Diagnosis and surgical treatment of renal cell carcinoma with supradiaphragmatic level invasion of the inferior vena cava

Abstract

Aim. Improvement of diagnosis and surgical treatment of renal cell carcinoma with supradiaphragmatic level invasion of the inferior vena cava. Materials and Methods. The peculiarities of the clinical course, diagnosis and surgical treatment of renal cell carcinoma with supradiaphragmatic level invasion of the inferior vena cava were analyzed in a 70-year-old patient. Results and Discussion. Treatment of patients with renal cell carcinoma, complicated by thrombosis of the inferior vena cava to the right atrium level, remains a challenge because of the very high risk of perioperative complications. In addition, among the majority of patients with renal cell carcinoma complicated with venous invasion, regional lymph nodes metastases and distant metastases are observed. Therefore, the issue of expediency of expanded palliative surgical interventions in this category of patients is the most acute. In our observation, in the 70-year-old patient, by clinical examination, laboratory and diagnostic imaging a tumor of the right kidney (T3c-4N2M1) was diagnosed, complicated by thrombosis of the inferior vena cava to the level of right atrium, disturbed outflow from the left renal, hepatic veins, portal hypertension; retroperitoneal lymphadenopathy, metastasis of the IV segment of the liver, and phlebothrombosis of the left lower limb. Progression of renal hematuria against the background of anticoagulant therapy became a direct indication for surgical intervention - right-sided radical nephrectomy, lymphadenectomy with thrombectomy from the inferior vena cava, left renal and hepatic veins. In the present clinical case, in order to prevent fatal embolism of the pulmonary artery together with cardiosurgeons, the patient also underwent thoracotomy (using a mini surgical approach) in the 5-th intercostal space, with subsequent pinching under the visual control of the inferior vena cava in the place of its falling into the right atrium. The intraoperative autohemotransfusion with the use of the "Cell-Saver" (Haemonetics) apparatus significantly reduced the amount of blood loss and the need of donor blood, and as a consequence, reduced the risk of infectious complications, coagulopathies and immunosuppressions. Upon intraoperative revision with the use of an ultrasonography the metastases of the liver were not detected. Thus, right-sided radical nephrectomy, lymphadenectomy with thrombectomy from the inferior vena cava, left renal and hepatic veins allowed saving the life of the patient and preventing the development of fatal complications. Conclusions. This clinical case demonstrates that an aggressive surgical approach is the treatment of choice for patients with renal cell carcinoma, complicated by a high level of venous invasion, and team collaboration of various specialists allows optimizing the surgical procedure, preventing the development of severe complications and providing satisfactory long-term results.

Keywords

• renal cell carcinoma, tumorous thrombus, inferior vena cava