SURGICAL MANAGEMENT OF CANCER KIDNEY WITH INFERIOR VENA CAVAL EXTENSION
C ANAND SOMAYA*, JN KULKARNI**, PRAFUL DESAI***, JJ VYAS****
*Consultant Cardio-Vascular Surgeon; **Consultant Uro Oncologist, Tata Memorial Cancer Center; ***Consultant Oncologist; ****Consultant Onco Surgeon, Bombay Hospital.
The problem of Cancer Kidney with an inferior vena caval extension is a complex one, which until the modern techniques of vascular surgery were devised was considered inoperable and a death sentence for the patient. We in our Institution have diagnosed and managed these cases as a joint effort between the Uro - Oncologist team and the Vascular team with excellent results. I have had the privilege of working with the doyens of Indian oncology, Dr. Praful Desai, Dr. JJ Vyas, and Dr. JN Kulkarni to reach this large experience and thank them for their total cooperation and faith in our Vascular surgical team and techniques over the past two decades.
MATERIAL AND METHODS
The cases in this series were only those with significant inferior vena caval involvement and did not include those involving only the renal vein which were tackled by the Onco- Urologist independently.
Total Cases of RCC with IV Extension - - 45
Sex Distribution M : F - 29 : 16
Mean age - 71 years
Age Range - 23-92 years
Side of (R/L) - 25/20
As one can see from the above figures this particular clinical condition encompasses a wide age range. Specially in the younger age group it is the possibility of a cure of a hitherto inoperable disease. Also even the very elderly age group patients are able to tolerate this major surgery and consequently live many more fruitful years.
a) Painless Haematuria - 11
b) Flank pain with Haematuria - 23
c) Pyrexia of unknown origin - 5
d) Backache - 3
e) Pain scrotum - 2
Unfortunately the symptoms in this condition appear very late and due to lack of facilities in the periphery they are not diagnosed until such time that they undergo a surgical exploration and are closed and referred to Mumbai or they are only diagnosed when referred to a peripheral centre. It is due to the late onset of symptoms that the average size of the specimen in our series was between 20 to 30 centimetres in length.
a)Find Site and Size of the tumour
b)Renal function of affected and opposite kidney
c)Extent of IVC involvement.
d)Loco - regional spread.
ROUTINE PRE - OP INVESTIGATIONS
Aa) Haematocrit b) Biochemistry c) Renal profile d) Coagulation profile e)X’Ray Chest f) Liver Scan g) Bone Scan h) 2D Echo Cardiography i) CAT j) Colour Doppler studies k) MRI (Fig. 1).
Depending on results of above investigations the classification by stage of our cases as per Robson classification as opposed to TNM classification I.
STAGE III a (RV) - Nil R - V - Rt Ventricular spread.
STAGE III a (CAV) f - 2 A - v - Rt Atrial spread
STAGE III a (CAV) a - 0 IVC - Infra Diaphragm
STAGE III a (IVCs) f - 2 IVCS - Supra Diaphragm
STAGE III a (IVCs) a - 0 IVC
STAGE III a (IVCi) f - 4 f - Free
STAGE III a (IVCi) a - 2 a - adherent
From the above investigations the pre operative profile of the patient is clear as well as the extent of the tumour spread both locally and regionally as well as the distant spread of the disease is completely clear. In our series all stage III cases have been operated with good results.
Fig 1 : MRI (Axial ) showing Right Renal Mass with dilated IVC which shows almost complete occlusion by thrombus
Fig 2 : Robson staging of renal cell carcinoma
Fig 3 : Classification of thrombus in IVC
Surgery if no evidence of distant spread to the liver, lung, or bones. Surgery is a joint venture of the Uro - Oncologist and the Vascular surgeon.
PRINCIPLES OF SURGICAL MANAGEMENT
1. Dissect and isolate diseased kidney.
2.Complete dissection of the IVC with tourniquet control above and below the tumour thrombus.
3.Isolation and control of opposite Renal vein.
4.Complete removal of tumour from IVC and repair.
Fig 4 : IVC Grain with filling defect
1.Preferably cardio - thoracic and vascular theatre with a Cardiac Anaesthetist.
2.Arterial pressure and CVP continuously monitored during procedure.
3.Three large venous access sites with one central line.
4.End tidal volume monitoring to diagnose intra op. pulmonary embolism
5.5-10 bottles of blood ready in theatre with blood warmers and auto - transfusion if possible.
INFRA HEPATIC INVOLVEMENT
1.Mid line abdominal incision (Xiphisternum to Pubis)
2.Colon and small intestine mobilized upwards giving excellent exposure of retro peritoneal structures.
3.Minimal manipulation of renal vein and IVC to prevent tumour embolisation.
4.Complete dissection of vena cava with control above and below thrombus. Control of opposite renal vein.
5.The caudate lobe of the liver can me mobilized and folded back to access the infraDiaphragmatic IVC.
6.Snugging of all IVC tourniquets and IVC opened. Tumour thrombus removed Completely by milking gently. Residual thrombus and air flush out by release of consecutive tourniquets. Repair of IVC and radical nephrectomy.
Fig 5 : Intraoperative photograph after completion of Radical Nephrectomy with IVC thrombectomy. This show sutured IVC and released vascular clamps.
SUPRA HEPATIC VENA CAVAL INVOLVEMENT
Modified operative techniques for distal control, prevention of severe bleeding and complete tumour removal.
a)Temporary occlusion of intra - pericardial IVC, is used in extension thrombi when control is not possible. Intraabdominally - causes fall in blood pressure - used in 5 cases in this series.
b)Veno venous bypass used to maintain BP in supra diaphragmatic occlusions.
c)Supra diaphragmatic aortic cross clamp. Useful to raise upper body blood pressure in cases of severe bleeding with hypertension. Can lead to paraplegia and intestinal gangrene.
d)Techniques of cardio pulmonary bypass
I) Abdomen reopened and tumour dissected.
II) Chest opened by midsternotomy
III) CPB initiated patient cooled to 17oC.
IV) Circulation stopped and blood drained completely into machine.
V) Right atrium and IVC opened and thrombus completely removed.
VI) Atrium and IVC closed. CPB restarted. De-aeration of heart done. Patient rewarmed and weaned off bypass.
Fig 6 : Intra right artrial thrombus
= Mid line Abdominal only - 33
= Mid line Abd + sternotomy only -8
= Cardio Pulmonary bypass + Deep Hypothemia - 4
i) Septicaemia - 3 Cases
ii) Transient renal dysfunction - 8 Cases
iii) Malaria - 3 Casesiv) Intra - Op/post op mortality - 1 Case
i) Free from disease - 15 Cases (3-8 yrs follow up)
ii) Alive and Metastasis - 3 Cases
iii) Died due to Metastasis (8 months - 2 yrs) - 2 Cases
iv) Lost to follow up - 25 Cases
Fig 7 : Specimen of cancer kidney with extensive thrombus
SUMMARY AND CONCLUSIONS
The problem of carcinoma kidney with inferior vena caval extension is a difficult and complex one requiring expertise in both uro-oncology and vascular surgery. Our series which ranks as one of the largest in World literature is a result of the National Drainage of such cases to the Tata Memorial Centre in Mumbai. They have then been transferred to the Bombay Hospital due to lack of Vascular expertise at Tatas.
Inferior Vena Caval involvement occurs in 10% of cases of renal cell carcinoma for which the only treatment is radical surgical excision. Our series was done between 1989 and 1999 which included these 45 cases.
Surgery in these patients was possible with careful pre-operative assessment Intra operative and post operative management. The invasive investigations of Doppler Ultrasound, CAT scan and MRI gave an accurate assessment of tumour thrombus extension into the renal vein and the Inferior vena cava.
Patient with distant metastasis the survival is 10 months and the five year survival is nil.
The morbidity and mortality in our series was well within an acceptable limit in the short term of 2-5 years.