinoma Patients with Inferior Vena Cava Thrombus

OBJECTIVE: To evaluate surgical and oncological outcomes after surgery in renal cell carcinoma (RCC) patients with inferior vena cava (IVC) tumor thrombus METHODS: A total of 58 patients from 2002 to 2019 underwent radical nephrectomy and IVC thrombectomy at Siriraj Hospital, Bangkok, Thailand, were retrospectively reviewed. Kaplan-Meier analysis was utilized to compare survival benefits between cohorts and Cox regression to evaluate predictors of patient survival. RESULTS: There were 5 (8.6%), 21 (36.2%), 23 (39.7%) and 9 (15.5%) patients with tumor thrombus level I, II, III and IV respectively. The major complications (Clavien 3-5) were observed in 15 patients (25.8%) and 80% were patients with high thrombus level (III-IV). There was 9% mortality (5 patients): 2 intraoperatively and 3 postoperatively. Median follow-up was 15 months (IQR:5-41). Two-year overall survival (OS) was 80% and 75% in all patients and pN0M0 cohort, respectively. There was significant difference in OS among each IVC thrombus level cohort (p<0.02). Two-year OS of metastatic RCC patients was 67% and not significantly different when compared to non-metastatic cohort (p=0.12). On multivariate analysis, only sarcomatoid dedifferentiation was associated with OS (p=0.04). Disease-free survival was not significantly different among thrombus-level cohorts (p=0.65). CONCLUSION: Our study suggested that surgical treatment for RCC with IVC thrombus provided acceptable OS outcomes, even in a small volume experience. Although the survival was significantly reduced with higher IVC thrombus level cohort, the level of thrombus itself was not an independent factor. Only sarcomatoid dedifferentiation was a predictor for OS after radical nephrectomy and tumor thrombectomy.

Streptococcus anginosus bacteremia: a septic IVC thrombus and a large empyema requiring decortication

A previously healthy 39 year old male presented with complaints of cough, fever, abdominal pain and chills. The patient was found to be in active sepsis with hypotension on presentation so was resuscitated while a full septic work-up was ordered. Initial chest X-ray showed only increased broncho-alveolar markings and no consolidations, but blood cultures eventually revealed Streptococcus anginosus bacteremia. Intravenous antibiotics were started and infective endocarditis was ruled out. Computerized tomography scan of the abdomen with contrast revealed findings suggestive of a septic hepatic inferior vena cava thrombus and right lower lung findings suggestive of septic embolization and an empyema. Later on during admission, CT scan of the chest with contrast revealed a moderate-sized empyema of the right lung which eventually required decortication. Discovering such findings concurrently in a single patient is extremely rare, particularly an embolizing septic IVC thrombus with confirmed bacteremia. For this reason it is described in the following case presentation

Renal Metastasis of Osteosarcoma with IVC Thrombus

Renal metastasis from osteosarcoma is a rare entity, and tumour thrombus is even rarer. To date, only 15 cases of osteosarcoma with tumour thrombus have been reported in the literature. We present a case of an 18-year-old female diagnosed as having right distal femur osteosarcoma, later presenting with renal osteosarcoma with IVC thrombus.

CTCs Detection from Intraoperative Salvaged Blood in RCC-IVC Thrombus Patients by Negative Enrichment and iFISH Identification - A Preliminary Study

Background: Intra-operative cell salvage (IOCS) and leukocyte-depleted filter (LDF) are widely used and effective in saving blood. However, the safety issue concerning reinfusion of IOCS-LDF processed blood to renal cell carcinoma (RCC) patients with inferior vena cava (IVC) thrombus were inconclusive for fear of increased risk of cancer metastases. This study intends to analyze the circulating tumor cell (CTC) eliminating effect of IOCS-LDF in 5 RCC-IVC thrombus patients. Methods: A novel strategy integrating negative enrichment by immunomagnetic beads and immunostaining-fluorescence in situ hybridization with probes identifying aneuploid of 8 and/or 7 were used to detect CTCs from salvages blood. Blood samples were collected from 4 stages in each patient. Results: The CTCs number decreased (from 3, 4, 10, 7, 3, respectively, to all zero) after IOCS-LDF treatment. And the triploidy of chrmosome 7 and/or chromosome 8 were most common karyotype for RCC patients with IVC thrombus. Tetraploid of chromosome 8 concurred in only one sample and no polypoid (number of chromosome＞4) were found. Conclusion: IOCS-LDF might be a viable option for reduction of allogeneic product transfusion based on current preliminary outcome. More convincing conclusions are to be drawn with enlarged sample size and long-term follow-up of patients prognosis.