Search

Objective: Primary angiosarcomas originating from the heart, aorta, or great vessels are extremely rare and hence poorly understood. We reviewed our experience to identify a preferred diagnostic and treatment strategy and evaluate the role of adjunctive therapy., Methods: We reviewed the clinical data of all patients diagnosed with primary angiosarcoma of the heart, aorta, and great vessels from 1985 to 2011, including presentation, diagnosis, management, and outcomes., Results: Thirteen patients (five males and eight females; mean age, 54 ± 4 years) had primary angiosarcoma arising from the aorta (n = 7), heart (n = 3), pericardium (n = 2), and pulmonary artery (n = 1). Patients with aortic tumors most commonly presented with lower extremity claudication (n = 2), renovascular hypertension (n = 3), abdominal pain (n = 5), and weight loss (n = 4). Patients with cardiac and pericardial tumors presented with dyspnea (n = 5) due to pleural effusion or cardiac tamponade. All 13 patients underwent computed tomographic scan, which demonstrated irregular, lobulated mass/thrombus with peripheral enhancement, and eight patients underwent diagnostic echocardiography. Metastatic disease was present in 10 patients. The most common site was the lungs (n = 6). All except one patient exhibited high-grade morphology histopathologically. Nine patients were treated surgically: resection with aortic reconstruction (n = 5), thromboendarterectomy (n = 2), pericardiectomy/atrial septal resection with patch reconstruction (n = 2), and just biopsy (n = 1). Adjunctive treatment included chemotherapy (n = 6) and radiation (n = 4). Median survival was 8 months (range, 1-75 months). Patients treated with all three treatment modalities had longer survival than did patients treated with a single modality (P = .013). Patients treated with chemotherapy had a more favorable survival than did those without chemotherapy (P = .048)., Conclusions: Primary angiosarcoma of the heart and great vessels is rare but is a harbinger of poor prognosis. Pathologic examination is necessary to confirm the diagnosis. Combined therapy with surgical resection and chemoradiotherapy offers patients the best survival., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) is rare. Surgical resection provides the only reasonable chance for cure, but the approach poses a challenge to the surgical team. We describe our technique to safely resect these tumors through a transabdominal incision that exposes the intrapericardial IVC and right atrium (RA) transdiaphragmatically, without the use of sternotomy, cardiopulmonary bypass (CBP), or deep hypothermic circulatory arrest (DHCA). Clinical outcomes of these patients and techniques are reported., Methods: Between May 1997 and January 2009, 102 patients (mean age, 63 years) underwent resection of renal tumor extending into the IVC by techniques developed to avoid sternotomy and CBP. The tumor thrombus in 12 patients (13%) extended into the supradiaphragmatic IVC and RA., Results: Complete resection was successful through the transabdominal approach without CBP in all patients. Mean operative time was 8 hours 15 minutes. Estimated blood loss was 2960 mL, and a mean of 9 U of blood was transfused. Two patients died postoperatively, 1 on day 4 of arrhythmia and 1 on day 22 of multisystem organ failure. All discharged patients were alive at the last follow-up. Three patients had tumor recurrence and have been referred for adjuvant therapy., Conclusions: In select cases, renal cell carcinoma extending into the IVC to the intrapericardial level and RA can be resected without sternotomy, CBP, or DHCA., (2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Advanced hepatocelluar carcinoma (HCC) with invasion of venous systems usually indicates not only a poor prognosis but also a contraindication for transcatheter arterial chemoembolization (TACE). This study evaluated the feasibility of TACE for advanced HCC with inferior vena cava (IVC) and right atrium (RA) tumors and, also, to search for the ideal embolization particle size. Twenty-six patients who had HCC invasion into the IVC included five patients with coexistent RA tumors that were treated with TACE. The chemoembolization method was cisplatin, doxorubicin, and mitomycin C mixed with Lipiodol and Ivalon. The selection of Ivalon particles was divided into two groups based on their size: (A) >180 microm, N = 9; and (B) 47-180 microm, N = 17. The overall response rate was 53.8% (14/26). Based on the response to TACE, the median survival period of the entire group was 4.2 months (range, 1.5 to 76.7 months). The median survival period of the 14 responders was 13.5 months (1.5-76.7 months), and that of the 12 nonresponders, 3.3 months (2.1 to 24.3 months) (p < 0.002). Comparing the two Ivalon particle sizes, the response rate was 12.5% (1/8 [corrected] patients) for group A and 72.2% [corrected] for group B (13/18 [corrected] patients) (p < 0.01). [corrected] No serious complication was observed post-chemoembolization. In conclusion, TACE is a safe and effective treatment for advanced HCC with IVC and RA tumors, and small Ivalon particles (47-180 microm) are superior to large ones (>180 microm).

Purpose: Surgery is the most effective treatment for renal cell carcinoma with tumor thrombus but predictors of outcome and patient survival are variable. Co-morbidity may affect therapeutic decision making and survival, although to our knowledge this factor has not been studied in patients with tumor thrombus. We analyzed the Charlson co-morbidity index as a predictor of outcome after surgery., Material and Methods: From 1970 to 1998, 303 patients underwent surgical resection. The Charlson index, surgical era, completeness of resection, patient age, sex, tumor level, TNM stage, grade and perinephric fat invasion were studied retrospectively as univariate and multivariate predictors of outcome., Results: The level of tumor thrombus was 0 (renal vein only) in 127 patients, and I to IV in 66, 58, 36 and 16, respectively. At 5 years overall, cause specific and metastasis-free survival were 32%, 42% and 41%, while at 10 years they were 21%, 32% and 30%, respectively. For the whole cohort significant multivariate predictors of cause specific survival were metastasis (p = 0.0001), grade (p = 0.0001), perinephric fat involvement (p = 0.02) and tumor levels 0 versus I to IV (p = 0.048). The Charlson index did not predict outcome (univariate model p = 0.65)., Conclusions: Characteristics of the primary tumor remained the most important predictors of cause specific survival in this cohort. The Charlson index did not predict cause specific survival in this cohort of surgically treated patients. Prospective assessment of co-morbidity in patients treated with surgery versus conservative therapy is warranted.

Background: While the veins are primarily affected by compressing or invasive tumors, the arteries usually undergo only a less pronounced stenosis, due to the higher internal pressure. However, some tumors infiltrate the arterial adventitia which should be resected or might be injured in cases where radical surgery is attempted., Patients and Methods: We report some technical principles utilized in various vascular localizations and mid-term survival observed in a group of 35 patients in whom a vascular reconstruction was performed during the surgical treatment of a malignant tumor. The following vessels were involved: carotid artery (n = 5), superior vena cava (n = 9), aortic arch (n = 1), subclavian artery (n = 1), right atrium +/- inferior vena cava (n = 6), abdominal aorta (n = 3) and finally iliac artery and/or vein (n = 10). The following surgical techniques were employed: extra-anatomic bypass (n = 3), in situ reconstruction (n = 23) using either prosthetic graft or saphenous vein interposition, patch angioplasty with autologous vein or xenopericardium and ligature of the involved artery or vein (n = 4). In 5 patients suffering from hypernephroma with a tumor thrombus, cardiopulmonary bypass was used to allow radical intracardiac excision., Results: There was no intraoperative mortality despite the fact that a majority of these vascular procedures was performed after incidental and unexpected finding during surgery. Two patients died before hospital discharge (one from pneumonia, the second one from sepsis). Mid-term survival was satisfactory with 45% of the patients still alive after a mean follow-up of 4.5 years--all tumor types confounded., Conclusions: This series demonstrates that an aggressive approach might be justified in appropriate patients who otherwise might not be considered as operative candidates.

Background: Radical resection using deep hypothermic circulatory arrest improves the survival of patients with transvenous intracardiac tumor extension of renal cell carcinomas. A less invasive surgical approach avoiding deep hypothermia, circulatory arrest, and cross-clamping of the aorta is presented., Methods: Between 1987 and 1999, 12 patients (mean age 57+/-8 years) underwent resection of a renal cell carcinoma extending into the right atrium, right ventricle, or pulmonary arteries. After median sterno-laparotomy, normothermic cardiopulmonary bypass is used cannulating the ascending aorta, superior caval vein, and inferior caval vein below the renal veins. The tumor and the corresponding kidney are radically excised, including the renal vein. Tumor fragments from the inferior caval vein, the right heart, and pulmonary arteries are removed either on the fibrillating or beating heart., Results: Operative mortality was 0%. Mean cardiopulmonary bypass time was 53+/-27 minutes (median 36; range 32-110 minutes). Mean blood loss per patient was 1200 mL. Mean duration of postoperative mechanical ventilation was 36+/-12 hours (median 36; range 30-77 hours), mean intensive care stay 5.5+/-5 days (median 3; range 1-48 days), and mean duration of hospitalization 22+/-12 days (median 21; range 10-58 days). All patients were discharged home. Patients with multiple tumor manifestations outside the cardiovascular systems died within 9 months after the operation., Conclusions: The use of normothermic cardiopulmonary bypass is a less invasive method for radical resection of renal cell carcinoma with intracardiac tumor extension. Radical resection does not improve survival in patients with multiple distant metastases.

From 1990 to 1995, 12 patients with cavo-atrial renal cell carcinoma underwent resection of the tumor. Circulatory arrest was employed in 11/12 cases. The neoplasm extended to the inferior vena cava in two patients and to the intrahepatic veins or right atrium in five cases. Two severely cardiac compromised patients died perioperatively. Of five patients who showed preoperative suspicion of isolated metastases, 3 patients died postoperatively because of relapsing disease after a mean period of 10.8 months. Five patients are alive and doing well after a mean follow-up of 14.8 months. In our experience myocardial dysfunction determined poor immediate survival. Mid-term survival was influenced by preoperative metastases and lymph-node involvement, but not by intracaval extension. Circulatory arrest appears to be a relatively safe technique to remove renal carcinoma with cavo-atrial extension and should be indicated whenever there are no metastases.

Objective: We analyzed the results of surgical treatment in patients with non-small cell lung cancer invading the great vessels (GV) and left atrium (LA) by direct extension and without distant metastases., Methods: From 1976 to 1993, 42 patients (37/male, 5/female) with lung cancer invading the GV and LA were treated surgically, 13 had invasion of the superior vena cava and innominate vein, 15 of the aorta and subclavian artery, and 14 of the left atrium. In all 42 the diagnosis was confirmed by pathological examination. Surgical resection included pneumonectomy (16 patients) and lobectomy (26 patients). The histologic type was squamous cell carcinoma in 27 patients, adenocarcinoma in 12, and large cell carcinoma in 3. Preoperatively, 13 patients were treated with radiation and chemotherapy. Postoperatively, further treatment was given to 22 patients. All were staged according to the international TNM staging system. Survival was calculated by the Kaplan-Meler method., Results: A total of 15 patients underwent complete resection. Reliability of clinical N factor was 80%. The overall survival was 17% at 3 years (median survival time (MST), 14 months). The operative mortality was 2.4%. Patients with lung cancer invading GV (MST, 19 months) had significantly longer survival than did those with cancer invading LA (MST, 10 months, P = 0.036). There were significant prognostic differences between N0-1 and N2-3 (MST, 22 months; MST, 9 months, respectively, P = 0.0013). Cox regression analysis identified pathological N factor, completeness of resection, and pre- and postoperative radiotherapy as important in affecting survival., Conclusions: We conclude that patients with pathological N0-1 non-small cell lung cancer invading great vessels can achieve long-term survival with adequate surgical treatment.