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Radical resection of a late-relapsed testicular germ cell tumour: hepatectomy, cavotomy, and thrombectomy.

Ní Leidhin C, Redmond CE, Cahalane AM, Heneghan HM, Motyer R, Ryan ER, Hoti E - Case Rep Surg (2014)

Bottom Line: We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein.Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus.This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.

View Article: PubMed Central - PubMed

Affiliation: Departments of Hepatobiliary Surgery and Radiology, The National Liver Transplant Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

ABSTRACT
Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.

No MeSH data available.


Related in: MedlinePlus

Schematic illustration demonstrating (a) IVC exposure and the extent of the tumour thrombus prior to resection. (b) Retrohepatic VC exposure via a right hepatectomy. (c) Infrarenal VC occlusion, enabling cavotomy and thrombus extraction. (d) Suprarenal VC occlusion, enabling cavotomy and thrombus extraction.
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fig3: Schematic illustration demonstrating (a) IVC exposure and the extent of the tumour thrombus prior to resection. (b) Retrohepatic VC exposure via a right hepatectomy. (c) Infrarenal VC occlusion, enabling cavotomy and thrombus extraction. (d) Suprarenal VC occlusion, enabling cavotomy and thrombus extraction.

Mentions: At laparotomy, the entire length of the IVC was exposed (Figure 3(a)). First, exposure of the retrohepatic vena cava was achieved via a right hepatectomy (Figure 3(b)). This was necessary for complete excision of the RHV tumour thrombus. The liver hanging manoeuvre [10] was used in order to minimise manipulation of the IVC/RHV and to prevent tumour fragmentation and/or embolisation. The ascending colon and duodenum were mobilised to expose the infrahepatic VC. The degree of extension of the tumour thrombus necessitated that the suprahepatic VC be controlled at the level of the RA. Complete dissection of the diaphragm around the VC was required. The renal veins and arteries were then controlled, followed by the VC above the iliac bifurcation. Control of and access to the inferior mesenteric vein (IMV) was obtained for venovenous bypass (VVBP). Thrombectomy was commenced at the infrarenal portion of the VC. Occlusion of the infrarenal VC was achieved and cavotomy and thrombus extraction was performed (Figure 3(c)). The infrarenal clamp was then briefly repositioned above the renal veins and the tumour thrombus was extracted from the renal veins (Figure 3(d)). Occlusion of the renal arteries was not required. The clamp was then repositioned below the renal veins and the cavotomy was closed. Total vascular exclusion (TVE) of the liver remnant was used to enable cavotomy and thrombectomy of the retrohepatic and suprahepatic VC with maximal haemorrhage control. Portal flow was diverted via a cannula placed in the IMV. Systemic blood flow was diverted through a cannula placed in the right femoral vein via Seldinger technique. Blood returned to the systemic circulation via a cannula sited in the left internal jugular vein. In addition to ensuring adequate cardiac return, VVBP prevented congestion of the portal system and avoided clamping of the renal vessels, thereby minimising the potential for ischaemia. Once the thrombus was extracted completely, the VC was closed. Finally, dissection of enlarged paracaval and aortocaval lymph nodes was performed.


Radical resection of a late-relapsed testicular germ cell tumour: hepatectomy, cavotomy, and thrombectomy.

Ní Leidhin C, Redmond CE, Cahalane AM, Heneghan HM, Motyer R, Ryan ER, Hoti E - Case Rep Surg (2014)

Schematic illustration demonstrating (a) IVC exposure and the extent of the tumour thrombus prior to resection. (b) Retrohepatic VC exposure via a right hepatectomy. (c) Infrarenal VC occlusion, enabling cavotomy and thrombus extraction. (d) Suprarenal VC occlusion, enabling cavotomy and thrombus extraction.
© Copyright Policy - open-access
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4281470&req=5

fig3: Schematic illustration demonstrating (a) IVC exposure and the extent of the tumour thrombus prior to resection. (b) Retrohepatic VC exposure via a right hepatectomy. (c) Infrarenal VC occlusion, enabling cavotomy and thrombus extraction. (d) Suprarenal VC occlusion, enabling cavotomy and thrombus extraction.
Mentions: At laparotomy, the entire length of the IVC was exposed (Figure 3(a)). First, exposure of the retrohepatic vena cava was achieved via a right hepatectomy (Figure 3(b)). This was necessary for complete excision of the RHV tumour thrombus. The liver hanging manoeuvre [10] was used in order to minimise manipulation of the IVC/RHV and to prevent tumour fragmentation and/or embolisation. The ascending colon and duodenum were mobilised to expose the infrahepatic VC. The degree of extension of the tumour thrombus necessitated that the suprahepatic VC be controlled at the level of the RA. Complete dissection of the diaphragm around the VC was required. The renal veins and arteries were then controlled, followed by the VC above the iliac bifurcation. Control of and access to the inferior mesenteric vein (IMV) was obtained for venovenous bypass (VVBP). Thrombectomy was commenced at the infrarenal portion of the VC. Occlusion of the infrarenal VC was achieved and cavotomy and thrombus extraction was performed (Figure 3(c)). The infrarenal clamp was then briefly repositioned above the renal veins and the tumour thrombus was extracted from the renal veins (Figure 3(d)). Occlusion of the renal arteries was not required. The clamp was then repositioned below the renal veins and the cavotomy was closed. Total vascular exclusion (TVE) of the liver remnant was used to enable cavotomy and thrombectomy of the retrohepatic and suprahepatic VC with maximal haemorrhage control. Portal flow was diverted via a cannula placed in the IMV. Systemic blood flow was diverted through a cannula placed in the right femoral vein via Seldinger technique. Blood returned to the systemic circulation via a cannula sited in the left internal jugular vein. In addition to ensuring adequate cardiac return, VVBP prevented congestion of the portal system and avoided clamping of the renal vessels, thereby minimising the potential for ischaemia. Once the thrombus was extracted completely, the VC was closed. Finally, dissection of enlarged paracaval and aortocaval lymph nodes was performed.

Bottom Line: We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein.Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus.This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.

View Article: PubMed Central - PubMed

Affiliation: Departments of Hepatobiliary Surgery and Radiology, The National Liver Transplant Unit, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.

ABSTRACT
Up to 3.2% of patients with testicular germ cell tumours represent with late-relapsing disease. Aggressive surgical resection confers the greatest chance of cure in this patient group. We present the case of a late and extensively relapsed nonseminomatous germ cell tumour with thrombus present along the entire length of the inferior vena cava, as well as in the right hepatic vein. Techniques practised in liver transplantation were used to achieve complete resection of the tumour thrombus. This case illustrates the enhanced potential for tumour resection through a fusion of principles derived from surgical oncology and liver transplantation.

No MeSH data available.


Related in: MedlinePlus