title: Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass.
abstract: BACKGROUND
  Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported.
  
  
  METHODS
  Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA.
  
  
  RESULTS
  Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy.
  
  
  CONCLUSIONS
  In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA.
authors.affiliation: Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, Florida 33101, USA. gciancio@miami.edu
authors.forename: Gaetano
authors.initials: G
authors.lastname: Ciancio
authors.forename: Samir P
authors.initials: SP
authors.lastname: Shirodkar
authors.forename: Mark S
authors.initials: MS
authors.lastname: Soloway
authors.forename: Alan S
authors.initials: AS
authors.lastname: Livingstone
authors.forename: Michael
authors.initials: M
authors.lastname: Barron
authors.forename: Tomas A
authors.initials: TA
authors.lastname: Salerno
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016063:Blood Loss, Surgical / Q000503:physiopathology; D002292:Carcinoma, Renal Cell / Q000401:mortality / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D017548:Echocardiography, Transesophageal; D005260:Female; D006325:Heart Atria / Q000601:surgery*; D006338:Heart Neoplasms / Q000401:mortality / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating / Q000473:pathology; D009392:Nephrectomy / Q000379:methods; D056346:Sternotomy; D016019:Survival Analysis; D019043:Vascular Neoplasms / Q000401:mortality / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000601:surgery*