Novel techniques for tumor thrombectomy for renal cell carcinoma with intraatrial tumor thrombus.
BACKGROUND
Radical nephrectomy with tumor thrombectomy in patients with renal cell carcinoma and level I to III thrombus extension is directly associated with an improved prognosis. However, radical surgery in patients with level IV thrombus extension is associated with high perioperative mortality, even if long-term survival is possible. In this report, we describe an alternative technique of vena caval and intraatrial tumor thrombectomy to decrease perioperative mortality and morbidity.


METHODS
A cohort of 6 patients aged 46, 50, 53, 56, 54, and 52 years underwent radical nephrectomy with tumor thrombectomy from the vena cava and right atrium under mild hypothermic cardiopulmonary bypass and intermittent cross-clamping of the supraceliac abdominal aorta. Intraatrial tumor thrombectomy was performed on a beating, perfused heart in 4 patients and a hypothermic, cardioplegia-perfused heart in 2 patients.


RESULTS
There were no early or late deaths. The aortic cross-clamp time was 12 and 15 minutes for patients 5 and 6, respectively. The cumulative hepatic and renal ischemic time was 16 minutes (range, 14 to 22 minutes) at 32 degrees C. The mean cardiopulmonary bypass time was 53.3 +/- 8.9 minutes (range, 40 to 65 minutes). At a mean follow-up of 43 +/- 24.6 months (range, 10 to 70 months), all patients are active and remain disease-free.


CONCLUSIONS
We conclude that radical nephrectomy and tumor thrombectomy in patients with level IV thrombi can be safely performed with cardiopulmonary bypass, mild hypothermia. and intermittent supraceliac abdominal aortic occlusion, avoiding potential hematologic, hepatic, renal, neurologic, and septic complications associated with circulatory arrest.
Chowdhury
Ujjwal K
UK
Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India. ujjwalchow@rediffmail.com
Mishra
Anand K
AK
Seth
Amlesh
A
Dogra
Prem N
PN
Honnakere
Jayanth H V
JH
Subramaniam
Ganapathy K
GK
Malhotra
Amber
A
Malhotra
Poonam
P
Makhija
Neeti
N
Venugopal
Panangipalli
P
D002292:Carcinoma, Renal Cell / Q000556:secondary / Q000601:surgery*; D006325:Heart Atria; D006338:Heart Neoplasms / Q000556:secondary / Q000601:surgery*; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009361:Neoplasm Invasiveness; D009392:Nephrectomy / Q000379:methods; D017131:Thrombectomy / Q000379:methods*; D019043:Vascular Neoplasms / Q000556:secondary / Q000601:surgery*