Interactive Cardiovascular and Thoracic Surgery 3:395-397(2004)
© 2004 European Association of Cardio-Thoracic Surgery
Institutional report - Cardiopulmonary bypass |
Surgical treatment of renal cell carcinoma with intravascular extension
Christoph Schimmera,*,
Felix Hilligb,
Hubertus Riedmillerb and
Olaf Elerta
a Department of Cardiothoracic Surgery, University Hospital Wuerzburg, Germany
b Department of Urology, University Hospital, Wuerzburg, Germany
* Corresponding author. Klinik und Poliklinik für Herz- und Thoraxchirurgie der Universität Würzburg, Josef-Schneider-Str. 6, 97080 Würzburg, Tel.: +49-931-2010; fax: +49-931-201-33447
schimmer_c{at}klinik.uni-wuerzburg.de
Received November 17, 2003;
received in revised form February 18, 2004;
accepted February 19, 2004
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Abstract
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Long-term survival after surgical treatment is possible in patients with renal cell carcinoma (RCC) extending in the right atrium. Different surgical techniques for the treatment of patients with RCC extending into the vena cava have been advocated, depending on the proximal extent of the tumor. We present and propose an algorithm regarding the operative strategy depending on the extent of tumor growth.
Key Words: Renal cell carcinoma; Right atrium involvement; Cardiopulmonary bypass; Deep hypothermic circulatory arrest
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1. Introduction
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Intravascular tumor growth along the vena renalis into the inferior vena cava (IVC) occurs in up to 15% of all patients with RCC and further extension of the tumor reaching the right atrium will be found in approximately 1% of all patients [1–9]. Perinephric infiltration of the tumor with disruption of the renal capsule, local lymph node involvement and distant metastasis have all a profound influence on disease-free and overall survival [3]. In patients with nonmetastatic RCC and inferior vena caval involvement, the 5-year survival rates range between 18 and 68% after complete surgical resection (with perioperative mortality of 2.7–13%) and an immediate palliation of symptoms of obstructive disease [4]. However, the intravascular tumor extension to whatever degree is not associated with an adverse prognosis, provided a complete resection (R0) is possible [2].
For this there is the rationale for an aggressive surgical approach. Yet intravascular tumor extension with involvement of the IVC and the right atrium requires surgical strategies, which may include extracorporal circulation with cardiopulmonary bypass (CPB) and sometimes deep hypothermic circulatory arrest (DHCA). We report the operative strategies and results at our institution of patients with RCC extending into the intrahepatic vena cava and the right atrium and provide an algorithm for the surgical management of such patients.
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2. Patients and surgical technique
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Between March 1994 and September 2003, seven patients with RCC with tumor thrombus extending into the right atrium were operated on at the Department of Cardiothoracic Surgery in cooperation with the Department of Urology of the University Hospital of Wuerzburg, Germany. Mean age was 60.5 years (range 53–66 years). All tumors were pathologically staged according to the Robson classification system [9] (Tables 1 and 2).
All patients in this review had tumors categorized as either stages IIIA, IIIB or IV. Four of seven patients presented with tumor extension into the intrahepatic vena cava (level III) and two of seven patients had an extension into the right atrium and in one of seven patient the tumor reached into the right ventricle (level IV). Diagnostic working included computerized tomography (CT) scan or magnetic resonance imaging (MRI) to define the level of intravascular tumor extension. Additional diagnostic imaging (angiography/duplex sonography) for assessment of tumor attachment/invasion or complete occlusion of the IVC is recommended, if suspected. Finally, transesophageal echocardiography is able to determine level III and level IV extension. All patients underwent nephrectomy with paraaortic lymphadenectomy. Cavotomy and tumor thrombus removal was carried out in all cases with CPB. After ascending aortic cannulation, a 28 French venous cannula is placed in the SVC. In order to achieve sufficient venous drainage a second 32 French cannula is used in either the femoral vein or above IVC bifurcation but below palpable thrombus. After initiation of CPB a vascular cross-clamp is then safely applied across the IVC below the renal vessel and superior vena caval tape is snugged. During beating heart procedure the right atrium is opened. Blood returning into the right atrium is aspirated with a high-vacuum sucker and discarded to avoid tumor embolization. The tumor is then dissected away from the endothelium of the IVC. After caval reconstruction and closure of the right atrium, de-airing of the right heart (under control of transesophageal echocardiography) and weaning from CPB is accomplished. Because of tumor attachment to the IVC, and tumor thrombus extension into the right ventricle two patients underwent resection of the tumor and reconstruction of the IVC during DHCA. Therefore, after CPB is established cooling is continued to a core temperature of 18 °C. Immediately before circulatory arrest, the ascending aorta is cross-clamped and a cardioplegia is administered for myocardial protection. The bloodless field allowed for complete intravascular thrombus extirpation. After caval reconstruction and closure of the right atrium CPB is reestablished, the aortic cross-clamp is removed and the patient is rewarmed. One patient died intraoperatively because of global heart failure (tumor reached into the right ventricle). In two patients relaparotomy was performed because of retroperitoneal haemorrhage. Despite one intraoperative death, three patients died 4, 11 and 84 months postoperatively due to recurrent tumor disease. The patient with metastatic disease (patient 4) was preoperative in stage IV (one single liver metastasis) and is still alive (operation date 09/99). Because of limited experience in level I and II (usually no cardio-surgeon is required therefore) the algorithm is not completely based on the cases presented in this report. In order to complete the algorithm data are obtained from literature [1–9] (Table 3, Fig. 1).
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3. Discussion
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Predictors of outcome and patient survival in RCC with tumor thrombus extending the right atrium are variably discussed. Most common is the fact, that prognosis is determined by local infiltration of perinephric tissue, lymph node involvement, distant metastases, the pathological stage of the RCC and the presence of vena cava side wall invasion but not by the level of tumor extension. The best chance of cure and long-term survival is a combination of radical surgery and adjuvant immunotherapy [5]. The use of CPB allows a safe and complete resection of RCC with retrohepatic intracaval extension (level III) [1,2,4–9] and even beyond the diaphragma (level IV) [3]. Welz et al. could demonstrate a significant lower intraoperative rate of complications (in level III and IV) when CPB was used [1]. Nesbitt et al. point out that CPB is not usually required unless the tumor extends into the heart and requires atriotomy for removal [3]. Obviating the need for CPB and atriotomy in level III is possible (digital manipulation of the tumor in an attempt to push it down into the IVC), but without the protection of a cardiopulmonary bypass it seems to be hazardous and may result in tumor embolization [8]. Controversy still exists in the need for DHCA. Concerning the efficacy of deep hypothermic circulatory arrest (DHCA) we believe that DHCA is not usually required unless the tumor thrombus is invading the caval wall or reaches the right ventricle. We treated two patients with DHCA. In one case the tumor extends into the right ventricle and in the other case the tumor thrombus invaded the caval wall. DHCA provides a bloodless surgical field, which minimizes the risk of tumor fragmentation, reduced risk of cellular spreading and subsequent pulmonary embolization and avoids severe haemorrhage from intra and suprahepatic veins. But the use of DHCA increases the potential for surgical complications like an extended bypass time as a result of rewarming, postoperative bleeding and coagulopathy, and increased neurologic risk (in terms of reversible neurophysiological disorders). Extensive bleeding is the most common intra, -and perioperative complication.
Anticoagulation in a patient who has undergone an extensive retroperitoneal procedure and who has accessory venous collaterals from IVC obstruction increases the risk of intraoperative and postoperative bleeding. DHCA further heightens this risk [3].
In conclusion, removal of the primary tumor and thrombus leads to an immediate palliation of obstructive tumor disease and prolonged survival even in some cases of metastatic disease. RCC with retrohepatic intracaval tumor thrombus extension (level III) can be safely operated with the use of CBP in order to reduce the risk of tumor embolization and unexpected haemorrhage with lifethreatening hypotension. For tumor thrombus extension into the right heart (level IV) CPB is essential. The surgical complications of using additionally DHCA are well known. However, the influences of DHCA on long-term results are still unsolved.
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Acknowledgements
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The authors thank Dr. Peter Keith for processing the photographs.
doi:10.1016/j.icvts.2004.02.014
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References
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Abstract
1. Introduction