Adrenal tumors of different types with or without tumor thrombus invading the inferior vena cava: An evaluation of 33 cases

Background and objectives: Adrenal tumors with/out tumor thrombus (TT) in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential of massive hemorrhage and tumor thromboembolism. We report our experience in managing different types of adrenal tumors. Methods: From 11/1996-5/2015, 33 patients underwent resection of adrenal tumors with/without TT/IVC in 8 and 25 patients, respectively. Transplant-based (TB) techniques were utilized to resect the tumors. Intraoperative as estimated blood loss (EBL) and cardiopulmonary bypass (CPB) use; post-operative as length of hospital stay (LOS); and actuarial survival outcomes were recorded. Results: Median EBL was 200 cc (10-8,000), tumor size was 9.0 cm (4-25), and LOS was 7days (5-60). Adrenocortical carcinoma (ACC,11/33) was the commonest type. Three ACC/level IV TT/IVC underwent CPB to extract TT from the right atrium(n = 1), right atrium and right ventricle(n = 1), and right atrium and right pulmonary artery(n = 1), respectively. A complete resection of the adrenal tumors was achieved in all patients, and no deaths were observed in the immediate postoperative period. With a median follow-up of 60 (range: 18-120) months, 4/11 ACC patients have died of their disease. Actuarial survival for ACC patients at 60 months was 57.1 +/- 16.4%. Conclusions: An aggressive surgical approach is the only hope for curing large adrenal tumors with/without TT/ IVC. TB techniques provide excellent exposure to the retroperitoneal space and safe removal of large adrenal masses.