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Locally advanced RCC, ivc in rcc - Coggle Diagram
Locally advanced RCC
Basics
Includes T3 & T4 with involvement of renal vein, IVC, peripelvic & perirenal fat, Adrenal gland or invasion beyond Gerota's fascia, LN involvement
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CT findings s/o venous involvement: venous enlargement, abrupt change in caliber of vein, filling defects, collateral vessels
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RCC wid venous thrombus at presentation: 10% LN (+), 25% (ass mets), 50% (perirenal fat invasion)
IVC involvement suspected: lower extremity edema, right side non collapsing varicocele, dilated superficial abdominal veins, proteinuria, PE, right atrial mass, non function of involved kidney
VTT
Types of thrombi: 1) Tumor thrombus- tumor cells contained within bland thrombus .. 2) Bland thrombus- blood coagulum w/o tumor cells
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Diagnosis
Both CT & MRI are non-invasive & accurate modalities for demonstrating both the presence & distal extent of IVC involvement
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Mx
Preop
Anticoagulants to be started as soon as its diagnosed: it ↓ r/o PE, tumor thrombus/bland thrombus shrinkage
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Preop Angioembolization: given 1 day prior, shrinks tumor thrombus .. a/w tumor lysis syndrome & pain
Thrombus extending into IVC below hepatic veins can be managed wid isolation of involved vasculature & removal of tumor thrombus
Vascular control for level III & level IV IVC thrombi requires more extensive dissection, venovenous bypass or CPB & hypothermic circulatory arrest
Misc
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Order of clamping & declamping: Infrarenal IVC, C/l renal vein, Suprarenal IVC
To prevent air/tumor thrombi/debri emboli: before tying the knot of IVC repair, 5-10 ml of blood should be released after release of infrarenal clamp
III & IV emboli
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Completely occluded thrombi: pt can tolerate supra-hepatic IVC clamping d/t collaterals .. partially occluded/floating thrombus: can't tolerate clamping
Suprahepatic clamping of IVC: 60% ↓ in cardiac preload, 80% ↑ in PVR, 50% ↑ in HR, 40% ↓ in cardiac output, 10-20% ↓ in MAP
If >50% ↓ in cardiac output or >30% ↓ in MAP: pt can't tolerate suprahepatic IVC clamping- needs bypass
Bypass for
III & IV
Indicated in those who can't tolerate cross clamping trial, pt wid cardiac/hepatic dysfunction, c/l renal dysfunction, portal HTN, intraop bleeding
Techniques: Venovenous bypass or CPB wid deep hypothermia (DHCA- deep hypothermic circulatory arrest)
Venovenous
bypass
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Can't be used: 1) Atrial thrombus that can't be milked completely into IVC, 2) Extensive bland thrombus in iliac veins, 3) Preexisting Budd-chiari syndrome
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Renal sarcoma
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MC histology: Leiomyosarcoma (50-60%)- derived from smooth muscle cells of capsule & perinephric tissue .. ♀ > ♂
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Miscellaneous
Mets: mc malignant neoplasm in kidney (even > than 1°) .. Sources: Lung (mc) > Breast > GI >Malignant melanoma
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