Intraoperative management of advanced renal cell carcinoma with tumor thrombus in retrohepatic inferior vena cava or beyond

IntroductionResection of renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) is associated with significant peri-operative morbidity and mortality, which poses a challenge to the anesthesiologists. Risks include massive hemorrhage, hemodynamic instability, embolism as well as complications of veno venous and cardiopulmonary bypass.

ConclusionsConsidering high perioperative mortality (4.3%) as well as intraoperative blood loss, RCC with IVC tumor thrombus without VVB poses a significant challenge to anesthesiologists. Intraoperative TEE provides most updated extension of tumor and helps detection of presence of tumor thrombus in the right heart system, as well as hemodynamic management. Our surgical technique allows this complex procedure to be performed without the need for CBP and its associated risks.

Results

Renal cell carcinoma is primarily staged by the 2009 TNM (tumor, nodes, metastasis) classification from the American Joint Committee on Cancer (AJCC). In this paper we focus on patients with T3 tumours, namely, those with extension of tumor into the IVC. To aid in planning the surgical approach we classify T3 tumors according to anatomical landmarks as described in table 1.

A tri-radiate incision is made and a Rochard self retaining retractor system is used to expose the abdomen. The liver and the entire IVC is mobilised using the piggy back technique developed in liver transplantation. We aim for early ligation of the renal artery. The tumor can be milked back or the IVC clamped above the liver to gain control and allow thrombus removal. With level IV thrombus the central tendon of the diaphragm is incised and the tumour milked back obviating the need for cardiopulmonary bypass.

70 patients underwent radical nephrectomy with IVC thrombectomy. 83% with level III thrombus and 17% with level IV thrombus. The majority of both level III ad IV thrombi originated from the right kidney (83% and 67% respectively) and the pathology was 90% clear cell and 10% papillary renal cell carcinoma.

5 patients required cardiopulmonary bypass (2 with level III and 3 with level IV). Patients with level IV thrombus had a higher estimated blood loss (6978 vs. 1540 p<0.05) with higher packed cell transfusion (13.9 vs. 3.5 units, p<0.05). Time to discharge from ICU was longer in patients with level IV thrombus (9.8 vs. 4.8 ± days, p=0.05 as well as time to discharge from hospital (18.8 vs. 8.1 days, p<0.05). Three patients (4.3%) died in the immediate postoperative period.

All patients had arterial lines, central lines and/or pulmonary artery catheters. Trans esophageal echocardiography was utilized in all patients with level IV thrombus and 78% of patients with level III thrombus.

Methods

After IRB approval, the chart review of patients who underwent resection of RCC tumor thrombus level III and IV, from 1997 to 2010 were performed. .

Proximal extent of the tumor was determined using CT and MRI with 3D reconstructions.

Patient data included physical characteristics and pre existing medical conditions.

The electronic anesthesia manager was reviewed to determine the use of arterial lines, central lines, pulmonary artery catheters, trans esophageal echocardiography and type of bypass if any.

The data was summarized by tumor stage and compared demographics, intraoperative managements and outcomes between level III and level IV patients using ANOVA. P values of less than 0.05 were considered significant.

AcknowledgementsNil

AimTo review our experience of this procedure and accurately describe our surgical technique which is based on liver transplantation methods.

To describe the anesthetic management and to propose key points in the anesthetic management of patients undergoing this complex procedure.

ReferencesLiver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description.Ciancio G, Gonzalez J, Shirodkar SP, Angulo JC, Soloway MS., Eur Urol. 2011 Mar;59(3):401-6. Epub 2010 Aug 3.

Renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass.Ciancio G, Shirodkar SP, Soloway MS, Livingstone AS, Barron M, Salerno TA. Ann Thorac Surg. 2010 Feb;89(2):505-10.

Kirstin Naguit1, M.D., Kyota Fukazawa1 M.D., Mohan Arianayagam2 M.D., Gaetano Ciancio3 M.D.1. Division of Solid Organ Transplantation, Dept. of Anesthesiology, University of Miami, Miller School of Medicine, Miami, Florida, USA

2. Department of Urology, University of Miami, Miller School of Medicine, Miami, Florida, USA

3. Division of Transplantation, Department of Surgery, University of Miami, Miller School of Medicine, Miami, Florida, USA

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Table 1: Classification of IVC thrombus

Level Description

I Thrombus limited to renal vein

II Superior extent of thrombus is below infrahepatic IVC

IIIa Intrahepatic thrombus extending into the retrohepatic IVC but below major hepatic veins

IIIb Hepatic thrombus extending into retrohepatic IVC reaching ostia of major hepatic veins

IIIc Thrombus extending into suprahepatic, infradiaphragmatic IVC

IV Thrombus extending above diaphragm