Abstract: Objective:To investigate surgical treatment for tumor involved inferior vena cava at the upper segment of kidney.
Methods:The clinical data of 35 patients with tumor involved inferior vena cava at the upper segment of kidney who were admitted to Changhai Hospital affiliated to the Second Military Medical University from January 2007 to May 2015 were retrospectively analyzed. All the patients received preoperative imaging examinations to insure the site and range of inferior vena cava involvement at the upper segment of kidney. Renal cell carcinomas with inferior vena cava involvement were found in 19 cases, leiomyosarcomas of inferior vena cava in 5 cases, leiomyomatosis involving inferior vena cava in 3 cases, adrenocortical carcinoma involving inferior vena cava in 3 cases, liver cancer involving inferior vena cava in 2 cases, right adrenal pheochromocytomas in 2 cases, retroperitoneal fibrosarcoma involving inferior vena cava in 1 case. According to tumor involvement types, the different surgical approaches, planes and method of inferior vena cava exclusion, reconstruction method and prevention of tumor embolus detachment were selected. Patients were followed up by outpatient examination and telephone interview till May 2015.
Results:Among 19 patients with renal cell carcinomas with inferior vena cava involvement, 10 patients were placed inferior vena cava filters through internal jugular vein before surgery, 10 patients underwent total hepatic vascular exclusion and 9 patients underwent intrahepatic inferior vena cava exclusion. All the 19 patients received tumor resection and inferior vena cava embolectomy.
Of the 5 patients with leiomyosarcomas of inferior vena cava, 3 patients underwent total hepatic vascular exclusion and 2 patients underwent intrahepatic inferior vena cava exclusion. The diseased segments of 5 patients were resected, including 4 patients of artificial vascular graft and 1 patient complicated with resection of right kidney receiving simple ligation of inferior vena cava and left renal vein at proximal and distal tumors. Of the 3 patients with leiomyomatosis involving inferior vena cava, 2 patients received total hepatic vascular exclusion and 1 was treated surgically under cardiopulmonary bypass. All the 3 patients underwent inferior vena cava embolectomy and hysterectomy. Three patients with adrenocortical carcinoma involving inferior vena cava and 2 patients with liver cancer involving inferior vena cava underwent total hepatic vascular exclusion. Among the 5 patients, 4 had direct suture after tumor removal combined with partial inferior vena cava resection, and 1 had patch repair after partial inferior vena cava resection. Two patients with right adrenal pheochromocytomas were exposed proximal and distal lifting devices of inferior vena cava without clamp, and the tumors were peeled off completely. Intraoperative death happened in the patient with retroperitoneal fibrosarcoma involving inferior vena cava who was prepared to undergo intrahepatic inferior vena cava exclusion but encountered intraoperative pulmonary embolism due to tumor thrombus shedding. Thirtyfour patients of 35 patients underwent operation successfully without serious perioperative complications and a patient died in the perioperative period. The mean operation time, volume of intraoperative blood loss and duration of postoperative hospital stay were 2.8 hours (range, 1.5-5.0 hours), 2 000 mL (range, 400- 5 000 mL) and 9.2 days (range, 6.0-16.0 days). Thirtyfour patients were followed up for a median time of 12 months (range, 1-60 months). During the followup period, a patient with leiomyosarcomas of inferior vena cava and 2 patients with adrenocortical carcinoma involving inferior vena cava died of tumor recurrence, a patient with liver cancer had tumor recurrence, other patients were tumorfree survival.
Conclusions:Inferior vena cava at the upper segment of kidney is not contraindication for tumor resection. The appropriate way to expose, clamp and reconstruct are selected to safely remove the tumor based on extension and method of tumor involving inferior vena cava.