Right Atrium Tumor Extension Through the Inferior Vena Cava. Considerations About Nine Cases Operated Under Cardiopulmonary Bypass

Abstract

[...]this unusual pathological situation has to be in mind of the “heart team”. Due mainly to the rarity of this complication, few studies have been performed with larger case numbers, providing reliable conclusions3. [...]the objective of this presentation was based on the relative scarcity of reported cases, presenting nine cases of RA invasion through the inferior vena cava (four adrenocortical and five renal tumors) performed over 13 years. According to Spanish data, collected between early 1975 and April 1997, among 212 patients who underwent surgery for RCC, only 2 cases showed right atrial extension5.

INTRODUCTION

Adrenocortical carcinoma (ACC) and renal cell carcinoma (RCC) are aware malignancies that occasionally present extending into the right atrium (RA) through the inferior vena cava. Patients can present with a variety of signs and symptoms, depending on the extent of the tumor. These neoplasms demand surgical treatment, are very aggressive and have poor prognosis and surgical outcomes. Therefore, this unusual pathological situation has to be in mind of the “heart team”. The discovery of a mass in the right atrium obliges the clinician to perform a broad differential diagnosis between a primary cardiac tumor (myxoma being the most frequent), invasion of an extracardiac tumor, vegetations on the tricuspid valve and atrial thrombus. Tumor extension with vena cava thrombosis is a relatively frequent complication of renal carcinoma, but only exceptionally reaches the right atrium. It is also exceptional that this was a chance finding in an asymptomatic patient¹.

As an overview, Castro-Dominguez et al.² stated that ACC is a highly aggressive malignant neoplasm with an incidence rate of 1 to 2 cases per million people per year. Overall 5-year survival is poor, ranging from 15 to 44% in reported series. Multimodality imaging with echocardiogram, computed tomography (CT), positron emission tomography (PET) and magnetic resonance imaging (MRI) aids not only in establishing the diagnosis but also in anatomic evaluation to determine the best surgical approach².

According to Locali et al., based on a series of 14 cases, these tumors are routine in urological surgery. But they are important in the context of cardiovascular surgery due to possible complications with intracaval and/or intracardiac thrombi. Studies in this area, however, are mostly case reports or case series with small sample numbers. Due mainly to the rarity of this complication, few studies have been performed with larger case numbers, providing reliable conclusions³.

Therefore, the objective of this presentation was based on the relative scarcity of reported cases, presenting nine cases of RA invasion through the inferior vena cava (four adrenocortical and five renal tumors) performed over 13 years.

Cases Series

Over 13 years (2002-2014), nine patients were operated in collaboration with the team of urologists. The patients were allocated into 2 groups presented in Table 1.

[ Table Omitted - see PDF ]

DISCUSSION

As already mentioned, adrenocortical carcinomas and renal cell carcinomas (RCC) are rare malignancies. According to Spanish data, collected between early 1975 and April 1997, among 212 patients who underwent surgery for RCC, only 2 cases showed right atrial extension⁵. Among the metastatic tumors of the heart, those arising from the genitourinary system are amongst the most common⁶. Most of the case reports references were presented in Table 2.

[ Table Omitted - see PDF ]

CONCLUSION

The present data retrospectively collected from public hospital patients reaffirm: 1) Low incidence with small published series; 2) The selected cases did not represent the whole historical casuistry of the hospital, since they are selected after the adoption of electronic documentation; 3) Demographic data and references reported in the literature were presented as tables to avoid wordiness; 4) The series highlights the propensity to invade the venous system; 5) Possible surgical treatment with the aid of CPB in collaboration with the urology team; 6) CPB with DHCA is a safe and reliable option; 7) Poor prognosis with disappointing late results, even considering that adverse effects of CPB on cancer prognosis are expected but have not been confirmed.

Author's roles & responsibilities
FC	Acquisition, analysis, or interpretation of data for the work; final approval of the version to be published
STJ	Acquisition, analysis, or interpretation of data for the work; final approval of the version to be published
SB	Acquisition, analysis, or interpretation of data for the work; final approval of the version to be published
RBR	Acquisition, analysis, or interpretation of data for the work; final approval of the version to be published
AJR	Substantial contributions to the conception or design of the work; final approval of the version to be published
WVAV	Substantial contributions to the conception or design of the work; final approval of the version to be published
PRBE	Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; drafting the work or revising it critically for important intellectual contente; final approval of the version to be published

This study was carried out at Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

Financial support: FAEPA, FAPESP, CNPq

References

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