Management of Renal Cell Carcinoma with Intracardiac Extension

Abstract

Renal cell carcinoma extended to the right atrium was operated by using cardiopulmonary bypass and deep hypothermic circulatory arrest. Hypothermic circulatory arrest provides bloodless surgical field for tumor thrombus removal and adequate visceral and brain protection. The surgical technique that we used in a patient was reported in light of the literature.

Selective Upper-Body Perfusion Technique for Removal of Renal Cell Carcinoma Extending into the Inferior Vena Cava and Right Atrium

“…[1][2][3] Whereas patients with level I to level III RCCs with transluminal IVC invasion are reported to have a 5-year survival rate of 32% to 69% after radical nephrectomy and tumor thrombectomy, 5 patients with level IV tumors, which have suprahepatic or intra-atrial extension, have poorer prognoses because of the risk of pulmonary embolism. 6 Such patients with intracardiac extension need proper cardiovascular evaluation and immediate intervention.…”

“…Using DHCA, which is generally safe, is advantageous to the surgeon because it provides a bloodless operative field for optimal viewing during the manipulation of the thrombus in the atrium and IVC; however, prolonged circulatory arrest is associated with increased mortality rates and risk of stroke. 3 To avoid the drawbacks of DHCA, Calcaterra and associates 12 operated on a beating heart, using normothermic CPB, with a snared superior vena cava and femoral venous cannulation. The technique was successful in 3 patients with RCC.…”

“…The usual surgical approach is to combine intra-abdominal and cardiac surgery with cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA); this provides a bloodless surgical field, eliminates the need for IVC cannulation, and facilitates complete removal of the cavoatrial mass. 3 However, DHCA has well-known deleterious systemic effects and increases the risk of neurologic complications. 4 To avoid DHCA, we used a selective upper-body perfusion technique during the operation to remove a tumor thrombus extending into the IVC and right atrium in a patient with RCC.…”

Simultaneous nephrectomy, intracaval and right atrial tumor excision, caval patchplasty and coronary artery bypass grafting in patient with renal cell carcinoma

“…The coexistence of the right atrial thrombus (Stage 4) is less than 1%. [2][3][4] In patients with non-metastatic RCC who underwent radical nephrectomy and complete thrombectomy, five-year survival rates of 30% to 72% have been reported. [1] However, surgical indication for patients with metastatic RCC and the use of cardiopulmonary bypass (CPB) during vena caval thrombectomy are still controversial.…”

“…[5] A very small percentage of non-metastatic RCC patients die from the surgical intervention and postoperative complications. [1][2][3][4] The presence of metastasis at the time of surgery significantly is associated with a poor survival. [6] Atrial extension of the tumors is associated with a significantly higher risk of the development of metastatic spread, but not with significantly increased risk of operation.…”