Clinical challenge Prof. Oliver Hakenberg
The Clinical challenge section presents interesting or difficult clinical problems which in a subsequent issue of EUT will be discussed by experts from different European countries as to how they would manage the problem. Readers are encouraged to provide interesting and challenging cases for discussion at h.lurvink@uroweb.org
Surgery with or without neoadjuvant treatment
Section editor Rostock (DE)
Comments by Prof. Axel Heidenreich Köln (DE)
such as blockage or infiltration of the right renal vein, blockage of the liver veins (Budd Chiari syndrome), repetitive haematuria, to name a few. However, surgery in this situation is complicated, extensive and needs the presence of a multidisciplinary team involved in a 2-cavitary approach with cavotomy and cardiopulmonary bypass surgery. A mere transperitoneal of thoraco-abdominal approach (which is our preference in first line surgery), will not be able to completely resect the thrombus. The peri- operative mortality is in the range of 2-5% and 90 day mortality is in the range of about 15%. Due to the high risk of systemic relapse, adjuvant
Oliver.Hakenberg@ med.uni-rostock.de
Reflecting the medical data given and the 2 CT images presented, we have to consider the following issues with regard to the most appropriate second-line management • the tumour thrombus was removed completely during the first surgery so recurrence could be due an infiltration of the wall of the inferior vena cava resulting in subsequent re-growth • just interpreting the abdominal CT image, the left renal vein seems to be in place with a local recurrence, which is quite unique since the vein needs to be resected including the left caval orifice of the renal vein at time of thrombus surgery • postoperative pulmonary embolism could have been due to tumour thrombus material or due to a classical apposition thrombus • postoperative recovery was prolonged for reasons we do not know (blood loss, comorbidities, SIRS, etc.), but which have to be integrated in the decision-making process with regard to the next step of treatment • postoperative adjuvant immune-oncological therapy with pembrolizumab was not delivered The next step of treatment could be first line immune-oncological therapy, redo surgery or a combination of neoadjuvant immuno-oncological therapy followed by surgery. What I need to know prior to the next step of therapy • pre-existing comorbidities and physical fitness of the patient. • presence, localisation and extent of the potential infiltration of the wall of the inferior vena cava. The thrombus looks like a floating thrombus in the right atrium, but I cannot identify the true extent of the intracaval thrombus. Therefore, MRI scan and an transoesophageal echocardiography should be performed since this information will dictate the primary treatment approach. Infiltration of the IVC above the diaphragm would be a severe contraindication for a surgical approach. • presence of or absence of metastatic systemic disease Treatment options Surgery is an option if the patient is in good general health and if the thrombus is only partially infiltrating the IVC wall below the diaphragm. In this scenario, the IVC can be replaced by a venous prosthesis (Figure 1). Our own data on redo surgery of intracaval relapses of tumour thrombi are good with long-term cure in all patients. Surgery will effectively prevent future complications to local growth
Case study No. 75
Case study No. 74 This 70-year-old man underwent left radical nephrectomy with cavotomy and extraction of a long intracaval tumour thrombus extending into the atrium in April 2022. The operation was performed together with cardiac surgeons and went well. The histology was clear cell renal carcinoma and some parts of the tumour thrombus had been adherent to the vena cava. Post-operative recovery was prolonged and complicated by a pulmonary embolism. Now the patient presents with a follow-up CAT scan showing extensive recurrence of the intracaval tumour thrombus, again extending into the right atrium.
A 28-year-old man complained of dysuria 3 weeks after a ureteroscopy with fragmentation of a ureteric stone. A urethrogram showed a bulbar stricture and direct vision internal urethrotomy was performed. Due to an intraoperative false passage, the indwelling urethral catheter was left in situ for one week. Three months later, the patient still has a weak urinary stream. The current urethrogram is attached.
immuno-oncological treatment with pembrolizumab should be initiated postoperatively.
Neoadjuvant systemic therapy with the combination of ipilimumab/nivolumab or PD-L1 inhibitors plus multityrosine kinase inhibitors might be another option. However, response rates are low and the tumour thrombus shrinkage is reported in the range of about 10%, which usually does not result in significant reduction of the difficulties of surgery. Treatment-associated side effects have to be considered as the fact that any progression will result in the impossibility to completely resect the thrombus with the negative consequences reported above. If a partial response would be achieved after four cycles of treatment, surgery can be performed with a lesser rate of complications. Stereotactic ablative radiation therapy might represent an individual and still experimental approach. However, the current series describe a response rate of 58% with a palliation of symptoms in all patients. Treatment associated side effects are low and only grade 1-2 side effects have been described. The median overall survival is 34 months which is not poorer as compared to surgery alone. Depending on the extent and size of the residual tumour thrombus, second line surgery can still be performed after radiation therapy. In my view, redo surgery represents the treatment modality with the highest chance for cure, but also with the highest probability of severe, life-threating complications.
Discussion point: What management is possible and advisable?
Fig. 1 Retrograde
Fig. 1
Fig. 2
Fig. 2 Antegrade
Case provided by Prof. Oliver Hakenberg, Dept. of Urology, University Hospital Rostock, Germany. E-mail: oliver.hakenberg@med.uni-rostock.de
Discussion point: • What treatment is advisable?
Case provided by Dr. Amin Bouker Coral Médical, Tunis, Tunisia E-mail: aminbouker@gmail.com
Fig. 1: Replacement of the subdiaphragmatic IVC and part of the left renal vein for relapsing intracaval thrombus
A surgical approach with assistance of both the liver transplantation and cardiothoracic teams
Case study No. 74 continued
The patient underwent surgery together with the cardiothoracic team. With cardiopulmonary bypass, the intracaval thrombus was removed; however, the intraatrial part of the thrombus was adherent to the wall of the atrium and had to be dissected after opening the atrium. Thus, the resection had to be considered incomplete at least on the microscopic level (R1). Histology again showed renal cell carcinoma, partially necrotic. The patient recovered well from surgery and was discharged after 8 days. Adjuvant immunotherapy was recommended.
Comment by Prof. Kilian Walsh Galway (IE)
of both the liver transplantation and cardiothoracic teams.
you are unable to get a clamp above the level of the thrombus, then the patient can be put on cardiopulmonary bypass so that the cardiothoracic team can open the atrium and milk the thrombus back into the IVC. This gives the liver transplant team more time for resection and anastomosis, and they will not have to work against the clock. I know this is possible as we performed such a case when I was a Consultant Urologist at King's College Hospital in London and the case went well. Sadly, my present institution in University Hospital Galway does not have liver transplantation, so I would have to refer to a suitable centre, but I believe surgery is the best option for this patient.
The liver transplant team usually have donor IVC from a previous retrieval, but if they do not, they can utilise a PTFE graft. After mobilisation of the liver they can resect the IVC and replace it with donor IVC tissue or a PTFE graft. When the IVC is clamped the tongue of tissue in the atrium can fall back into the IVC with a reduction of flow and a vascular clamp can be applied above the level of the thrombus. This will give a 30 to 40 minute window to resect and replace the IVC with graft and if necessary anastomose the left renal vein back into the graft. However, if
The original surgery was performed with the assistance of cardiothoracic surgery and I assume the patient was put on cardiopulmonary bypass for the procedure. As you stated, technically the procedure went well and the patient has recovered from his pulmonary embolism. The present CAT scan shows caval recurrence, the options include a biotherapy regimen with a combination of oncological agents, but I would favour a surgical approach and utilise the assistance
European Urology Today
April/May 2023
9
Powered by FlippingBook