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Tumor Thrombus & Budd Chiari Syndrome in Kidney Cancer

Author Ishaan Sangwan covers Tumor Thrombus & Budd Chiari Syndrome in Kidney Cancer on BackTable Urology

Ishaan Sangwan • Aug 2, 2021 • 34 hits

Kidney cancers are known to invade blood vessels, specifically the vena cava, which can cause tumor thrombus formation. This is an important consideration during kidney cancer surgery because disturbing the tumor thrombus may lead to pulmonary emboli and, in extreme cases, may require resection of the vena cava. Thrombi can also lead to Budd-Chiari syndrome, which has a high mortality if operated on, and is a major contraindication to kidney cancer surgery if it has progressed.

Dr. Margulis shares his approach to these complex procedures. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable Urology Brief

• Anticoagulation may be indicated in cases of bland thrombus and pulmonary emboli, but the benefit must be balanced with the risk of a massive bleed.

• During surgery, the primary tumor and its arterial supply are managed first with the goal of shrinking the tumor thrombus, making the thrombectomy easier.

• Before operating, it is essential to work up the patient for Budd-Chiari syndrome, since surgery has a near 100% mortality in these cases. However, surgery may be possible in early manifestations of the condition.

• A reliable, multi-specialty team is essential for achieving good outcomes in tumor thrombus cases.

Renal cell carcinoma with tumor thrombus in the interior vena cava

Table of Contents

(1) Management of Bland Thrombi & Pulmonary Emboli in Kidney Cancer

(2) Tumor Resection & Thrombectomy in Kidney Cancer

(3) Management of Budd-Chiari Syndrome in Locally Advanced Kidney Cancer

Management of Bland Thrombi & Pulmonary Emboli in Kidney Cancer

Kidney cancer leads to tumor thrombus formation if it invades the vasculature, and can lead to bland thrombus and pulmonary emboli. Bland thrombi that form below the tumor thrombus can lead to lower extremity swelling and can also result in pulmonary emboli. While anticoagulation may be indicated here, it is important to balance that with the risk of a massive bleed. Dr. Margulis also warns against the practice of putting in a vena cava filter to prevent pulmonary emboli in these patients, since it complicates further surgical intervention.

[Dr. Aditya Bagrodia]
Got it. You'd mentioned a little bit of leg swelling and so forth. And sometimes with tumor thrombus cases, we see two clinical scenarios, one is bland thrombus, and one can be pulmonary emboli. Can you talk about how that impacts your perioperative management and approach to those patients?

[Dr. Vitaly Margulis]
Yeah. These now we're started getting to some of the more challenging scenarios and what you're alluding to are our patients with cava tumor thrombus and sequelae, which can be bland obstruction or bland thrombus that form below the tumor thrombus resulting in lower extremity swelling, and also obviously pulmonary emboli. These are tricky situations and what you've... one has to balance anticoagulation, but also you have to carefully balance that with the risk of pretty massive bleeding from the primary.

Generally, patients with evidence of bland thrombus and or pulmonary emboli, I would probably anticoagulate going into surgery and resume that anticoagulation shortly once the patient is deemed safe after the operation.

[...]

[Dr. Vitaly Margulis]
That's a good question. I wanted to add something to our previous discussion with something that I routinely see in the communities, is this going back to the thrombus, and it'll answer your subsequent question, I didn't mean to skip, but just for the audience, it's not uncommon for me to see a patient with thrombus and for example, maybe a pulmonary embolus who's completely stable, but comes in with a filter.

And so there's this knee jerk reaction to place a vena cava filter to suppress further, or prevent further tumor thrombus emboli from the tumor thrombus in the patient. That's actually exactly the wrong thing to do. Not only complicates further surgical intervention, I think it then makes it a lot more dangerous and really has not been really shown to prevent additional pulmonary emboli. So I think we just have to temper our immediate need to put a vena cava with tumor thrombus. It's just one of those things that don't be reminded, but I see that happen very frequently in the community.

Listen to the Full Podcast

Management of Locally Advanced Kidney Cancer with Dr. Vitaly Margulis and Dr. Aditya Bagrodia on the BackTable Urology Podcast)
Ep 10 Management of Locally Advanced Kidney Cancer with Dr. Vitaly Margulis and Dr. Aditya Bagrodia
00:00 / 01:04

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Tumor Resection & Thrombectomy in Kidney Cancer

If a tumor thrombus is present, it can cause pulmonary emboli if disturbed, and hence must be considered while planning kidney cancer surgery. Typically, the primary tumor and its arterial supply are managed first, as this can make the thrombectomy portion easier by shrinking the tumor thrombus. In some cases, if the vena cava has been obstructed for a long time, it may be safer to remove the cava along with the tumor thrombus as long as there is sufficient collateral flow to ensure venous return. It is important to have a reliable team of specialties pertinent to the thrombus in question, including cardiothoracic surgeons if the thrombus is above the diaphragm, and liver transplant surgeons if it is under. A good anesthesiology team with cardiac echo capabilities is also valuable, especially in more complex cases.

[Dr. Vitaly Margulis]
Yeah, so again how big is the primary? So I started thinking, okay. I mean, obviously if we start talking about tumor thrombus, that patient, obviously the level of the thrombus, degree of obstruction, degree of colorization, I almost think about my thrombus patients completely differently when I plan my surgical approach, almost every single one of these cases will be done in an open fashion.

And some of the things to understand is, as we said, what team do I need with me? And so when you, when you do these thrombus cases, I think you need to have a well oiled team. This has to be... you don't want to experiment, you want to have a well assembled partner in crime, whether it be a cardiovascular thoracic surgeon, vascular surgeon, liver transplant surgeon, I actually utilize probably all of them, depending on where the thrombus is for your retro hepatic thrombi, the thrombi did want to extend above the diaphragm. I've recently shifted to partnering with a liver transplant colleague, and these surgeons are very useful to help you mobilize the liver, get all the hepatic branches controlled, get the liver out of the way, control the cava just below the diaphragm. And so the tumor thrombi that radiographically are above the diaphragm, obviously this is where you have to have a good partnership with their cardiovascular and thoracic team which we do here, and those cases probably are best done in collaboration with them in case of bypass or circ arrest will be needed.

So, again, the level of thrombus is critical. Is there a blunt thrombus? Do we need to resect the cava? Is there enough colorization to allow for safe resection of cava up without reconstruction? Those are all the technical things that go through my mind. But these specific to the thrombus cases. Now, when you start looking at other cases-

[...]

[Dr. Aditya Bagrodia]
So you'd mentioned bland thrombus, caval resection, broad strokes, when you start these operations, do you typically work on the vascular structures first? If it's a right sided tumor, early control of the artery, for instance in the intra caval space, gaining access to your contralateral renal vein, your infrahepatic IVC, super thrombus IVC. Can you just talk a little bit about how you think about that and approach that?

[Dr. Vitaly Margulis]
There'll be some differences in technique among different institutions. So what I've done over the years is have good control of the primary without unnecessarily disturbing the thrombus. And the idea here is we don't want the thrombus to embolize. So the primaries control the arterial flow to the primaries control and in some cases, this results in shrinking at the thrombus, perhaps making the thrombectomy portion easier. Once the primary and the arterial inflow is controlled then we go through our routine steps to isolate the tumor thrombus within the venous system.

So it's generally isolating the super thrombus cava, isolating that portal system if necessary, certainly infra thrombus cava. So once you have the cava isolated, then thrombectomy ensues and the rest of the primary is removed once the cava is closed. Some of the nuances you mentioned in some cases the cava has been obstructed for a long time, and it's probably even safer to resect the thrombus with the cava. And if that is your clinical judgment, then it's very important to preserve that colors, collaterals that have formed over the years, the patient has proper venous return.

[Dr. Aditya Bagrodia]
Excellent points. I think it's very obvious to me that each one of these cases is unique. You've really got to study the imaging. You've got to have a plan going into it. And I think you've also got to be ready for some various things that can happen intra-operatively. I recall as a resident doing a case with Vitaly. It was a relatively low level two thrombus, for no reason, with no manipulation of the cava, there was an embolization event, rapidly mobilized, performed thoracotomy embolectomy and the patient had a wonderful post-operative course, but you can imagine that if you don't take these cases seriously, you could have a very different outcome.

I think again, Vitaly's really stressed the need to prepare, to plan, to be ready, intra-operatively. I think you routinely use intraoperative echo in close collaboration with the cardiovascular anesthesiologists, but any other things that you'd like to mention specifically about obviously thrombus cases?

[Dr. Vitaly Margulis]
Again, if I have to mention one thing is to have a well-oiled team put together and it can be your choice, but you want to work with people that you're comfortable working. You want to have a good anesthesia, anesthesiologists that generally understands all of the nuances are there applicable to the cases where it could be high volume blood loss. You want to have an anesthesiology team with cardiac echo capabilities. And as you know, I do. Essentially every one of these cases in a situation where access to a quick pump, if we need to crash on pump during some of the situations you've just described is available.

That would be the most critical aspect you have to have... then you have to think about how am I going to reconstruct my cava. So you have to have access to things like catheters to embolize bland thrombus or de-embolize bland thrombus. If necessary, you have to have access to your Dacron grafts. You have to have access to your patches that they were given needs to be patched. It's a highly nuanced surgery, but the key here is it cannot overstress this, to have a team in place that is familiar with those cases.

Management of Budd-Chiari Syndrome in Locally Advanced Kidney Cancer

Budd-Chiari syndrome can occur in locally advanced kidney cancer if a thrombus blocks the hepatic veins. It can usually be diagnosed prior to surgery, and should be a complete contraindication to surgery as mortality rates are near 100% in these situations. However, surgery may be possible in early manifestations of Budd-Chiari syndrome prior to liver toxicity. While ascites can point towards Budd-Chiari syndrome, it is not a contraindication on its own. If other signs of liver dysfunction, such as a congested or friable liver, are present, it is prudent to close up and manage with systemic therapy and radiation.

[Dr. Aditya Bagrodia]
Budd-Chiari syndrome. If you get in, you've got to evidence of liver chemistry elevation, or you encounter ascites, any unique considerations in that patient population?

[Dr. Vitaly Margulis]
Well, I mean, ideally yes, of course, but ideally this is something that you... it's true Budd-Chiari syndrome should be identifiable prior to surgery. And these are not the patients that should be managed with upfront surgery. So this is one rare indication where I would consider leading in with multi-modality therapies first to allow for recanalization and proper drainage to deliver, because these are not generally survivable surgeries.

So if you have a full blown Budd-Chiari syndrome, I think rushing into the surgery is not the best thing for the patient, it's mortality rates are nearly a 100% in that case, if you have, for whatever reason, encountered some maybe early manifestations of a Budd-Chiari syndrome as maybe some degree of hepatic dysfunction without full blown hepatic toxicity, then it's a clinical decision, I think, whether one should proceed and remnants of it... in some cases very hard to make that decision, just presence of ascites alone doing surgery probably is not contraindication. Then in case we get in, but there are other signs of liver dysfunction, such as terrible appearing, completely congested liver that’s friable, this with immediate bleeding upon everything that you touch with ascites and this may be the case where I would say, "You know what? Maybe we’ll close and manage with systemic and or radiation therapy first and then come back to fight another day. But ascites alone probably wouldn't be the reason to stop. And again, I just want to stress that this is one condition where we really need to diagnose before taking the patient to surgery.

Podcast Contributors

Dr. Vitaly Margulis discusses Management of Locally Advanced Kidney Cancer on the BackTable 10 Podcast

Dr. Vitaly Margulis

Dr. Vitaly Margulis is a Professor of Urologic Oncology at UT Southwestern Medical Center in Dallas, Texas.

Dr. Aditya Bagrodia discusses Management of Locally Advanced Kidney Cancer on the BackTable 10 Podcast

Dr. Aditya Bagrodia

Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.

Cite This Podcast

BackTable, LLC (Producer). (2021, July 1). Ep. 10 – Management of Locally Advanced Kidney Cancer [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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