Search Results (29)

The prognosis for untreated renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVC TT) is poor, and the only curative treatment option is extirpative surgery. However, radical nephrectomy with IVC thrombectomy is associated with high rates of morbidity and mortality. Historically, RCC was considered radioresistant, but it appears to be sensitive to higher doses per fraction. Stereotactic body radiation therapy (SBRT), which delivers high ablative radiation doses to focal targets, has been shown to be an effective treatment option for both non-metastatic and metastatic RCC. Emerging data also suggest its role in the management of RCC with IVC TT. This article reviews the available evidence on the use of SBRT in RCC patients with IVC TT, considering its application as curative, palliative, and neoadjuvant therapy. Full article

Background: Renal cell carcinoma tends to invade venous structures, frequently extending beyond the inferior vena cava and into the heart itself, such as into the right atrium or right ventricle. Resection of tumor burden, particularly tumor thrombus, often requires cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA), which is not feasible for all patients. Methods: Described in this study is a novel, minimally invasive endovascular approach involving endovascular thrombectomy as a viable approach in these select patients. Results: There were no surgical complications, shorter operating times, less blood loss and an average length of stay of 5.5 days in the four patients undergoing this procedure. Conclusions: We demonstrate that this technique can eliminate the need for cardiac bypass and deep hypothermic cardiac arrest and its associated risks, thereby making surgery safer and more accessible for patients with advanced kidney cancers with an inferior vena cava tumor thrombus. Furthermore, it allows for this life-saving surgery to be carried out in medical centers or hospitals where cardiac surgery is unavailable, or when cardiopulmonary bypass is medically contraindicated. Full article

Background: The purpose of this study is to report the experience of a single Portuguese oncology center in the management of patients with renal cell carcinoma (RCC) and venous tumor thrombus (VTT). Methods: This is a retrospective analysis of all patients with RCC and VTT surgically treated in our center between 2008 and 2023. Only patients with VTT up to level III (Mayo Clinic classification) were included. Patient, tumor characteristics and peri-operative outcome data were registered. Administration of systemic therapy was performed upon progression. Survival analysis was conducted with the collected data. Results: A total of 64 patients (n = 16 women) were included in this study. The mean age at diagnosis was 66.3 ± 10.7 years old. The VTT level was 0, I, II and III in 40 (62.5%), 12 (18.7%), 6 (9.4%) and 6 (9.4%) patients, respectively. Nine patients (14.1%) had distant metastasis at diagnosis. No peri-operative deaths occurred, and the major complication rate was 3.1%. Histology revealed 98.4% of clear cell RCC, with sarcomatoid differentiation present in 12.5% of the cases. A negative margin status was achieved in 54 (84.4%) patients. Systemic therapy was administered in 24 (37.5%) patients during follow-up. The median progression-free (PFS), cancer-specific (CSS) and overall (OS) survival were 23, 60 and 48 months, respectively. In multivariable analysis, significant predictors of CSS were tumor size, sarcomatoid differentiation and collecting system invasion. Conclusions: Radical nephrectomy with VTT excision up to level III is a feasible and safe procedure. Patients with large tumor size, sarcomatoid differentiation and collecting system invasion are at the highest risk and should be closely monitored. Full article

Background/Objectives: Radical nephrectomy (RN) with inferior vena cava thrombectomy (IVCT) is indicated for the curative management of renal cell carcinoma (RCC) with tumor thrombus (TT). In the literature, any direct comparison of complications between RNs with or without IVCT is lacking. The objective of this study was to analyze and compare complications after RNs with or without IVCT. Methods: A retrospective evaluation of the complications recorded in RCC patients who underwent RN with (TT group, n = 44) or without (non-TT group, n = 44) IVCT between 2009 and 2021 was conducted. The non-TT group was identified via propensity-score matched-pair analysis. Postoperative complications up until discharge or postoperative day 30, whichever came first, were classified using the Clavien–Dindo classification (CDC). Complications were categorized into cardiovascular, pulmonary, bleeding, gastrointestinal, neurological/psychiatric, wound, urinary tract, dysglycemia, and other groups. Statistical analyses using descriptive statistics included the chi² and Mann–Whitney U tests. Results: All CDC-grade postoperative complications were more frequent in the TT than in the non-TT group regarding the number of patients affected (93% vs. 73%), as well as per patient (median: 3 vs. 1; p < 0.001). Complications in CDC grade ≥ 3 were rare and comparable between groups. Cardiovascular, gastrointestinal, neurological/psychiatric, and bleeding complications occurred significantly more often in the TT group. However, its small study population and retrospective character limit this study. Conclusions: Significantly more patients undergoing an RN-IVCT experience more frequent postoperative complications than patients with an RN but without IVCT. Surgeons performing the procedures should be experienced, and hospital staff should be trained in the early recognition and treatment of complications. Full article

We present the case of a 49-year-old female of Caucasian European descent with chest tightness, fatigue, and palpitations, ultimately diagnosed with primary intracardiac angiosarcoma. Initial echocardiography revealed a significant mass within the right atrium, infiltrating the free wall. Surgical intervention included tumor excision and partial resection of the superior vena cava. Histopathological examination confirmed a high-grade angiosarcoma. Postoperative imaging identified a recurrent mass in the right atrium, suggestive of thrombus, alongside Takotsubo cardiomyopathy. Considering the elevated surgical risks and the presence of cardiomyopathy, management included anticoagulation therapy with Warfarin and adjuvant chemotherapy with Paclitaxel. Follow-up cardiac magnetic resonance imaging demonstrated a recurrent angiosarcoma with superimposed thrombus. This case presents the complex diagnostic and therapeutic landscape of angiosarcoma, highlighting the critical importance of early surgical intervention, advanced imaging techniques, and vigilant postoperative monitoring. Full article

Background: Renal angiomyolipoma (AML) without local invasion is generally considered benign. However, it may extend to the renal sinus, even the renal vein, or the inferior vena cava (IVC). In patients with non-tuberous sclerosis complex, coexistence of renal cell carcinoma (RCC) and renal AML is uncommon. Case presentation: A 72-year-old woman was incidentally found to have a solitary right renal mass with an IVC thrombus extending into the right atrium during a routine health checkup. Robot-assisted laparoscopic radical nephrectomy and thrombectomy were successfully performed through adequate preoperative examination and preparation. Two tumor lesions were found and pathologically confirmed as renal AML and RCC, and the tumor thrombus was derived from the renal AML. During the one-year follow-up period, no signs of recurrence or metastatic disease were observed. Conclusions: Renal AML with a tumor thrombus in the IVC and right atrium accompanied by RCC may occur, although rarely. In clinical practice, if preoperative manifestations differ from those of common diseases, rare diseases must be considered to avoid missed diagnoses. In addition, adequate examination and multidisciplinary discussions before making a diagnosis are necessary. For a level 4 tumor thrombus with no infringement of the venous wall, adoption of robot-assisted minimally invasive surgery, without extracorporeal circulation technology, is feasible. Full article

Thrombosis after severe acute respiratory syndrome coronavirus 2 vaccination is a serious complication in patients with a thrombophilic predisposition. Herein, we present a 17-year-old female who had underlying antiphospholipid syndrome (APS) and developed deep vein thrombosis (DVT) 6 months after her second BNT162b2 vaccine dose. Although she had no family history of thrombosis, she had previously developed DVT at 6 years of age, with thrombus formation in the right common iliac vein and the inferior vena cava, along with concomitant left pulmonary infarction. The patient had received anticoagulant therapy for 6 years after DVT onset, with subsequent treatment cessation for 5 years without recurrence. She received the BNT162b2 vaccine at 17 years of age, 1 week before a routine outpatient visit. Platelet factor 4 elevation was detected 14 days after the first vaccination, persisting for 5 months without thrombotic symptoms. Six months after the second vaccine dose, the DVT recurred and was treated with a direct oral anticoagulant. The vaccine was hypothesized to exacerbate the patient’s APS by activating coagulation. Platelet factor 4 levels may indicate coagulation status. When patients predisposed to thrombosis are vaccinated, coagulation status and platelet activation markers should be monitored to prevent DVT development. Full article

Wilms tumor (WT) is the most common kidney tumor in pediatric patients. Intravascular extension of WT above the level of the renal veins is a rare manifestation that complicates surgical management. Patients with intravascular extension are frequently asymptomatic at diagnosis, and tumor thrombus extension is usually diagnosed by imaging. Neoadjuvant chemotherapy is indicated for thrombus extension above the level of the hepatic veins and often leads to thrombus regression, obviating the need for cardiopulmonary bypass in cases of cardiac thrombus at diagnosis. In cases of tumor extension to the retrohepatic cava, neoadjuvant therapy is not strictly indicated, but it may facilitate the regression of tumor thrombi, making resection safer. Hepatic vascular isolation and cardiopulmonary bypass increase the risk of bleeding and other complications when utilized for tumor thrombectomy. Fortunately, WT patients with vena caval with or with intracardiac extension have similar overall and event-free survival when compared to patients with WT without intravascular extension when thrombectomy is successfully performed. Still, patients with metastatic disease at presentation or unfavorable histology suffer relatively poor outcomes. Dedicated pediatric surgical oncology and pediatric cardiothoracic surgery teams, in conjunction with multimodal therapy directed by a multidisciplinary team, are preferred for optimized outcomes in this patient population. Full article

The development of novel anticoagulants requires a comprehensive investigational approach that is capable of characterizing different aspects of antithrombotic activity. The necessary experiments include both in vitro assays and studies on animal models. The required in vivo approaches include the assessment of pharmacokinetic and pharmacodynamic profiles and studies of hemorrhagic and antithrombotic effects. Comparison of anticoagulants with different mechanisms of action and administration types requires unification of the experiment scheme and its adaptation to existing laboratory conditions. The rodent thrombosis models in combination with the assessment of hemostasis parameters and hematological analysis are the classic methods for conducting preclinical studies. We report an approach for the comparative study of the activity of different anticoagulants in vivo, including the investigation of pharmacodynamics and the assessment of hemorrhagic effects (tail-cut bleeding model) and pathological thrombus formation (inferior vena cava stenosis model of venous thrombosis). The reproducibility and uniformity of our set of experiments were illustrated on unfractionated heparin and dabigatran etexilate (the most common pharmaceuticals in antithrombic therapy) as comparator drugs and an experimental drug variegin from the tick Amblyomma variegatum. Variegin is notorious since it is a potential analogue of bivalirudin (Angiomax, Novartis AG, Basel, Switzerland), which is now being actively introduced into antithrombotic therapy. Full article

Renal cell carcinoma (RCC) is a common diagnosis, of which a notable portion of patients present with an extension into the venous circulation causing an inferior vena cava (IVC) tumor thrombus. Venous extension has significant implications for staging and subsequent treatment planning, with recommendations for more aggressive surgical removal, although associated surgical morbidity and mortality is relatively increased. The methods for surgical removal of RCC with IVC thrombus remain complex, particularly surrounding the use of robot-assisted surgery. Robot assistance for radical nephrectomy in this context is recently emerging. Thrombus level has important implications for surgical technique and prognosis. Other preoperative considerations may include location, laterality, size, and wall invasion. The urology literature on treatment of such tumors is largely limited to case series and institutional studies that describe the feasibility of various surgical options for these complex tumors. Further understanding of the outcomes and patient-specific risk factors would shed increased light on the optimal treatment for such cases. This narrative review provides a thorough overview on the previously reported use of robot-assisted nephrectomy in RCC with IVC thrombus to inform further studies which may optimize outcomes and guide shared decision-making. Full article

Aims: Deep vein thrombosis (DVT) is a prevalent cardiovascular condition. Endothelial-derived extracellular vesicles (EVs) may play a crucial role in platelet-dependent DVT development via platelet activation, but the mechanism is not clear yet. This research aims to understand how platelets and endothelial-derived EVs work in DVT. Methods: The interaction between protein disulfide isomerase (PDI) and glucose-regulated protein 94 (GRP94) was founded by molecular docking. Inferior vena cava stasis–induced mice received PDI and GRP94 inhibitor treatments. Platelet activation, endothelial-derived EVs, and PDI were measured using flow cytometry. The expression of PDI and dimetric GRP94 in platelets co-cultured with hypoxic endothelial cells was confirmed by Western blot or native PAGE. The fluorescence resonance energy transfer assay shows conformational changes in GPIIb/IIIa on platelet surfaces. A tracking experiment was performed using PKH26, which labelled endothelial-derived EVs, and the endocytosis of EVs by platelets was tracked by confocal microscope. Results: In a DVT mouse model, platelets enhance venous thrombus formation in a coagulation-independent manner, instead, platelet activation and the length of the thrombus are related to PDI and GRP94 activity. Next, we found that the expression level of endothelial-derived EVs carrying PDI is significantly increased in plasma. Endothelial-derived EVs carrying PDI are endocytosed by platelets, in which the content of GRP94 dimer is elevated, and consequently increases the expression of surface GPIIb/IIIa. In addition, PDI allosterically interacts with GPIIb/IIIa, which is re-configurated into an activated form. Conclusion: Endothelial-derived EVs carrying PDI induce DVT via interplay with GRP94 and GPIIb/IIIa in platelets. These findings emphasize the significance of platelets in DVT formation, and PDI may be a suitable target in DVT prevention. Full article

(1) Background: Clear cell renal cell carcinoma extending into the inferior vena cava (ccRCC^IVC) represents a clinical high-risk setting. However, there is substantial heterogeneity within this patient subgroup regarding survival outcomes. Previously, members of our group developed a microRNA(miR)-based risk classifier—containing miR-21-5p, miR-126-3p and miR-221-3p expression—which significantly predicted the cancer-specific survival (CSS) of ccRCC^IVC patients. (2) Methods: Examining a single-center cohort of tumor tissue from n = 56 patients with ccRCC^IVC, we measured the expression levels of miR-21, miR-126, and miR-221 using qRT-PCR. The prognostic impact of clinicopathological parameters and miR expression were investigated via single-variable and multivariable Cox regression. Referring to the previously established risk classifier, we performed Kaplan–Meier analyses for single miR expression levels and the combined risk classifier. Cut-off values and weights within the risk classifier were taken from the previous study. (3) Results: miR-21 and miR-126 expression were significantly associated with lymphonodal status at the time of surgery, the development of metastasis during follow-up, and cancer-related death. In Kaplan–Meier analyses, miR-21 and miR-126 significantly impacted CSS in our cohort. Moreover, applying the miR-based risk classifier significantly stratified ccRCC^IVC according to CSS. (4) Conclusions: In our retrospective analysis, we successfully validated the miR-based risk classifier within an independent ccRCC^IVC cohort. Full article

Introduction: Duplication of the inferior vena cava (IVC) is a congenital venous malformation that occurs in 0.2%–3% of the population as a result of persistent left and right supracardinal veins. The IVC duplication is prone to deep vein thrombosis due to endothelial dysfunction and associated venous stasis. This is a rare case of recurrent venous thrombosis due to IVC duplication and decreased protein C activity. Case: A 57-year-old male presented with swelling of the left lower limb that gradually developed over a one-week period preceding his visit. He reported a history of superior mesenteric vein thrombosis, approximately three years ago, for which he received anticoagulation therapy for three months. Thoracoabdominal contrast-enhanced computed tomography (CT) revealed thrombi in the locations of the bilateral main pulmonary arteries, IVC duplication, left common iliac vein, left IVC, and left renal vein. Blood work confirmed protein C activity of 21% (baseline 64%–146%), that could have contributed to the recurrent IVC thrombosis and formation of pulmonary artery thrombus. Subsequently, the patient was hospitalized and started on anticoagulation therapy. The swelling in the left lower extremity gradually improved, and the patient was instructed to continue anticoagulation therapy permanently. Conclusion: When investigating venous thrombosis of unknown or recurrent origin, it is necessary to include venous malformations and abnormal activity of blood coagulation factors in differential diagnosis. Full article

Background and Objectives: The recommended therapeutic management in renal cell carcinoma (RCC) with supradiaphragmatic inferior vena cava/right atrial thrombus (IVC/RA) is surgery. Extracorporeal circulation is required. Acute kidney injury (AKI), a frequent complication after nephrectomy and cardiac surgery is associated with long-term kidney disease. This study aims to identify the risk factors involved in the occurrence of the severe postoperative AKI (AKI3) and to analyse various preoperative validated risk scores from cardiac and noncardiac surgery in predicting this endpoint. Materials and Methods: The medical data of all patients with RCC with supradiaphragmatic IVC/RA thrombus who underwent radical nephrectomy with high thrombectomy, using extracorporeal circulation, between 2004–2018 in the Prof. C. C. Iliescu Emergency Institute for Cardiovascular Diseases, Bucharest, were retrospectively analysed. The patients who died intraoperatively were excluded from the study. The predefined study endpoint was the postoperative AKI3. Preoperative, intraoperative and postoperative data were collected according to the stratification of study population in two subgroups: AKI3-present and AKI3- absent patients. EuroSCORE, EuroSCORE II, Logistic EuroSCORE, NSQIP any-complications and NSQIP serious-complications were analysed. Results: We reviewed 30 patients who underwent this complex surgery between 2004–2018 in our institute. Two patients died intraoperatively. Nine patients (32.14%) presented postoperative AKI3. Age (OR 1.151, CI 95%: 1.009–1.312), preoperative creatinine clearance (OR 1.066, CI 95%: 1.010–1.123) and intraoperative arterial hypotension (OR 13.125, CI 95%: 1.924–89.515) were risk factors for AKI3 (univariable analysis). Intraoperative arterial hypotension emerged as the only independent risk factor in multivariable analysis (OR 11.66, CI 95%: 1.400–97.190). Logistic EuroSCORE (ROC analysis: AUC = 0.813, p = 0.008, CI 95%: 0.633–0.993) best predicted the endpoint. Conclusions: An integrated team effort is essential to avoid intraoperative arterial hypotension, the only independent risk factor of AKI3 in this highly complex surgery. Some risk scores can predict this complication. Further studies are needed. Full article

Renal cell carcinoma (RCC) accounts for 2–3% of all malignant disease in adults, with 30% of RCC diagnosed at locally advanced or metastatic stages of disease. A form of locally advanced disease is the tumor thrombus (TT), which commonly grows from the intrarenal veins, through the main renal vein, and up the inferior vena cava (IVC), and rarely, into the right cardiac chambers. Advances in all areas of medicine have allowed increased understanding of the underlying biology of these tumors and improved preoperative staging. Although the development of several novel system agents, including several clinical trials utilizing immune checkpoint inhibitors and combination therapies, has been shown to lower perioperative morbidity and increase post-operative recurrence-free and progression-free survival, surgery remains the mainstay of therapy to achieve a cure. In this review, we provide a description of specific surgical approaches and techniques used to minimize intra- and post-operative complications during radical nephrectomy and tumor thrombectomy of RCC with TT extension of various levels. Additionally, we provide an in-depth review of the major developments in neoadjuvant and adjuvant immunotherapy-based treatment and the impact of ongoing and recently completed clinical trials on the surgical treatment of advanced RCC. Full article