BACKGROUND: Renal cell carcinomas and other retroperitoneal tumours propagate tumour thrombi in the inferior vena cava, often well into the thorax. These intrathoracic caval tumour thrombi (ICTT) are of interest to the cardiothoracic surgeon: We consider two ICTT subgroups that correspond to the wider ‘Neves and Zincke’ classification: ICTT-III (extracardiac) extending just above the hepatic veins and ICTT-IV (intracardiac).
METHODS: Review of case series for evidence on the peri-operative management of ICTT.
RESULTS: We identified and retained for data extraction 29 series with 784 patients, 453 cases of extracardiac and 331 of intracardiac tumour thrombi. Average age was 59 years. 98% of the tumours were RCC, 1% adrenal and Wilms’ tumours and 1% transitional cell carcinomas.
The prevalent incision was chevron (rooftop) with or without tandem sternotomy. Mortality was 10% (5% for ICTT-III, 15% for ICTT-IV). Morbidity was 56% (36% for ICTT-III, 64% for ICTT-IV). Bleeding necessitating reoperation was the commonest complication (14%). The transfusion requirements reflected the estimated blood loss: 2.6 Litres of blood loss and 2.4 Litres of blood products for the ICTT-III subgroup and 3.7 Litres of blood loss and 3.5 Litres of blood products for ICTT-IV. Operative and anaesthetic times exceeded 5 hours Hospital stay averaged 13 days.
Variations in perioperative care included: pre-operative embolisation, peri-operative transoesophageal echo, surgical incisions and use of extracorporeal circulation (perfusion).
CONCLUSIONS:
-Surgery for ICTT is resource-intensive.
-It requires provision for massive transfusion and prolonged in-hospital recovery times.