CASE REPORT

            CASE REPORT- A                                                       CASE REPORT- B

CASE REPORT - A
Combined One-stage Coronary Surgery and Extended Radical Nephrectomy
Case report and review of the literature

SRune Haaverstad1, MD PhD, Fikri Abdullah1 MD FRCS, Peter H. Groves2 MD FRCP, Philip N. Matthews3, MB BS FRCS 1Departments of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom, 2Department of Cardiology, University Hospital of Wales, Cardiff, United Kingdom, and 3Department of Urology, University Hospital of Wales, Cardiff, United Kingdom.

 ABSTRACT

 Case Presentation

 DISCUSSION
 References
 Qaboos Mosque / Muscat , Oman

ABSTRACT

Two patients with renal cell carcinoma that extended into the inferior vena cava (IVC) to the level of the hepatic veins and also had coronary artery disease are presented.
Both patients underwent a one-stage combined coronary revascularization and extended right nephrectomy with the use of cardiopulmonary bypass, deep hypothermia and circulatory arrest.
When pre-operative angioplasty is not feasible, a one-stage combined operation for ischaemic heart disease and advanced renal carcinoma with IVC extension can be performed safely.
(Heart Views. 2001;2(2): 69-72) © 2001 Hamad Medical Corporation.

Key Words:

   Renal cell carcinoma     Inferior vena cava     Coronary disease
   Coronary artery bypass surgery

Renal cell tumors have a propensity for involving the IVC and may even grow up into the right atrium.
Radical nephrectomy and complete resection of tumor thrombus is still the only potentially curative treatment for these patients.
If the tumor thrombus is extending into the retrohepatic IVC (level 3) or further into the right atrium (level 4) (1), surgical resection of the tumor should be performed through a combined thoraco-abdominal approach.
Many surgeons now believe that the safest method of removing all visible tumour tissue is with the use of cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) (2,3).
When pre-operative assessment reveals simultaneous significant coronary artery disease, the treatment is even more challenging and a well-planned surgical strategy is warranted.
Two cases that illustrate a primarily successful one-stage combined extended nephrectomy with IVC thrombectomy and coronary bypass surgery are presented.

Case Presentation

Patient 1

A 60-year-old man was referred with a 12-month history of general lethargy, weight loss, night sweats, intermittent right loin pain and a palpable abdominal mass.
He was an ex-smoker with a marked limitation of physical activity, equivalent to a Canadian Cardiovascular Society class 3 angina.
Thoraco-abdominal MRI revealed a 12 x 10 cm right-sided renal mass with tumor thrombus extending into the retrohepatic IVC up to the level of the hepatic vein (Fig 1).
Following a positive exercise electrocardiogram (ECG), coronary angiography showed a significant ostial stenosis of the left main stem, as well as proximal stenoses in the left anterior descending (LAD) and obtuse marginal (OM) arteries.
The operation commenced with a midline laparotomy to confirm tumor operability.
This was extended into a median sternotomy, and the left internal mammary artery (LIMA) as well as the long saphenous vein was harvested.
Cardiopulmonary bypass (CPB) was initiated and the patient was systemically cooled, whilst simultaneously

Fig. 1 MRI (transverse section) of a large right-sided renal tumour invading the inferior vena cava

the urologist continued to display the tumor and the IVC.
Once the IVC was satisfactorily exposed and the core temperature reached 15oC, circulatory arrest was commenced and the patient was exsanguinated.
After exploration of the IVC through a longitudinal venacavotomy, the entire tumor thrombus was removed from below and the IVC was closed with continuous monofilament 3/0 suture.
Circulation was then re-established and systemic rewarming commenced after a circulatory arrest time of 29 minutes.
During rewarming, a standard radical nephrectomy was carried out. Further, the coronary surgery could proceed following cross clamping of the ascending aorta and with the use of warm blood cardioplegia.
Separate saphenous vein grafts were directed to the first OM and a large diagonal artery.
A pedicle LIMA graft was anastomosed to the LAD. After 30 minutes the cross clamp was released and two proximal anastomoses were performed.
CPB was easily discontinued followed by a stable hemodynamic condition. Except for mild temporary renal failure and a right pleural effusion requiring chest tube drainage, there were no major postoperative complications.
The patient was discharged home on the tenth postoperative day.
Histopathological examination of the tumour specimen confirmed a well-differentiated renal cell carcinoma without any extra-capsular spread.
Postoperatively, warfarin was given for three months and then replaced by aspirin.
He initially did well following his surgery, but 14 months later he developed liver metastases and died 17 months after his nephrectomy.

Fig. 2 MRI (sagital section) of a large tumour thrombus from a renal cell carcinoma involving the intrahepatic part of the inferior vena cava

Patient 2

A 46-year-old man was referred with three months history of general lethargy, painless hematuria, and a palpable right hypochondriac mass.
He was a heavy smoker, but without any family history of heart disease.
Ultrasound, CAT and MRI scans collectively confirmed the presence of a large right-sided renal tumor with retrohepatic IVC extension to the level of the right hepatic veins (Fig 2).
A pre-operative exercise ECG showed ischemia of the inferior myocardial wall.
A subsequent coronary angiography revealed single-vessel disease with significant stenosis of a dominant right coronary artery (RCA).
A similar operative protocol was carried out as in the first patient with the use of CPB and DHCA. One coronary anastomosis between a SVG and the distal RCA was performed during the cooling phase without cross clamping of the aorta.
The tumor thrombus was adherent to the IVC wall and therefore an atriotomy was performed to facilitate the dissection from above.
The circulatory arrest time was 56 minutes with retrograde cerebral perfusion being performed for ten minutes. The proximal anastomosis was carried out during the rewarming period.
Acute tubular necrosis that required hemodialysis, as well as a hemopericardium that needed subxiphoidal drainage of the pericardium on the nineteenth post-operative day, delayed the recovery.
Histopathological examination of the kidney confirmed renal cell carcinoma.
He stayed on warfarin and remained dialysis dependent for the following five months and then the remaining kidney started producing urine.
Six months following surgery he was readmitted to hospital with an acute confusional state and a subsequent CT scan showed cerebral metastases. He died a few days later.

DISCUSSION

Extended radical nephrectomy and venacavotomy with complete resection of IVC thrombus is mandatory for the potential achievement of long-term survival.
The level of the cephalic extension of the IVC involvement does not appear to be of prognostic importance as opposed to regional lymph node metastases and infiltration of the tumor thrombus into the IVC wall, which are both signs of a poor outcome (2, 4).
There is disagreement about the necessity of CPB in the surgery of patients with tumors that extend behind the liver, but not above the diaphragm (5).
We believe that a key factor is the width of tumor thrombus in the retrohepatic IVC.
In both of these cases the IVC was greatly distended by the tumour and the only way of being sure that the IVC was cleared was to have a good bloodless exposure.
Operating without CPB and DHCA invariably leads to bleeding from lumbar veins that can be very difficult to control and sometimes necessitates cross clamping of the aorta.
It has been suggested that the routine use of CPB and DHCA may decrease peri-operative morbidity and mortality, especially relating to proximal embolization of the tumor thrombus (3,6).
In our institution over the last 11 years, 21 patients with renal carcinoma and tumor thrombus into the retrohepatic IVC have routinely been treated with the use of CPB and DHCA, and there has only been one perioperative death.
Our initial experience has previously been reported (7). Both patients were referred with an advanced renal carcinoma with extensive involvement of the IVC, but without any signs of metastatic spread at the time of surgery.
Without surgical treatment even their short-term prognosis was expected to be poor.
They were both rare cases as they also suffered from severe coronary artery disease.
The main indications for a combined one-stage operation have been either a left main stenosis or severe triple vessel disease (8-11).
In the first patient routine grafting with LIMA and SVG was feasible as part of a combined operation with the use of CPB and DHCA.
In the second case a SVG was anastomosed to a dominant RCA, as angioplasty had not been done before the operation took place.
The one-stage combined approach was chosen to avoid any delay before the cancer operation could go ahead. As the coronary surgery was performed during the systemic cooling and rewarming phase, any prolonged circulatory arrest time was avoided.
The use of cardiopulmonary bypass or cell-saver in cancer patients is controversial, as it could potentially promote systemic dissemination of malignant cells.
However, the filtering mechanism of the heart-lung machine may be efficient in avoiding hematogenous tumor spread during surgery (3,11).
In patients with advanced renal cell carcinoma, pre-operative assessment for coronary disease should be carried out routinely.
If myocardial ischemia is suspected, a coronary angiogram and possible angioplasty should be performed pre-operatively.
If there is severe coronary disease and angioplasty is not feasible, we believe that a well-planned combined one-stage procedure can be carried out with relative safety.

References

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       Br J Urol 1987;59:390-5.

2.   Cocco Glazer AA, Novick AC. Long-term followup after surgical treatment for renal
      cell carcinoma extending into the right atrium. J Urol 1996;155:448-50.

3.   Hatcher PA, Everett Anderson E, Paulson DF, Carson CC, Robertson JE. Surgical
      management and prognosis of renal cell carcinoma invading the vena cava.
       J Urol 1991;145:20-4.

4.    Welz A, Schmeller N, Schmitz C, Reichart B, Hofstetter A. Resection of
       hypernephromas with vena caval or right atrial tumour extension using
       extracorporeal circulation and deep hypothermic arrest: a multidisciplinary approach.        Eur J Cardio-thorac Surg 1997;12:127-32.

5.    Matthews PN, Evans C, Breckenridge IM. Involvement of the inferior vena cava by
       renal tumour: surgical excision using hypothermic circulatory arrest.
       Br J Urol 1995;75:441-4.

6.    Belis JA, Levinson ME, Walter EP. Complete radical nephrectomy and vena caval
       thrombectomy during circulatory arrest. J Urol 2000;163:434-6.

7.    Nesbitt JC, Soltero ER, Dinney CPN, Walsh GL, Schrump DS, Swanson DA, et al.
       Surgical management of renal cell carcinoma with inferior vena cava tumor
       thrombus. Ann Thorac Surg 1997;63:1592-600.

8.    Wickey GS, Martin DE, Larach DR, Belis JA, Kofke A,Hensley FA. Combined carotid
       endarterectomy, coronary revascularization and
       hypernephroma excision with hypothermic circulatory arrest.
       Anesth Analg 1988;67:473-6.

9.    Belis JA, Pae WE, Rohner TJ, Myers JL, Thiele BL, Wickey GS, Martin DE.
       Cardiovascular evaluation before circulatory arrest for removal of vena caval
       extension of renal carcinoma. J Urol 1989;141:1302-7.

10.  DeSouza E, Klingman RR, Peetz D, Alberttucci M, Tyndall S.
        Extension of renal cell carcinoma into the vena cava with concomitant coronary
        artery disease:
        surgical considerations. Nebr Med J 1991;76:274-7.

11.  Akcurin RS, Davidov MI, Partgulov SA, Brand SA, Shiriaev AA, Lepilin MG, Dolgov IM.        Cardiopulmonary bypass and cell-saver technique in combined oncologic and
       cardiovascular surgery.
       Artificial Organs 1997;21:763-5.

Qaboos Mosque / Muscat , Oman