Objective Recurrent endometrial cancer presenting as isolated lymph node metastases is considered suitable for secondary debulking surgery, since a complete cytoreduction can be performed in most cases. However, the resection of enlarged lymph nodes can result in severe intraoperative complications, including the laceration of major retroperitoneal vessels and increased blood loss [1]. Here, we report the details of a surgical technique for the resection of metastatic para-aortic lymph nodes with involvement of the inferior vena cava (NC) requiring circumferential resection of the IVC. Methods The subject was a 43-year-old woman who had been initially treated for endometrial cancer at another hospital. A lymphadenectomy was not performed during the primary surgery. The histopathologic results revealed G2 endometrioid adenocarcinoma. Following the surgery, she was treated with adjuvant chemotherapy, comprised of 6 cycles of paclitaxel and carboplatin. One year after the initial management, paraaortic lymph node recurrence was suspected. She was referred to our hospital at that time. A computed tomography (CT) examination revealed para-aortic adenopathy in the lateroaortic and retrocaval regions. No other lesions were observed. The patient subsequently underwent a secondary debulking surgery for diagnostic and therapeutic purposes. The lymph nodes around the inferior vena cava at the portion of the bifurcation to the iliac veins adhered to the vena cava. During the resection of these lymph nodes, the NC was injured and severe bleeding occurred. To achieve hemostatic control, proximal and distal clamps were applied to the injured portion of the IVC. During clamping of the IVC, changes in the vital signs, including the systolic blood pressure and the urinary volume, were not noted. As the metastatic nodes involved the posterior surface of the IVC wall, an en bloc resection of the lymph nodes with the involved portion of the IVC was performed at a level immediately above the bifurcation to the common iliac veins and up to the right renal vein. Results The metastatic lymph nodes with involvement of the IVC were completely removed without encroaching on the tumor planes or causing tumor rupture. Histopathologically, the lymph nodes were confirmed to be metastatic. As thrombosis in bilateral common iliac veins occurred postoperatively, the patient complained of pain and edema of the bilateral lower extremities. Consequently, she required the administration of a non-steroidal anti-inflammatory drug for 2 weeks and a direct oral anticoagulant (apixaban) for 6 months. The lower extremity edema had mostly resolved at 1 month after the surgery. No other complications occurred. She subsequently received chemotherapy 4 weeks after surgery. Three month after the surgery, an enhanced CT examination showed that the blood flow in the collateral circulation was providing sufficient venous drainage. The inferior mesenteric vein was one of the collateral branch. Conclusions Previously, we reported a case that underwent a para-aortic lymphadenectomy combined with a wedge resection and primary repair of the IVC [2]. In that case, no intraoperative or postoperative complications, including vascular complications, occurred. Thus, blood flow in the IVC should be maintained whenever possible. According to our criteria, if 40% or more of the circumference of the IVC wall is involved, IVC reconstruction using synthetic or autogenous grafts may be necessary. In the present case, we confirmed the stable vital signs including the systolic blood pressure during IVC clamping below the renal vein, and evaluated the presence of collateral vein network. In addition, the cut end located just above the bifurcation to the common iliac veins became tattered and was not suitable for anastomosis with a graft. Because of the stable vital signs during IVC clamping and the intraoperative appearance of the cut end of the IVC, we decided not to reconstruct the IVC. A para-aortic lymphadenectomy combined with circumferential resection of the IVC below the renal vein seems to be a feasible surgical option in selected patients.
