Diagnosis and Treatment of Inferior Vena Caval Invasion by Hepatic Cancer

Abstract

Hepatectomy with concomitant resection of the inferior vena cava (IVC) has become common for hepatic malignancies involving the IVC. However, diagnosing IVC invasion and the procedure of choice have yet to be standardized. Medical records of nine patients with liver cancer (five metastatic tumors from colorectal cancer and four intrahepatic cholangiocarcinomas) believed to have directly invaded the IVC wall were retrospectively abstracted for data on preoperative radiologic studies, surgical procedures, histology of the resected specimen, and treatment outcome. All nine patients underwent hepatectomy: Five did not undergo IVC resection because the IVC could be isolated from the tumor; the remaining four underwent combined IVC resection (wedge and segmental resections in two each). The segmentally resected IVC was reconstructed using an external iliac vein graft. Total hepatic vascular exclusion, venovenous bypass, and the ex vivo technique were not used. Interestingly, the tumor was smaller and the percentage of the IVC circumference in contact with tumor as seen on computed tomography (CT) was less in patients with IVC invasion than in those without it (40 +/- 11 vs. 134 +/- 61 mm, p < 0.05; 30% +/- 8% vs. 60% +/- 20%, p < 0.05). The length of the IVC compressed by tumor on cavography was similar in the two patient groups (47 +/- 9 vs. 55 +/- 8 mm). All patients were discharged from the hospital in good condition: Seven died of cancer recurrence, and the remaining two are currently alive and disease-free 15 and 73 months after surgery, respectively. In conclusion, imaging modalities demonstrating caval deformation, such as CT and cavography, are unreliable for diagnosing direct invasion of the IVC wall. Even when IVC invasion is strongly suggested by conventional radiologic studies, the surgeon should endeavor to peel the tumor from the IVC. This strategy is important to avoid unnecessary resection of the IVC, use of a prosthetic graft, or ex vivo hepatectomy.

Combined liver and inferior vena cava resection for hepatic malignancy

“…Cholangitis and abnormal creatinine deemed a patient unsuitable for surgery in fact of a possible deterioration of the renal function after even a transient vena cava exclusion. A thorough metastatic workup with CT and MRI and precise evaluation of the tumor extension by means of CT, MRI, or vena cavogram is suggested by the authors though the absence of a reliable imaging to confirm IVC invasion besides the demanding percutaneous endocaval sonography (PECS) raised questions regarding the role of invasion techniques in the preoperative mapping [6]. Ohwada et al [7] and Lodge et al [9] using MRI and cavography found no histologic IVC invasion in a significant percentage (40%) of patients with combined IVC resection .In agreement with these studies our surgical feeling is that the examiner's impression along with experience ultimately replace and render more sophisticate imaging besides a CT scan and intraoperative ultrasound obsolete.…”

Modified hanging manoeuvre facilitates inferior vena cava resection and reconstruction during extended right hepatectomy: A technical case report

“…Despite malignant IVC invasion, an aggressive attempt was made at R0 margin clearance, as IVC resection and reconstruction is currently considered to be potentially curative when it results in histologically clear margins (3,4,(6)(7)(8). In these cases, the conventional techniques for liver resection may not be feasible.…”

“…Most authorities recommend IVC reconstruction, as complete ligation usually results in venous insufficiency and acute renal failure (3,6,8). Ohwada et al (7) recommended reconstruction with an interposed segment of polytetrafluoroethylene when primary closure would result in >50% narrowing of the normal IVC diameter.…”

“…However, in certain, more complex cases, applying techniques such as the liver hanging manoeuvre may be required (2). In addition, when there is compression or malignant invasion of the inferior vena cava (IVC) by hepatic tumours, as indicated by preoperative radiological imaging (3,4), the associated perioperative morbidity and mortality increase. In order to mitigate these risks and safely perform complex resections, modifications of the conventional liver resection techniques become necessary.…”

Hepatobiliary resection with inferior vena cava resection and reconstruction using an autologous patch graft for intrahepatic cholangiocarcinoma

“…[1][2][3][4][5][6] Intrahepatic cholangiocellular carcinoma (CCC) originating from or involving the caudate lobe occasionally necessitates an extensive hepatobiliary resection including concomitant IVC resection and reconstruction to achieve negative surgical margins. In the setting of IVC resection and reconstruction, the total hepatic vascular exclusion technique (THVE) [7][8][9][10] is sometimes useful to reduce the blood loss during the procedure, although the indication or necessity of active veno-veno bypass between portal system and systemic circulation remains controversial.…”