Renal cell carcinoma invading the hepatic veins

BACKGROUND. Hepatic vein invasion by renal cell carcinoma with inferior vena cava tumor thrombus is relatively uncommon. The Budd-Chiari syndrome that results from obstruction of the suprahepatic venous drainage by the tumor could evolve toward liver fibrosis and death. Early diagnosis and surgical treatment of this condition is of prime importance. Complete mobilization of the liver and rotation of the inferior vena cava enhances exposure of the ostium of the hepatic veins. This maneuver allows for the complete removal of tumor from the hepatic veins and decompression of the liver. METHODS. Between May 1997 and April 2000, four patients with renal cell carcinoma and inferior vena cava thrombus with hepatic vein invasion underwent surgery at the study institution.. Three of the patients had Budd-Chiari syndrome. Surgical techniques were developed to handle these difficult tumors safely. RESULTS. Three patients presented with the Budd-Chiari syndrome, one of whom was found to have severe liver failure before surgery. The fourth patient presented with a hepatic vein tumor thrombus. A caval atrial thrombus and hepatic vein thrombus in one patient were removed successfully without opening the chest. Three patients required cardiopulmonary bypass. Hypothermic arrest was required in one patient. At the time of last follow-up, 2 patients were alive at 14 months and 30 months after surgery, respectively, without recurrence. One patient died 6 months after surgery due to metastatic renal carcinoma and 1 patient who had prior severe liver failure died of multiple organ failure 2 weeks after undergoing surgery. None of the four patients required reoperation. CONCLUSIONS. Prompt surgical treatment should be performed to avoid hepatic failure and disease progression. The surgical technique described in the current study allowed for removal of the tumor from the hepatic veins and the authors believe it can be used with cardiopulmonary bypass to enhance visibility of the hepatic veins. (C) 2001 American Cancer Society.