Intravascular extension of Wilms tumor: Characteristics of tumor thrombus and their impact on outcomes

Qureshi, Sajid; Bhagat, Monica; Smriti, Vasundhara; Murli, Divya; Baheti, Akshay D.; Yadav, Subhash; Prasad, Maya; Khanna, Nehal; Laskar, Siddharth; Kembhavi, Seema; Vora, Tushar; Chinnaswamy, Girish; Amin, Nayana; Ramadwar, Mukta; Talole, Sanjay

doi:10.1016/j.jpurol.2020.10.003

Cited by 19 publications

(26 citation statements)

References 15 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…In WT, survival does not change due to thrombus presence and preoperative chemotherapy can modify the thrombus level and avoid the need for cardiac bypass. For this reason, different protocols indicate preoperative chemotherapy in such cases ( 8 , 9 , 14 , 15 ). Even with careful preoperative workup, it is advisable that surgeons palpate both the IVC and renal vein, in order to avoid the transection of an unidentified vascular extension during the surgical approach because it can upstage the tumor to stage III ( 16 ).…”

Section: Discussionmentioning

confidence: 99%

Management of Pediatric Tumors With Vascular Extension

et al. 2022

View full text Add to dashboard Cite

Background: Pediatric tumors can present with vascular extension to the inferior vena cava and right atrium, which impacts the surgical strategy and can be challenging during surgical treatment. Wilms tumor (WT) is the most common retroperitoneal tumor that can present with vascular extension, but also adrenal tumors, clear cell tumors from the kidney, and hepatoblastomas can present with this situation. Surgical aims include obtaining complete tumor resection without risk for patients, to avoid severe bleeding, cardiac arrest, and embolization, and to avoid cardiac bypass if possible.Objective: To describe and discuss the surgical strategies to deal with pediatric tumors with vascular extension and propose a protocol.Method: Retrospectivly review the experience of treating patients with vascular extension in a single institution, describing different scenarios and a decision making fluxogram based on the preoperative evaluation regarding the surgical techniques and the need for cardiac bypass that are adequate for each situation. Image studies are important to guide the surgical strategy. Depending on the quality of image available, computerized tomography (CT) or magnetic resonance imaging (MRI) can be enough to give the information needed for surgical decisions. Ultrasonography (US) with Doppler is helpful to confirm diagnosis and describes factors to guide the adequate surgical strategy, like the upper level extension and presence or absence of blood flow around the thrombus. Neoadjuvant chemotherapy is indicated in most cases, in order to reduce the upper level of extension (and avoid the need for cardiac bypass) and to lower the risk of embolization. The approach is based on the upper level of the thrombus and can include cavotomy or cavectomy, sometimes with cardiac bypass and cardiac arrest with hypothermia, when the thrombus reaches the diaphragmatic level or above. Pathology analysis of the thrombus can guide staging and the need for radiotherapy postoperatively.Results: A decision making fluxogram protocol is presented focusing on the surgical treatment of such condition.Conclusion: Surgery strategy is highly impacted by the presence of vascular extension in pediatric tumors. Surgeons should be aware of potential complications and how to prevent them. Such cases should be treated in reference centers.

show abstract

Section: Discussionmentioning

confidence: 99%

Management of Pediatric Tumors With Vascular Extension

et al. 2022

View full text Add to dashboard Cite

show abstract

“…Cardiac surgical backup is essential since thrombi in the RA usually require CPB and those isolated to HVs require a veno-venous bypass. Our large experience of surgical management of tumor thrombi in the IVC and RA from Wilms tumor has allowed us to successfully deal with new challenges of hepatic venous thrombectomy [ 7 ]. The other learning point is that pediatric solid tumors are relatively rare.…”

Section: Discussionmentioning

confidence: 99%

Extensive cavo-atrial and hepatic venous tumor thrombus in a mismanaged retroperitoneal pediatric germ cell tumor: A unique surgical challenge

Kazi

Kaushik

Saini

et al. 2021

Ann Hepatobiliary Pancreat Surg

View full text Add to dashboard Cite

Retroperitoneal germ cell tumor with tumor thrombosis of the inferior vena cava (IVC) represents a rare phenomenon. Its extension to the hepatic veins (HVs) has not been reported yet. In the present case, a 30-month-old girl had a recurrent retroperitoneal yolk sac tumor with liver metastasis. In addition, there were tumor thrombi in the IVC, right atrium (RA), and all three HVs. The child was operated after a satisfactory response to chemotherapy. Excision of the retroperitoneal tumor with right hepatectomy, retrohepatic caval resection, HV, and RA thrombectomy was performed under a cardiac bypass. HV cloaca was patched with pericardium while the IVC resection was tolerated without reconstruction. Her postoperative recovery was normal. The child currently remains disease-free and symptom-free at 12 months. This case demonstrates the technique of hepatic venous thrombectomy and the feasibility of radical surgery even for a metastatic disease when tumor biology is favorable. Despite wide-spread tumor thrombosis that would have been deemed unresectable, complete resections are possible in referral centers.

show abstract

“…In 4-10% of patients with WT, the tumor extends into the renal vein or inferior vena cava, whereas an extension into the right atrium or ventricle occurs in around 1-3% of cases (43,(54)(55)(56)(57). A complete picture of a possible intravascular extension is essential for planning anesthesia and surgery.…”

Section: Intravascular Extensionmentioning

confidence: 99%

Multidisciplinary Treatment Strategies for Wilms Tumor: Recent Advances, Technical Innovations and Future Directions

et al. 2022

View full text Add to dashboard Cite

Significant progress has been made in the management of Wilms tumor (WT) in recent years, mostly as a result of collaborative efforts and the implementation of protocol-driven, multimodal therapy. This article offers a comprehensive overview of current multidisciplinary treatment strategies for WT, whilst also addressing recent technical innovations including nephron-sparing surgery (NSS) and minimally invasive approaches. In addition, surgical concepts for the treatment of metastatic disease, advances in tumor imaging technology and potentially prognostic biomarkers will be discussed. Current evidence suggests that, in experienced hands and selected cases, laparoscopic radical nephrectomy and laparoscopic-assisted partial nephrectomy for WT may offer the same outcome as the traditional open approach. While NSS is the standard procedure for bilateral WT, NSS has evolved as an alternative technique in patients with smaller unilateral WT and in cases with imminent renal failure. Metastatic disease of the lung or liver that is associated with WT is preferably treated with a three-drug chemotherapy and local radiation therapy. However, surgical sampling of lung nodules may be advisable in persistent nodules before whole lung irradiation is commenced. Several tumor markers such as loss of heterozygosity of chromosomes 1p/16q, 11p15 and gain of function at 1q are associated with an increased risk of recurrence or a decreased risk of overall survival in patients with WT. In summary, complete resection with tumor-free margins remains the primary surgical aim in WT, while NSS and minimally invasive approaches are only suitable in a subset of patients with smaller WT and low-risk disease. In the future, advances in tumor imaging technology may assist the surgeon in defining surgical resection margins and additional biomarkers may emerge as targets for development of new diagnostic tests and potential therapies.

show abstract

Intravascular extension of Wilms tumor: Characteristics of tumor thrombus and their impact on outcomes

Cited by 19 publications

References 15 publications

Management of Pediatric Tumors With Vascular Extension

Management of Pediatric Tumors With Vascular Extension

Extensive cavo-atrial and hepatic venous tumor thrombus in a mismanaged retroperitoneal pediatric germ cell tumor: A unique surgical challenge

Multidisciplinary Treatment Strategies for Wilms Tumor: Recent Advances, Technical Innovations and Future Directions

Contact Info

Product

Resources

About