A case of right renal cell carcinoma with an inferior vena cava tumor thrombus extending above the diaphragm resected without cardiopulmonary bypass

Abstract

We preoperatively evaluated the tumor thrombus of right renal cell carcinoma cT3cN0M0 extending close to the right atrium using abdominal ultrasound. We found that invasion of the inferior vena cava (IVC) by the tumor thrombus was limited to the caudal side of the hepatic vein. We clamped the caudal IVC, left renal, and hepatic veins but not the cranial IVC. Incising the IVC in this situation caused retrograde flow, moving the floating tumor thrombus caudally. This enabled rapid extraction of the tumor thrombus and cranial IVC clamping below the hepatic vein. Consequently, tumor thrombectomy was successfully performed without cardiopulmonary bypass.

Highlights

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Information on tumor thrombus dynamics can be obtained by ultrasonography.
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Backflow of blood in IVC moves the floating tumor thrombus caudally.
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After tumor thrombus removal, the cranial IVC can be clamped at a more caudal site.
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Some Level IV tumor thrombus can be resected without cardiopulmonary bypass.

1 Introduction

Despite rapid advances in pharmacological therapy, nephrectomy and tumor thrombectomy are the most effective treatments for non-metastatic renal cell carcinoma (RCC) with a tumor thrombus extending into the inferior vena cava (IVC). In cases where the tumor thrombus extends cranially beyond the diaphragm, cardiopulmonary bypass is typically required to ensure optimal surgical exposure and bleeding control. However, the use of cardiopulmonary bypass carries a high risk of severe complications and is highly invasive. Herein, we report a case of renal cancer with a tumor thrombus extending near the right atrium, which was successfully resected without cardiopulmonary bypass. At the start of the IVC incision, the cranial IVC was not clamped, but the caudally directed blood flow within the IVC moved the floating tumor thrombus caudally. We were able to extract the tumor thrombus from the IVC swiftly and clamp the cranial IVC caudal to the hepatic vein. As a result, we could perform tumor thrombectomy safely without the use of cardiopulmonary bypass.

2 Case presentation

A 72-year-old man presented to our hospital with a complaint of gross hematuria. He had hypertension and diabetes. There was no other past medical history. Abdominal ultrasonography (US) revealed a mass in the right kidney. Abdominal contrast-enhanced computed tomography (CT) revealed a mass measuring 44 mm in the right kidney that showed heterogeneous enhancement in the early phase and a washout effect in the delayed phase. In addition, a tumor thrombus extending from the right renal vein to the IVC was observed, whose tip was in proximity to the right atrium ( Fig. 1 a–c). No metastasis was detected. The patient was diagnosed with right RCC (cT3cN0M0). His general condition was good, and he had no symptoms other than mild gross hematuria. After consulting the patient and his family, we decided to perform radical right nephrectomy and tumor thrombectomy. We initiated anticoagulation therapy to prevent thrombus formation on the patient’s tumor thrombus.

Preoperatively, we evaluated the tumor thrombus using US. The thrombus extended continuously to the vicinity of the right atrium; however, the area suspected of having IVC wall invasion was caudal to the hepatic vein. At this site, the tumor occupied the IVC, and blood flow was poor. In contrast, the thrombus cranial to the occupied segment was floating, highly mobile, and surrounded by abundant blood flow ( Fig. 2 ). Considering the dynamic assessment of the tumor thrombus and surrounding hemodynamics, we concluded that surgery could be performed safely without the use of cardiopulmonary bypass.

To prioritize safety, we initiated surgery after placing venous drainage catheters in the femoral and jugular veins so that we could switch to cardiopulmonary bypass as soon as possible, if necessary. Intraoperative US revealed no changes from the preoperative assessment. Following ligation and cutting of the right renal artery and completion of dissection around the right kidney, we attempted to interrupt the IVC cranial to the tumor thrombus from the abdominal cavity. However, no regression of the tumor thrombus was observed after renal artery ligation. Therefore, it was not possible to manually move the tip of the tumor thrombus caudally, and this proved difficult even after diaphragmatic incision. Conventionally, this would have been the time to switch to cardiopulmonary bypass, but per our preoperative plan, we blocked the IVC caudal to the tumor, left renal vein, and hepatic veins, without cranial interruption, and commenced IVC incision. We started the incision in the thrombus-filled segment devoid of wall infiltration and progressed cranially without compromising the tumor. This segment exhibited poor blood flow, resulting in minimal bleeding. Advancing the incision cranially past the thrombus-filled segment to the floating segment increased bleeding. Then, the tip of the thrombus moved caudally with retrograde flow, facilitating swift and easy extraction of the floating thrombus segment via forceps manipulation. Consequently, after removing the tumor thrombus, we were able to clamp the IVC on the caudal side of the hepatic vein, and then, the hepatic vein could be declamped. ( Fig. 3 a–c). Subsequently, good hemostasis was achieved, and we could resect the wall of the IVC infiltrated by the tumor. We removed the right kidney and tumor thrombus en bloc. We repaired the IVC using a pericardial patch, and surgery was completed. The operative time was 8 h and 3 min, and the volume of blood loss was 2370 mL. The total hepatic vein occlusion time was 7 min and 30 s. No abnormalities were detected during intraoperative transesophageal ultrasound monitoring of the tumor thrombus or pulmonary embolus. As the defect in the IVC was reconstructed using a bovine pericardial patch, anticoagulation therapy was resumed intraoperatively to prevent thrombus formation and was continued permanently postoperatively. The pathological diagnosis was grade III clear-cell RCC, with complete resection of the vascular wall infiltration and negative surgical margins ( Fig. 4 ). The patient’s postoperative course was uneventful, and he was discharged without complications on postoperative day 21.