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Surgical treatment for carcinoma of the suprahepatic inferior vena cava
Surgical treatment for carcinoma of the suprahepatic inferior vena cava Chu-Leng Yu, MD, Shih-Rong Hsieh, MD, Mei-Chin Wen, MD, Cheng-Chung Wu, MD, Tse-Jia Liu, MD, and Fang-Ku P’eng, MD, FACS, Taipai and Taichung, Taiwan
From the Department of Surgery and Pathology, Taichung Veterans General Hospital, Taichung; Department of Surgery, Chung-Shan Medical College, Taichung; and Department of Surgery, Faculty of Medicine, National Yang-Ming University, Taipei; Taiwan
A 70-YEAR-OLD WOMAN presented with exertional dyspnea, leg edema, and abdominal distension for 1 month. On physical examination, only pitting edema over both legs was noted. Other than proteinuria and hypoalbuminemia, the laboratory data including hemogram, conventional liver function tests, hepatitis B surface antigen, antihepatitis C antibody, and tumor markers (α-fetoprotein, carcinoembryonic antigen) were normal. However, the patient’s indocyanine-green 15-minute retention rate was 52% (normal ≤ 10%). Abdominal sonogram revealed a tumor over the suprahepatic inferior vena cava (IVC). Contrastenhanced magnetic resonance angiography using gadolinium diethylene-triamine-penta-acetate infusion demonstrated a large suprahepatic IVC tumor just above the orifices of the hepatic veins, extending close to the right atrium (RA) (Fig 1). The operation was performed via sternotomy and midline laparotomy. A hard tumor measuring 1.97 1.2 1.2 in (5 3 3 cm)3 in size was found originating from the suprahepatic segment of the IVC with invasion to the surrounding diaphragm. The liver was congested without cirrhosis. After cholecystectomy, cardiopulmonary bypass (CPB) was performed by arterial cannulation from the ascending aorta, and venous cannulations from the superior vena cava and the IVC. The body temperature was then gradually lowered to 26°C. Total excision of the tumor (including the suprahepatic IVC, part of the RA, and surrounding This work was supported in part by grant NSC 90-2314-B-075A018 from the National Science Council, Taipei, Taiwan. Accepted for publication January 18, 2002. Reprint requests: Cheng-Chung Wu, MD, Department of Surgery, Taichung Veterans General Hospital, Sec. 3, 160, Chung-Kang Road, Taichung, Taiwan. Surgery 2003;133. © 2003, Mosby, Inc. All rights reserved 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.56
342 SURGERY
Fig 1. Contrast-enhanced magnetic resonance angiography using gadolinium diethylene-triamine-penta-acetate infusion shows large tumor (T) at suprahepatic IVC extending close to RA.
diaphragm) was performed under CPB and hepatic pedicle clamping. The junction of the superior vena cava and RA, and IVC above the level of the right adrenal vein, were clamped during CPB. A bovine pericardial graft preserved in a buffered glutaraldehyde solution (Edwards pericardial patch; Baxter Co, Santa Ana, Calif), measuring 2.36 3.15 in (6 8 cm), was sutured to form a cylinder for reconstruction of the IVC. One end of
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Fig 3. Histology of the resected tumor, hematoxylin-eosin stain, 100.
Fig 2. A, Reconstruction of suprahepatic IVC. One end of cylinder, which was formed using bovine pericardial graft (asterisk), was sutured to RA, and the other end was attached to IVC just above hepatic vein confluence. (L, liver.) B, Papillary tumor (T ) protruding on intimal surface of IVC, and part of right diaphragm (D) was also resected.
the cylinder was sutured to the RA, and the other end was attached to the IVC just above the hepatic vein confluence (Fig 2, A). Care was taken to avoid stenosis of the hepatic vein orifice. Afterwards, circulation and body temperature were allowed to return to normal levels, and the CPB was removed. The diaphragm was directly repaired. The hepatic inflow blood occlusion time was 36 minutes, the total aortic clamping time was
144 minutes, and the total CPB time was 173 minutes. The estimated blood loss was 860 mL. Blood components consisting of 20 units of fresh frozen plasma, 12 units of platelet, and 3000 mL of whole blood were replaced. Total operative time was 10.3 hours. Subcutaneous injection of 20 mg of enoxaparin sodium (Rhone-Poulene Rorer, Bellon, France), every 12 hours, was administered commencing postoperative day 1. Then, oral warfarin was started on postoperative day 5 after bowel function returned. The patient’s postoperative course was uneventful. She was discharged on the 10th postoperative day. Oral warfarin, 2.5 to 5 mg, was given for 3 months to maintain the prothrombin time level at international normalized ratio 2.0 to 3.0. Grossly, the tumor protruded on the intimal surface of the IVC (Fig 2, B). Histological diagnosis showed a poorly differentiated adenocarcinoma (Fig 3). The cranial and caudal resection margins and the resection margin of the diaphragm were negative for malignancy. Immunohistochemical stain was positive for anticytokeratin antibody but negative for leucocyte common antigen, actin 851, and factor VIII-related antigen.1 After the patient’s discharge, extensive surveys of the respiratory, digestive, and genitourinary tracts failed to determine the primary site of cancer. Adjuvant chemotherapy with intravenous injection of 500 mg of 5-fluorouracil and 50 mg of methotrexate was administered every month for 6 months. At the time of this writing, the patient is alive and remains symptom-free 18 months after operation. The IVC prosthesis remained patent on follow-up magnetic resonance imaging study.
344 Yu et al
DISCUSSION Tumors originating from the IVC are rare. Most primary tumors of the IVC are leiomyosarcomas.2,3 Because the tumor in our case was positive for epithelial antigen (cytokeratin) and negative for antigens of white blood cell, smooth muscle, and vascular endothelium, it was histologically diagnosed as “carcinoma.”1 Because of the lack of epithelial tissue in the IVC wall, carcinomas of the IVC are always considered as a metastatic lesion.1-3 Nevertheless, extensive survey for other organs has not determined the primary cancer site at present. Surgical resection remains the only hope for primary or secondary malignancy of the IVC.2,3 The mean survival time of patients with an unresectable IVC tumor is only 3 months.2 Because of low incidence, high operative risk, and poor prognosis, only a few reports have been published concerning the management of tumor of the suprahepatic IVC.2 Under CPB and hepatic inflow clamping, resection and reconstruction of suprahepatic IVC can be carefully performed in a bloodless field without jeopardizing the orifice of the hepatic vein. In this procedure, an optimal safe margin can also be obtained. Moreover, as in our previous experience,4 under hypothermic protection, prolonged liver ischemia can be tolerated even when the preoperative liver function is not sound. Both of our experiences confirm the safety of such a procedure.
Surgery March 2003
For IVC replacement after resection, most surgeons favor polytetrafluoroethylene prosthesis.2,3 In this case, because of the lack of availability of a suitably sized polytetrafluoroethylene prosthesis, a bovine pericardial graft was used. Combined with the use of temporary postoperative anticoagulants, this material can replace a short segment of IVC defect with long-term patency. Further studies are required to determine the best treatment for suprahepatic IVC tumors. The procedure reported here may be considered a salvage option for suprahepatic IVC maligancy.
REFERENCES 1. Rosai J. Ackerman’s Surgical Pathology. 8th ed. St Louis: Mosby-Year Book; 1996. p. 29-62. 2. Bower TC, Stanson A. Diagnosis and management of tumors of the inferior vena cava. In: Rutherford RB, editor. Vascular Surgery. 5th ed. Philadelphia: WB Saunders; 2000. p. 2077-92. 3. Hardwigsen J, Baque P, Crespy B, Moutardier V, Delpero JR, Le Treut YP. Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series. Ann Surg 2001;233:242-9. 4. Wu C-C, Hseih S, Ho W-M, Tang J-S, Liu T-J, P’eng F-K. Surgical resection for recurrent hepatocellular carcinoma with tumor thrombi in right atrium: using cardiopulmonary bypass and deep hypothermic circulatory arrest. J Surg Oncol 2000;74:227-31.
From the Department of Surgery and Pathology, Taichung Veterans General Hospital, Taichung; Department of Surgery, Chung-Shan Medical College, Taichung; and Department of Surgery, Faculty of Medicine, National Yang-Ming University, Taipei; Taiwan
A 70-YEAR-OLD WOMAN presented with exertional dyspnea, leg edema, and abdominal distension for 1 month. On physical examination, only pitting edema over both legs was noted. Other than proteinuria and hypoalbuminemia, the laboratory data including hemogram, conventional liver function tests, hepatitis B surface antigen, antihepatitis C antibody, and tumor markers (α-fetoprotein, carcinoembryonic antigen) were normal. However, the patient’s indocyanine-green 15-minute retention rate was 52% (normal ≤ 10%). Abdominal sonogram revealed a tumor over the suprahepatic inferior vena cava (IVC). Contrastenhanced magnetic resonance angiography using gadolinium diethylene-triamine-penta-acetate infusion demonstrated a large suprahepatic IVC tumor just above the orifices of the hepatic veins, extending close to the right atrium (RA) (Fig 1). The operation was performed via sternotomy and midline laparotomy. A hard tumor measuring 1.97 1.2 1.2 in (5 3 3 cm)3 in size was found originating from the suprahepatic segment of the IVC with invasion to the surrounding diaphragm. The liver was congested without cirrhosis. After cholecystectomy, cardiopulmonary bypass (CPB) was performed by arterial cannulation from the ascending aorta, and venous cannulations from the superior vena cava and the IVC. The body temperature was then gradually lowered to 26°C. Total excision of the tumor (including the suprahepatic IVC, part of the RA, and surrounding This work was supported in part by grant NSC 90-2314-B-075A018 from the National Science Council, Taipei, Taiwan. Accepted for publication January 18, 2002. Reprint requests: Cheng-Chung Wu, MD, Department of Surgery, Taichung Veterans General Hospital, Sec. 3, 160, Chung-Kang Road, Taichung, Taiwan. Surgery 2003;133. © 2003, Mosby, Inc. All rights reserved 0039-6060/2003/$30.00 + 0 doi:10.1067/msy.2003.56
342 SURGERY
Fig 1. Contrast-enhanced magnetic resonance angiography using gadolinium diethylene-triamine-penta-acetate infusion shows large tumor (T) at suprahepatic IVC extending close to RA.
diaphragm) was performed under CPB and hepatic pedicle clamping. The junction of the superior vena cava and RA, and IVC above the level of the right adrenal vein, were clamped during CPB. A bovine pericardial graft preserved in a buffered glutaraldehyde solution (Edwards pericardial patch; Baxter Co, Santa Ana, Calif), measuring 2.36 3.15 in (6 8 cm), was sutured to form a cylinder for reconstruction of the IVC. One end of
Surgery Volume 133, Number 3
Yu et al 343
Fig 3. Histology of the resected tumor, hematoxylin-eosin stain, 100.
Fig 2. A, Reconstruction of suprahepatic IVC. One end of cylinder, which was formed using bovine pericardial graft (asterisk), was sutured to RA, and the other end was attached to IVC just above hepatic vein confluence. (L, liver.) B, Papillary tumor (T ) protruding on intimal surface of IVC, and part of right diaphragm (D) was also resected.
the cylinder was sutured to the RA, and the other end was attached to the IVC just above the hepatic vein confluence (Fig 2, A). Care was taken to avoid stenosis of the hepatic vein orifice. Afterwards, circulation and body temperature were allowed to return to normal levels, and the CPB was removed. The diaphragm was directly repaired. The hepatic inflow blood occlusion time was 36 minutes, the total aortic clamping time was
144 minutes, and the total CPB time was 173 minutes. The estimated blood loss was 860 mL. Blood components consisting of 20 units of fresh frozen plasma, 12 units of platelet, and 3000 mL of whole blood were replaced. Total operative time was 10.3 hours. Subcutaneous injection of 20 mg of enoxaparin sodium (Rhone-Poulene Rorer, Bellon, France), every 12 hours, was administered commencing postoperative day 1. Then, oral warfarin was started on postoperative day 5 after bowel function returned. The patient’s postoperative course was uneventful. She was discharged on the 10th postoperative day. Oral warfarin, 2.5 to 5 mg, was given for 3 months to maintain the prothrombin time level at international normalized ratio 2.0 to 3.0. Grossly, the tumor protruded on the intimal surface of the IVC (Fig 2, B). Histological diagnosis showed a poorly differentiated adenocarcinoma (Fig 3). The cranial and caudal resection margins and the resection margin of the diaphragm were negative for malignancy. Immunohistochemical stain was positive for anticytokeratin antibody but negative for leucocyte common antigen, actin 851, and factor VIII-related antigen.1 After the patient’s discharge, extensive surveys of the respiratory, digestive, and genitourinary tracts failed to determine the primary site of cancer. Adjuvant chemotherapy with intravenous injection of 500 mg of 5-fluorouracil and 50 mg of methotrexate was administered every month for 6 months. At the time of this writing, the patient is alive and remains symptom-free 18 months after operation. The IVC prosthesis remained patent on follow-up magnetic resonance imaging study.
344 Yu et al
DISCUSSION Tumors originating from the IVC are rare. Most primary tumors of the IVC are leiomyosarcomas.2,3 Because the tumor in our case was positive for epithelial antigen (cytokeratin) and negative for antigens of white blood cell, smooth muscle, and vascular endothelium, it was histologically diagnosed as “carcinoma.”1 Because of the lack of epithelial tissue in the IVC wall, carcinomas of the IVC are always considered as a metastatic lesion.1-3 Nevertheless, extensive survey for other organs has not determined the primary cancer site at present. Surgical resection remains the only hope for primary or secondary malignancy of the IVC.2,3 The mean survival time of patients with an unresectable IVC tumor is only 3 months.2 Because of low incidence, high operative risk, and poor prognosis, only a few reports have been published concerning the management of tumor of the suprahepatic IVC.2 Under CPB and hepatic inflow clamping, resection and reconstruction of suprahepatic IVC can be carefully performed in a bloodless field without jeopardizing the orifice of the hepatic vein. In this procedure, an optimal safe margin can also be obtained. Moreover, as in our previous experience,4 under hypothermic protection, prolonged liver ischemia can be tolerated even when the preoperative liver function is not sound. Both of our experiences confirm the safety of such a procedure.
Surgery March 2003
For IVC replacement after resection, most surgeons favor polytetrafluoroethylene prosthesis.2,3 In this case, because of the lack of availability of a suitably sized polytetrafluoroethylene prosthesis, a bovine pericardial graft was used. Combined with the use of temporary postoperative anticoagulants, this material can replace a short segment of IVC defect with long-term patency. Further studies are required to determine the best treatment for suprahepatic IVC tumors. The procedure reported here may be considered a salvage option for suprahepatic IVC maligancy.
REFERENCES 1. Rosai J. Ackerman’s Surgical Pathology. 8th ed. St Louis: Mosby-Year Book; 1996. p. 29-62. 2. Bower TC, Stanson A. Diagnosis and management of tumors of the inferior vena cava. In: Rutherford RB, editor. Vascular Surgery. 5th ed. Philadelphia: WB Saunders; 2000. p. 2077-92. 3. Hardwigsen J, Baque P, Crespy B, Moutardier V, Delpero JR, Le Treut YP. Resection of the inferior vena cava for neoplasms with or without prosthetic replacement: a 14-patient series. Ann Surg 2001;233:242-9. 4. Wu C-C, Hseih S, Ho W-M, Tang J-S, Liu T-J, P’eng F-K. Surgical resection for recurrent hepatocellular carcinoma with tumor thrombi in right atrium: using cardiopulmonary bypass and deep hypothermic circulatory arrest. J Surg Oncol 2000;74:227-31.