title: Surgical management of large adrenal masses with or without thrombus extending into the inferior vena cava.
abstract: OBJECTIVE
  Surgical extirpation is the only curative treatment for large adrenal masses with or without thrombus extending into the inferior vena cava. However, occasionally complex surgical techniques are required, including venovenous bypass or cardiopulmonary bypass (CPB). Additionally, applying techniques used for organ transplantation can provide better exposure with less blood loss to allow milking of the thrombus downward, limiting the need for bypass.
  
  
  METHODS
  Ten patients underwent surgery for large adrenal masses using these techniques. Five patients had thrombi extending into the inferior vena cava, causing Budd-Chiari syndrome in 1. A classification system was proposed for adrenal masses associated with venous thrombus.
  
  
  RESULTS
  Median patient age was 51 years. Surgery was completed successfully in all patients. Only 1 patient with an adherent intra-atrial thrombus required CPB. Mean blood loss was 450 ml (range 50 to 1,500) except in the patient who required CPB. Postoperative complications occurred in 2 patients. One patient died on the postoperative day 7 of a presumed pulmonary emboli. Pneumothorax and empyema following traumatic line placement developed in the other patient. Nine patients (90%) were free of disease at a median followup of 18 months (range 10 to 84).
  
  
  CONCLUSIONS
  Applying transplant techniques in the surgical extirpation of large adrenal masses with or without tumor thrombus affords curative surgery enhanced access and vascular control, and decreases the requirement for venovenous bypass and/or CPB with less morbidity. It also provides acceptable midterm survival and quality of life.
authors.affiliation: Department of Urology, Hacettepe University School of Medicine, Ankara, Turkey.
authors.forename: Sinan
authors.initials: S
authors.lastname: Ekici
authors.forename: Gaetano
authors.initials: G
authors.lastname: Ciancio
mesh_terms: D000293:Adolescent; D000310:Adrenal Gland Neoplasms / Q000473:pathology* / Q000601:surgery*; D000315:Adrenalectomy / Q000379:methods; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009360:Neoplastic Cells, Circulating; D014682:Vena Cava, Inferior