Circumferential Resection of the Inferior Vena Cava for Primary and Recurrent Malignant Tumors

Circumferential Resection of the Inferior Vena Cava for Primary and Recurrent Malignant Tumors Jorge Caso, John Seigne,* Martin Back, Phillipe E. Spiess, Julio Pow-Sang and Wade J. Sexton† From the Genitourinary Oncology Program, Moffitt Cancer Center and Division of Vascular Surgery (MB), University of South Florida, Tampa, Florida

Purpose: Circumferential vena caval resection is occasionally performed in patients with advanced malignancy. We explored the oncological effectiveness of inferior vena caval resection, as determined by margin status, cancer recurrence and survival. Also, we addressed the morbidity associated with inferior vena caval obstruction and resection, and determined indications for inferior vena caval reconstruction. Materials and Methods: A total of 18 patients underwent attempted inferior vena caval resection from 1999 to 2008. Primary tumor type was renal cell carcinoma in 7 patients, metastatic testicular cancer in 5, leiomyosarcoma in 3, and adrenal cortical carcinoma, primary retroperitoneal germ cell tumor and upper tract transitional cell carcinoma in 1 each. Data reviewed included preoperative and postoperative sequelae of inferior vena caval obstruction, postoperative complications, pathological results, cancer recurrence, graft requirements and functional outcomes. Results: Mean followup in the entire patient cohort was 24 months. Inferior vena caval resection was completed in 15 of 18 patients, of whom 12 (80%) had negative surgical margins. Of the patients 50% presented with symptoms of venous hypertension, including lower extremity edema with or without venous thrombosis, or abdominal wall varicosity. After inferior vena caval resection symptoms resolved in half of them, likely due to the ongoing formation of collateral vessels. Five asymptomatic patients with incomplete inferior vena caval occlusion underwent reconstruction with inferior vena caval vascular grafts of polytetrafluoroethylene (4) or Dacron® (1). The polytetrafluoroethylene grafts remained patent. A total of 12 patients underwent simultaneous nephrectomy and/or left renal vein ligation in the same setting with acceptable alterations in postoperative renal function and no need for permanent dialysis. Cancer recurred locally in 4 of 15 patients who underwent resection. Five of 15 patients in the resection group died of disease or were lost to followup compared to all 3 in whom resection was aborted or macroscopically incomplete (mean followup 19.2 vs 4.3 months). Conclusions: Local cancer control and potentially increased cancer specific survival can be achieved with successful complete circumferential resection of the inferior vena cava as a component of multimodality care in select patients with locally advanced malignancy. Polytetrafluoroethylene is the preferred prosthetic material when inferior vena caval replacement is indicated. The most common postoperative complications are renal insufficiency and lower extremity edema, which are generally transient.

Abbreviations and Acronyms ACC ⫽ adrenal cortical carcinoma DVT ⫽ deep vein thrombosis GCT ⫽ germ cell tumor IVC ⫽ inferior vena cava LEE ⫽ lower extremity edema LMS ⫽ leiomyosarcoma LRV ⫽ left renal vein MRI ⫽ magnetic resonance imaging NSGCT ⫽ nonseminomatous GCT PTFE ⫽ polytetrafluoroethylene RCC ⫽ renal cell carcinoma TCC ⫽ transitional cell carcinoma Submitted for publication December 17, 2008. * Current address: Department of Urology, Dartmouth-Hitchcock University Medical Center, Lebanon, New Hampshire. † Correspondence: Genitourinary Oncology Program, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, Florida 33612-9416 (telephone: 813-7453973; FAX: 813-745-8494; e-mail: Wade.Sexton@ Moffitt.org).

Key Words: kidney; testis; neoplasms; vena cava, inferior; prostheses and implants

0022-5347/09/1823-0887/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION

Vol. 182, 887-893, September 2009 Printed in U.S.A. DOI:10.1016/j.juro.2009.05.015

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IVC obstruction in patients with abdominal malignancies results from intrinsic and extrinsic tumor characteristics, and signifies locally advanced disease. RCC has a particular propensity for IVC involvement from direct thrombus extension with a reported rate of 4% to 25%.1– 4 Bulky residual post-chemotherapy retroperitoneal lymph node metastases of testicular GCTs and less commonly from primary retroperitoneal extragonadal GCTs may encase or directly involve the IVC.5–7 Radical excision is sometimes necessary for retroperitoneal sarcoma, including that arising from or involving the vena caval wall.8 –10 IVC invasion or tumor thrombus formation is also documented for ACC, lymphoma and hepatic tumors, among others.11–13 Achieving negative surgical margins is necessary in most cases to achieve a successful oncological outcome regardless of tumor histological subtype.2,3,6,8,11,13 Thus, circumferential IVC resection is justified in select patients. IVC internal diameter can be decreased by approximately 50% without significantly impairing vascular flow. Small cavotomies may be closed primarily or by incorporating an autologous or prosthetic patch. When circumferential resection is performed, the surgeon has the option of reconstructing the IVC with a vascular graft or ligating the vena cava, thereby promoting venous return through established collaterals. Significant sequelae are associated with abrupt IVC interruption, including signs and symptoms of venous insufficiency in the lower extremities.11,13 Varying clinical, radiological and intraoperative findings have been suggested to determine whether IVC reconstruction or interruption would be optimal in a given patient.1,11–13 Few guidelines aid in perioperative and intraoperative treatment in patients who undergo abdominal exploration with planned circumferential resection of the IVC. Thus, management often depends on surgeon preference. We report our experience with such cases, discuss the preoperative and postoperative sequelae associated with IVC obstruction, and review the functional and oncological outcomes associated with IVC resection and reconstruction.

PATIENTS AND METHODS In an institutional review board approved database at a single institution from 1999 to 2008 we identified 18 patients who underwent surgical exploration by the genitourinary oncology service with planned segmental IVC resection for malignancy. Most commonly the procedure was related to IVC wall invasion by tumor thrombus associated with primary or recurrent RCC, or secondary to encasing, extrinsic IVC involvement by residual post-chemotherapy retroperitoneal lymphadenopathy associated with metastatic testis cancer. Other tumor types were LMS, ACC, TCC and primary retroperitoneal GCT. Of 18 patients 12 were treated with a multimodality approach incorporating

perioperative systemic chemotherapy and/or external radiation for therapeutic purposes. Preoperatively cross-sectional imaging was performed using computerized tomography or MRI to stage cancer and determine whether complete or incomplete IVC obstruction was evident. Patient charts were reviewed for presenting clinical signs and symptoms, perioperative therapy, tumor histology and cancer stage, intraoperative findings and management, complications, disease recurrence, graft requirements and graft patency, as applicable. Particular attention was given to perioperative symptoms of venous obstruction. Patients in this review underwent circumferential IVC resection rather than resection of a portion of the vena caval wall with tapering or patch cavoplasty. Likewise we did not include patients with bland nonmalignant thrombus in the IVC who underwent vena caval ligation or interruption without circumferential resection. Surgical margins were evaluated according to standard practice. In patients with IVC tumor thrombus margins were not considered positive when a portion of the thrombus was extracted in piecemeal fashion. Likewise the margin was not considered positive when there was nonadherent thrombus protruding from the transected vein wall at the vascular margin. These margins were evaluated with intraoperative frozen sections when the interface between the tumor and the IVC wall could not be established easily. Margin status was defined as negative—R0, microscopically positive—R1 and macroscopically or grossly positive—R2.14 The decision to place an interposition graft was based on preoperative and intraoperative findings, including the degree of IVC obstruction (partial vs complete), the presence or absence of radiographically detected vascular collaterals outside the anticipated resection field, the presence and duration of lower extremity edema, and whether the tumor could be completely excised, including tumor thrombus or bland thrombus when present. Only patients with partial IVC obstruction were considered candidates for an IVC interposition graft. A vascular surgeon participated in all cases in which a vascular graft was placed and in some to assist with vascular dissection and IVC resection. When possible, the retroperitoneal, mesenteric (eg inferior mesenteric vein), gonadal and pelvic collateral vessels were preserved to promote venous return. All of our patients underwent active lower extremity compression with sequential compression devices intraoperatively and postoperatively. On day 1 postoperatively those who underwent vascular reconstruction were started on prophylactic low molecular weight heparin, eg 30 to 40 mg enoxaparin subcutaneously daily. If serum hemoglobin remained stable for 24 to 48 hours, the patient was placed on a therapeutic dose of low molecular weight heparin (1 mg/kg every 12 to 24 hours depending on renal function), which was transitioned to warfarin with a target international normalized ratio of 2.5 to 3. Full anticoagulation was maintained for at least 2 to 3 months. The consultant vascular surgeons followed patients after graft placement and determined the ongoing need for anticoagulation.

CIRCUMFERENTIAL RESECTION OF INFERIOR VENA CAVA

RESULTS Table 1 lists demographics, surgical variables and oncological outcomes in the 18 patients who underwent attempted circumferential resection of the IVC as a primary procedure (13) and as a secondary procedure related to a recurrent retroperitoneal tumor or recurrent tumor as IVC thrombus (5). Complete resection, defined as circumferential resection of the tumor and the IVC with R0 margins, was achieved in 12 of 18 patients. In 3 patients IVC resection was incomplete or aborted and in another 3 who underwent IVC resection the margins were R1. The IVC resection level was infrarenal in 10 cases, suprarenal in 1 and combined infrarenal plus suprarenal in 4. Table 2 lists postoperative complications that occurred within 1 month of surgery. Major complications were defined as those requiring escalating postoperative care, most commonly related to cardiopulmonary issues. Minor complications might have prolonged hospitalization but did not result in escalation of care or maintenance of a higher level of care, eg critical care. No patients were returned to surgery and no deaths were attributable to surgical complications. Many patients had LEE at presentation (table 1), which resolved in half after surgery but persisted or was new onset in several others (table 2). Estimated blood loss was not included as a complication but 9 patients had an estimated blood loss of greater than 1,500 ml. Perioperative systemic therapy and/or radiation therapy was done in 12 of the 18 patients. Four patients with RCC were treated with different systemic therapies postoperatively, including 1 with a tyrosine receptor kinase inhibitor in the context of an adjuvant therapy clinical trial. Another 3 patients with concurrent or delayed metastasis received various therapies determined by response and performance status, including interleukin-2, vaccine therapy, chemotherapy, monoclonal antibodies and tyrosine receptor kinase inhibitors. All 6 patients with GCT were treated with platinum based chemotherapy before surgery (range 3 to 8 cycles). Only 1 patient, who had primary retroperitoneal seminoma, was treated postoperatively. He received radiation for R1 disease and additional chemotherapy for viable seminoma in the pathological specimen. One patient with LMS of the IVC received neoadjuvant doxorubicin based chemotherapy and external radiation. Unfortunately she had R1 disease and experienced rapid disease progression postoperatively. A second patient with LMS with delayed local recurrence was treated with salvage radiation to the retroperitoneum. The remaining 3 patients with LMS, ACC and TCC, respectively, received no preoperative or postoperative therapy.

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Nine patients (50%) had IVC thrombus. Extensive thrombus invaded the IVC wall, causing occlusion in all 7 patients with clear cell RCC, including 1 with recurrence in a Greenfield filter. One patient with metastatic GCT showed incomplete vena caval obstruction associated with tumor thrombus formation secondary to extrinsic invasion of the IVC. Another patient with locally advanced TCC of the renal pelvis had invasion and complete obstruction of the IVC with bland thrombus extending to each lower extremity. Extrinsic IVC wall invasion in the remaining patients was due to metastatic GCT, LMS and recurrent ACC, respectively. Complete IVC occlusion was most commonly heralded by clinical symptoms involving the lower extremities. Presenting signs were DVT and LEE, although no patient required supportive devices to work or ambulate. Postoperatively LEE resolved or was transient in several patients who had preoperative clinical and radiographic evidence of complete IVC obstruction. The improvement in LEE was likely related to the continued development of vascular collaterals combined with anticoagulants in select patients. Seven patients had incomplete vena caval occlusion according to preoperative imaging and were believed to be candidates for IVC interposition grafts. Only 1 of these 7 patients had preoperative clinical symptoms directly related to tumor or involvement of the IVC. This man had recurrent bulky retroperitoneal LMS causing back pain and bilateral LEE, although the IVC was partially patent. An IVC graft was planned but complete resection was not possible and the obstructed IVC was left in situ. All remaining 6 patients with incomplete IVC obstruction were asymptomatic preoperatively. Treatment was aborted in 1 woman since she was found to have unresectable recurrent RCC involving the intrahepatic and supradiaphragmatic vena cava. Each of the remaining 5 asymptomatic patients underwent complete surgical resection (R0), followed by placement of an IVC interposition graft of PTFE (4) or Dacron (1). An additional female patient required a PTFE graft between the LRV and the suprarenal IVC stump. The IVC Dacron graft was patent at 1 month on Doppler ultrasound, although MRI 8 months later showed graft occlusion with the formation of vascular collaterals. PTFE grafts remained clinically and radiographically patent on ultrasound or MRI, although followup in most patients was limited (mean 16 months in those with an IVC PTFE graft). At the most recent outpatient visit patients with a graft remained asymptomatic except for left lower extremity edema in 1 with an IVC interposition graft to the right common iliac vein only. The graft was not extended to the left common iliac vein due to adherent chronic bland thrombus. No patient

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Table 1. Patient characteristics Preop Demographics

Tumor Type

Primary/ Recurrent

Surgical Variables

Preop IVC Obstruction

Preop Signs ⫹ Symptoms LEE, DVT, abdominal wall varices LEE, abdominal wall varices Gross hematuria

Nephrectomy

1—59 —M

RCC

Primary

Complete

2—62 —F

RCC

Recurrent

Complete

3—50 —F

RCC

Primary

Partial

4—72 —M 5—73 —F 6—71 —F

RCC RCC RCC

Primary Recurrent Recurrent

Complete Partial Complete

Gross hematuria None Gross hematuria, DVT

Rt Lt Rt

7—71 —F 8—36 —M

RCC NSGCT

Primary Primary

Complete Partial

LEE None

9—41 —M

NSGCT

Primary

Complete

10—30 —M

NSGCT

Primary

Complete

11—21 —M

NSGCT

Primary

12—38 —M

NSGCT

13—56 —M

14—58 —F

Primary retroperitoneal seminoma LMS

15—42 —M 16—63 —F

17—33 —M 18—42 —M

IVC Resection Level

Margins

Tumor Stage

Oncological Outcomes

Graft

Graft Patency

Mos to 1st Local/Distant Recurrence or Progression

Mos Followup 61

Disease Status

Rt

Infrarenal

R0

pT3BN0M1

No

Not applicable

Distant, 16

Rt

Aborted

Not applicable

pT3CNxM0

No

Not applicable

Unresectable

Rt

R0

pT3bN0M0

Dacron

Distant, 53

84

Disease

R0 Not applicable R0

pT3CN0M0 pT3BN0M0 pT3BNxM0

No No No

Occlusion at 9 mos Not applicable Not applicable Not applicable

Local/distant, 3 Unresectable Local/distant, 38

5 10 79

Dead of disease Lost to followup Disease

Rt No

Suprarenal, LRV tapered Infrarenal Aborted Suprarenal, infrarenal, LRV divided Infrarenal Infrarenal

R0 R0

No PTFE

Not applicable Patent

None None

11 14

No disease evidence No disease evidence

LEE

No

Infrarenal

R0

No

Not applicable

None

37

No disease evidence

Rt

Infrarenal

R0

No

Not applicable

None

26

No disease evidence

Partial

LEE, DVT, abdominal wall varices None

No

Infrarenal

R0

PTFE

Patent

None

2

No disease evidence

Primary

Partial

None

Rt

Infrarenal

R0

PTFE

Patent

None

3

No disease evidence

Primary

Complete

None

Rt

R1

No

Not applicable

Local, 2

3

Disease

Primary

Complete

LEE, DVT, abdominal wall varices

Rt

R0

Unknown

No

Not applicable

Local, 7

38

Lost to followup

LMS LMS

Recurrent Primary

Partial Complete

LEE, back pain None

Rt Rt

Not applicable R1

Unknown cT4N0M0

No PTFE

Not applicable Patent

Incomplete resection Distant, 2

2 6

Dead of disease Dead of disease

ACC TCC

Recurrent Primary

Partial Complete

None LEE

Rt Rt

Suprarenal, infrarenal, LRV divided Suprarenal, infrarenal, LRV divided Aborted Suprarenal, Infrarenal, LRV reconstructed Infrarenal Infrarenal

pT3BN0M0 cT2S1N3M0, pN0 cT2SxN3M0, pN0 cT2SxN3M0, pN3 cT2S3N3M1, pN0 cT1S1N3M1a, pN0 cTxS1N3M0, pN3M0

R0 R1

Unknown cT3N2M0, pT4N3

PTFE No

Patent Not applicable

Distant, 39 Distant, 1

45 2

Lost to followup Dead of disease

1

Disease Dead of disease

CIRCUMFERENTIAL RESECTION OF INFERIOR VENA CAVA

Pt No.—Age—Sex

CIRCUMFERENTIAL RESECTION OF INFERIOR VENA CAVA

Table 2. Complications No. Pts (%)* Major: Acute renal failure Cardiac tamponade Respiratory failure Cerebrovascular accident Congestive heart failure Minor: Persistent LEE New onset LEE Transient renal insufficiency Prolonged ileus Pleurotomy

No. Occurrences

4 (22) 1 1 1 1 1 11 (61) 4 2 3 1 1

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7 months, respectively. Another 6 patients, representing 5 tumor types, experienced persistent disease, metastatic recurrence or progression of metastatic disease (mean 19 months, range 1 to 53). Although 9 of the 15 patients (60%) who underwent IVC resection experienced cancer recurrence or progression, 5 have survived beyond 3 years (mean 61 months). All 3 patients in whom IVC resection was aborted or macroscopically incomplete died of disease or were lost to followup (mean 4.3 months) compared to 5 of 15 in the IVC resection group who died of disease or were lost to followup (mean 19.2 months).

* Some patients experienced multiple complications.

DISCUSSION with a graft experienced a postoperative pulmonary embolic event and none required placement of an IVC filter. A total of 15 patients underwent previous nephrectomy (4) or nephrectomy concurrent with attempted IVC resection (11). Infrequently tumors involved the confluence of the IVC and the LRV. Four patients had portions of the suprarenal plus infrarenal IVC resected. In 3 of the 4 patients the development of retrograde collateral flow from the LRV through the lumbar-hemiazygos system was believed to be sufficient to permit division of the renal vein proximal to the adrenal and lumbar vessels (see figure). Two of the 3 patients experienced transient renal insufficiency postoperatively, including 1 who required continuous venovenous hemodialysis while in the intensive care unit. There was no incidence of renal vein thrombosis. As discussed, the fourth patient received a PTFE graft from the LRV to the remaining suprarenal IVC stump. In this woman preoperative MRI did not reveal adequate collaterals to support renal outflow without reconstruction. In the fifth patient a tapered LRV remained connected to the infrarenal IVC after the suprarenal IVC was resected. Reconstruction of the suprarenal IVC was performed with a Dacron graft, which later thrombosed. The 12 patients who underwent simultaneous nephrectomy and/or LRV ligation in the same setting had a 0.7 mg/dl mean peak increase in serum creatinine postoperatively. After at least 1 month of followup serum creatinine stabilized to a mean of 0.2 mg/dl above baseline. Mean followup in all 18 patients was 24 months (range 1 to 84). Six of the 15 patients who underwent circumferential IVC resection and had relatively short followup (range 2 to 37 months) showed no evidence of disease, including 1 of 7 with RCC and all 5 with metastatic testicular cancer. Two patients with RCC and 1 with LMS, of whom all were believed to have undergone complete tumor and IVC resection (R0), showed local recurrence at 3, 38 and

The IVC may be compromised by different tumor types. Most commonly IVC obstruction occurs in patients with RCC due to tumor thrombus.1– 4,15 In most cases the tumor thrombus can be completely extracted from the vena cava using well described techniques.15,16 However, in a small percent of patients the thrombus invades the IVC wall and segmental resection is required to render the patient disease-free locally. Up to 3% of patients with metastatic NSGCT need IVC resection for complete retroperitoneal lymphadenectomy.5 Extrinsic or intrinsic IVC involvement may also arise from primary retroperitoneal tumors, adrenal tumors and tumors arising from other regional solid or hollow organs.6 –13,16 Clinically the alteration in blood flow due to IVC involvement may be heralded by LEE and the development of a peripheral network of venous collaterals that may be visible radiographically (eg dilated lumbar-hemiazygos veins) or clinically (eg dilated abdominal wall

MRI in patient with primary retroperitoneal germ cell tumor and occluded IVC with bland thrombus. Arrow indicates dilated lumbar-hemiazygos venous collateral from LRV. IVC and LRV junction were resected proximal to collateral vein.

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CIRCUMFERENTIAL RESECTION OF INFERIOR VENA CAVA

veins), resulting from chronic, long-standing vascular obstruction. In asymptomatic patients silent IVC obstruction may be noted during the preoperative radiological evaluation.11 We routinely use 3-phase abdominal computerized tomography. When the IVC appears partially or completely occluded, MRI with magnetic resonance cavography accurately defines the proximal and distal limits of IVC involvement by tumor, the association with tumor thrombus or bland thrombus and the degree of vascular flow in the IVC. IVC resection may disrupt established collaterals, causing postoperative symptoms such as LEE in previously asymptomatic patients.1,4,11,13 To prevent these postoperative sequelae some groups advocate replacing the IVC with graft material despite complete IVC obstruction and adequate radiographic evidence of venous collaterals.4,11 Others reserve reconstruction for patients with partial obstruction and poor collateral flow.13 Clinical signs may be misleading. In 1 series the presence or lack of lower extremity symptoms preoperatively, indicating adequate collateralization, correlated with postoperative sequelae in only 40% of patients.5 Ringed PTFE grafts have a low thrombogenic potential and the reported patency rate for low flow vessels appears good initially, although it decreases with time.2,4,12 Sarkar et al noted that only 1 of 10 patients with prosthetic IVC replacement had graft thrombosis at a mean followup of 19 months.11 However, some patients were not followed radiographically and it is possible that clinically silent occlusion developed. Complications of graft occlusion include severe LEE and death from pulmonary embolism.4,10 Dacron grafts are used for reconstruction, although there is a concern that the greater compressibility of Dacron leads to a higher rate of thrombosis than of observed for PTFE.10 In our experience most patients have complete IVC occlusion and graft reconstruction is not necessary. We reserved grafting for patients who preoperatively had incomplete IVC occlusion with radiographically visible vascular flow. Of patients with reconstruction only 1 in whom the PTFE graft was reconstructed unilaterally to the common iliac vein had problematic edema involving the contralateral leg, possibly exacerbated by poor compliance with anticoagulation recommendations. Otherwise no patient experienced pulmonary embolus or a vascular complication in the immediate postoperative setting. Radiological followup for patency was accomplished by Doppler ultrasound and cross-sectional imaging. The Dacron graft was thrombosed 9 months after surgery, although collateral blood flow had developed in the interim. All of our patients wear sequential compression devices intraoperatively and postoperatively. In patients who undergo

vascular grafting we recommend prophylactic doses of low molecular weight heparin beginning on day 1 postoperatively, followed by therapeutic administration of low molecular weight heparin 24 to 48 hours later. After patients resume solid food intake they should be started on warfarin or continue subcutaneous therapeutic doses of low molecular weight heparin for at least 2 to 3 months. Otherwise in patients with preexisting severe LEE and complete vena caval occlusion in whom the IVC is resected and not reconstructed a similar regimen could be considered to encourage the development of vascular collaterals. Chronic anticoagulation and antiplatelet use varies in other reported series. Some groups advocate indefinite use of 1 or the other, while others believe that the high PTFE patency rate obviates the need for such therapy.9,11,12 In most patients, including ours, the IVC is not reconstructed.15,6,16 Only 1 patient received a graft of the 19 who underwent post-chemotherapy retroperitoneal lymph node dissection and were reported on by Spitz et al.6 IVC reconstruction was performed after the original surgery as therapeutic management for postoperative compartment syndrome. Other patients had mild venous sequelae. In the post-chemotherapy retroperitoneal lymph node dissection series reported by Beck and Lalka only 1 of 24 patients had symptoms deemed severe enough to warrant IVC reconstruction.5 Retrospectively this patient had additional recurrences requiring reoperations, which would likely have resulted in later removal of the graft. The authors concluded that if delayed IVC reconstruction was contemplated, it should be done at least 1 year after IVC resection. All instances of acute renal insufficiency or renal failure were reversible in patients who underwent simultaneous nephrectomy. The LRV was not reconstructed in 3 of 4 cases in which it was completely divided. This issue has been addressed previously. The LRV may be transected proximal to the lumbar vein because of the hemiazygos system, a collateral system that is not present on the right side.3,16 Some surgeons determine LRV pressure to see whether established vascular collaterals would support renal vein isolation from the IVC (pressure less than 40 mm Hg). Reconstruction may be necessary at higher renal vein pressure.3 We relied on preoperative imaging to determine whether reconstruction was required. The right renal vein should always be reconstructed.3,13,16 Our series represents a heterogeneous group of patients with different patterns of local and distant recurrence. It should be stressed that most of these patients were treated with perioperative systemic therapy and some received localized external radiation. Certainly the preoperative response to these nonsurgical treatment modalities influenced patient

CIRCUMFERENTIAL RESECTION OF INFERIOR VENA CAVA

selection for aggressive surgical resection and the oncological outcome. Greater scrutiny is warranted when considering surgical resection in patients with recurrent or relapsed tumor involving the IVC. Three of the 5 patients in this series with disease relapse underwent aborted or macroscopically incomplete surgical resection compared to 0 of 13 with primary disease. Thus, complete resection in the setting of disease relapse is more difficult to achieve and should be weighed against surgical risks and expected oncological outcomes. However, in select patients in whom tumors partially or completely occlude the IVC aggressive surgical resection is justified based on the low local recurrence rate when there is complete excision with R0 margins. While we strive to preserve the IVC, its segmental en bloc removal is technically straightforward and facilitates complete resection. Although 9 of 15 patients who underwent IVC resection had disease recurrence or progression, 5 of the 9 are long-term survivors. Aggressive vascular resection has long been recommended in patients with metastatic tes-

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tis cancer, given the survival potential even in those with poor prognosis.7–9 Likewise, in patients with locally advanced RCC or limited metastatic RCC and adequate performance status aggressive local resection may extend disease specific survival.1– 6

CONCLUSIONS Surgery for malignancies involving the IVC and requiring its resection is technically feasible. Recognizing the importance of multimodality therapy, we believe that disease specific survival can be positively impacted after complete resection of malignancies invading the IVC in select patients. Incomplete or aborted resection is associated with a poor outcome and, as such, patients should be chosen carefully. A PTFE graft is preferred for IVC reconstruction and it appears to be safe and associated with limited postoperative complications. With complete obstruction reconstruction may not be necessary since most negative sequelae are transient in nature.

REFERENCES 1. Blute ML, Boorjian SA, Leibovich BC et al: Results of inferior vena caval interruption by Greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J Urol 2007; 178: 440. 2. Bissada NK, Yakout HH, Babanouri A et al: Longterm experience with management of renal cell carcinoma involving the inferior vena cava. Urology 2003; 61: 89. 3. Jibiki M, Iwai T, Inoue Y et al: Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava. J Vasc Surg 2004; 39: 829. 4. Tsuji Y, Goto A, Hara I et al: Renal cell carcinoma with extension of tumor thrombus into the vena cava: surgical strategy and prognosis. J Vasc Surg 2001; 33: 789. 5. Beck SD and Lalka SG: Long-term results after inferior vena caval resection during retroperitoneal lymphadenectomy for metastatic germ cell cancer. J Vasc Surg 1998; 28: 808.

6. Spitz A, Wilson TG, Kawachi MH et al: Vena caval resection for bulky metastatic germ cell tumors: an 18-year experience. J Urol 1997; 158: 1813. 7. Mullen JC, Lemermeyer G, Tittley J et al: Metastatic testicular tumor requiring inferior vena cava resection. Urology 1996; 47: 263. 8. Hollenbeck ST, Grobmyer SR, Kent KC et al: Surgical treatment and outcomes of patients with primary inferior vena cava leiomyosarcoma. J Am Coll Surg 2003; 197: 575. 9. Hardwigsen J, Balandraud P, Ananian P et al: Leiomyosarcoma of the retrohepatic portion of the inferior vena cava: clinical presentation and surgical management in five patients. J Am Coll Surg 2005; 200: 57. 10. Ruh J, Lang H, Paul A et al: Surgical aspects in the therapy of primary sarcoma of the vena cava. J Am Coll Surg 2006; 202: 559.

11. Sarkar R, Eilber FR, Gelabert HA et al: Prosthetic replacement of the inferior vena cava for malignancy. J Vasc Surg 1998; 28: 75. 12. Caldarelli G, Minervini A, Guerra M et al: Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies. BJU Int 2002; 90: 368. 13. Yoshidome H, Takeuchi D, Ito H et al: Should the inferior vena cava be reconstructed after resection for malignant tumors? Am J Surg 2005; 189: 419. 14. AJCC Cancer Staging Manual, 6th ed. New York: Springer-Verlag 2002. 15. Rodriguez A and Sexton WJ: Management of locally advanced renal cell carcinoma. Cancer Control 2006; 13: 199. 16. Ciancio G and Soloway M: Resection of the abdominal inferior vena cava for complicated renal cell carcinoma with tumour thrombus. BJU Int 2005; 96: 815.