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CASE REPORT

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RESECTION OF RECURRENT INFERIOR VENA CAVATUMOR AFTER RADICAL NEPHRECTOMY FOR RENAL

CELL CARCINOMA

MARC C. SMALDONE, GLENN M. CANNON, JR, AND RONALD L. HREBINKO

ABSTRACTanagement of recurrent tumor in the inferior vena cava (IVC) after radical nephrectomy is surgically

hallenging. We report 3 cases of recurrent renal cell carcinoma within the IVC managed by three differenturgical techniques. One patient was treated with tumor thrombus removal and primary cavotomy closure.he second patient was treated with IVC ligation and removal without vascular reconstruction. A third patientas treated with IVC wall excision and placement of a bovine pericardium graft. Although technically difficult,

epeat resection of IVC tumor recurrence after nephrectomy for renal cell carcinoma is an acceptable methodf treatment. UROLOGY 67: 1084.e5–1084.e7, 2006. © 2006 Elsevier Inc.

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solated recurrence of renal cell carcinoma (RCC)in the inferior vena cava (IVC) after surgical re-

ection has been infrequently reported. Resectionnd reconstruction of the IVC for primary or recur-ent malignancy is rarely performed owing to therevalence of concurrent metastases at diagnosisnd the operative morbidity and mortality risks.owever, aggressive surgical management in selectatients may offer an opportunity for cure or pal-iation. We report our operative experience with 3ases of recurrent RCC after nephrectomy involv-ng the IVC.

CASE REPORTS

ASE 1A 58-year-old woman was referred to our clinic

or evaluation of lower extremity edema that hadeveloped after undergoing right radical nephrec-omy at a community hospital 12 months earlieror Stage T1 clear cell carcinoma. The primary tu-

or margins were negative, with no evidence ofenal vein or lymph node involvement.Computed tomography (CT) revealed a right renal

ossa mass involving the IVC. Abdominal magnetic

rom the Department of Urology, University of Pittsburgh Schoolf Medicine, Pittsburgh, Pennsylvania

Address for correspondence: Marc C. Smaldone, M.D., Depart-ent of Urology, University of Pittsburgh School of Medicine,uite 700, 3471 Fifth Avenue, Pittsburgh, PA 15213. E-mail:maldonemc@upmc.edu

Submitted: August 1, 2005, accepted (with revisions): Novem-

ber 1, 2005

2006 ELSEVIER INC.LL RIGHTS RESERVED

esonance imaging (MRI) and transesophageal echo-ardiography were performed and confirmed cavalumor thrombus extending to the intrahepatic por-ion of the IVC. The metastatic workup was nega-ive, and the decision was made to take the patientack to the operating room for resection.The retroperitoneal mass was excised through aedian sternotomy extending into a chevron inci-

ion. The patient was placed on cardiopulmonaryypass, and, under hypothermic arrest, the righttrium and IVC were opened, the tumor was ex-ised, and the cavotomy was primarily closed withrunning suture.The patient tolerated the procedure well and was

ischarged home after a 22-day hospital stay com-licated by pacemaker placement for cardiac dys-hythmia. Pathologic examination showed recur-ent clear cell RCC. The patient had no complaintst her 24-month postoperative visit.

ASE 2A 77-year-old man presented with bilateral lower

xtremity edema 4 years after right radical nephrec-omy for Stage T3b clear cell RCC at a communityospital. CT revealed a large enhancing intracavalass extending to the infrahepatic level. MRI con-rmed the level of infrahepatic extension. The met-static workup was negative, and the decision wasade to perform resection.The cava was approached through an eighth-rib

horacoabdominal incision. The IVC appeared to

e chronically occluded with well-developed col-

0090-4295/06/$32.00doi:10.1016/j.urology.2005.10.058 1084.e5

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ateralization. After clamping superior to the throm-us, the IVC was opened and examined, with novidence of flow found beyond the presence of or-anized tumor thrombus. The decision was madeo resect and ligate the IVC because of the risk ofulmonary embolism from incomplete thrombec-omy. The distal infrahepatic cava was stapled withn EndoGIA stapler (U.S. Surgical, Norwalk, Conn)nd then oversewn.The patient tolerated the procedure well andas discharged home after an uncomplicated 7-dayospital stay. Pathologic examination confirmed re-urrent clear cell RCC. At his 6-month follow-upisit, his only complaint was lower extremity edema.

ASE 3A 51-year-old man was evaluated in our clinic for

ower extremity edema 6 months after right radicalephrectomy and IVC thrombectomy for Stage3c clear cell RCC. On pathologic examination,

he 16.0 � 14.0 � 6.5-cm mass grossly extendednto the renal vein with tumor thrombus within theumen of the vena cava. The surgical margins werelear of tumor.CT revealed a mass with IVC involvement. Ad-

itional evaluation with MRI revealed an intracavalass extending to the intrahepatic level, 1 to 2 cm

ephalad from the renal vein takeoff (Fig. 1). Theetastatic workup was negative, and the patientas taken back to the operating room for resection.The previous chevron incision was used for sur-

ical exploration. Without requiring cardiopulmo-

IGURE 1. MRI scan demonstrating enhancing tumorhrombus in partially occluded IVC, extending from thenfrarenal to the retrohepatic level.

ary bypass, the tumor was resected en bloc, and o

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he anterior portion of the vena cava was recon-tructed with bovine pericardium. The pathologicxamination results were consistent with recurrentlear cell RCC. The patient had an uncomplicated-day hospital stay and had no complaints at his-month follow-up visit.

COMMENT

Isolated local recurrence after radical nephrec-omy for RCC occurs in 2% to 3% of patients.1owever, isolated recurrence in the IVC has rarelyeen described.2– 6 A proposed source of isolatedVC recurrence is microscopic involvement of theVC wall present at the original operation but notn continuity with the primary tumor.4 Few pre-enting symptoms of venous obstruction wereresent in the reported cases. However, shortness ofreath2 and syncope5 were the presenting symp-oms in 2 patients with isolated recurrent tumorsnvolving the right atrium. In our series, all 3 pa-ients presented with complaints of lower extrem-ty edema.

To formulate an operative strategy for resection,t is essential to determine the cephalad extensionnd degree of adherence/invasion of the IVC tu-or. MRI is a noninvasive and accurate modality

or demonstrating presence and distal extent ofena caval involvement and has become the pre-erred diagnostic study at most centers, replacingT and ultrasonography.7For patients with intraluminal involvement, butinimal evidence of IVC wall invasion, an open

hrombectomy or patch resection may be performed.his carries the risk of late recurrence from theenous wall.8 With IVC wall invasion, partial orotal circumferential resection of the IVC with ad-quate surgical margins is necessary.The method of venous reconstruction after re-

ection of the suprarenal IVC is controversial. Lib-rtino et al.9 proposed that wall defects less thanne third the circumference of the IVC shoulde closed primarily. If the wall defect is more thanne third of the vena cava circumference, venouseconstruction with a pericardial patch10 or tubu-ar polytetrafluoroethane graft8,11 has been recom-ended to maintain patency. With invasion of more

han one half the circumference of the vessel wallr massive intraluminal tumor growth suspectedo be adherent to the venous wall, circumferentialesection and IVC replacement are necessary torevent the development of venous insufficiencynd renal failure.8For patients with chronic, complete suprarenal

cclusion of the IVC, resection and ligation with-ut venous reconstruction is an option. Duckettt al.12 reported that suprarenal IVC resection w ith-

ut venous replacement can be tolerated owing to

UROLOGY 67 (5), 2006

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he well-developed collateral pathways from chroniccclusion. In our series, 1 patient who underwentVC resection and ligation developed lower ex-remity swelling that was less severe than that ofis preoperative presentation.Indications for IVC resection and replacement

re currently undefined. The reported long-termraft thrombosis, infection, and survival data haveeen encouraging, but inconclusive. After reviewf published reports in conjunction with our owneries, patients with recurrent RCC localized to theVC, minimal comorbidity, and good preoperativeerformance status should be considered candi-ates for tumor excision or resection with appro-riate venous reconstruction.

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enal cell carcinoma fossa recurrence after nephrectomy.Urol 164: 322–325, 2000.

2. Finkelstein MP, Drinis S, Tortorelis DG, et al: Recur-ence of renal cell carcinoma with extensive vena caval throm-us three years after radical nephrectomy. Urol Int 68: 199–01, 2002.

3. Smith RB: Long-term survival of a vena caval recur-

ence of renal cell carcinoma. J Urol 125: 575–578, 1981. G

ROLOGY 67 (5), 2006

4. Minervini A, Salinitri G, Lera J, et al: Solitary floatingena caval thrombus as a late recurrence of renal cell carci-oma. Int J Urol 11: 239–242, 2004.

5. Ioannis V, Panagiotis S, Anastasios A, et al: Tumor ex-ending through inferior vena cava into the right atrium: a lateecurrence of renal cell carcinoma. Int J Cardiovasc Imaging9: 179–182, 2003.

6. Horger DC, Bissada NK, Curry NS, et al: Isolated lateecurrence of renal cell carcinoma in the inferior vena cava.an J Urol 11: 2467–2469, 2004.

7. Goldfarb DA, Novick AC, Lorig R, et al: Magnetic res-nance imaging for assessment of vena caval tumor thrombi: aomparative study with venacavography and computerizedomography scanning. J Urol 144: 1100–1104, 1990.

8. Hardwigsen J, Baque P, Crespy B, et al: Resection of thenferior vena cava for neoplasms with or without prostheticeplacement: a 14-patient series. Ann Surg 233: 242–249, 2001.

9. Libertino JA, Zinman L, and Watkins E Jr: Long-termesults of resection of renal cell cancer with extension intonferior vena cava. J Urol 137: 21–24, 1987.

10. Marshall FF, and Reitz BA: Supradiaphragmatic renalell carcinoma tumor thrombus: indications for vena cavaleconstruction with pericardium. J Urol 133: 266–268, 1985.

11. Huguet C, Ferri M, and Gavelli A: Resection of theuprarenal inferior vena cava: the role of prosthetic replace-ent. Arch Surg 130: 793–797, 1995.12. Duckett JW Jr, Lifland JH, and Peters PC: Resection of

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