Ali TEKİN, İsmail YAĞMUR, Orkan ERGÜN, Mehmet Fatih AYIK, Yüksel ATAY, İbrahim ULMAN, Ali AVANOĞLU

Excision of the atrial Wilms’ tumor thrombus without sternotomy, atriotomy and cardiovascular By-pass

The treatment of atrial-extention Wilms’ tumor thrombus is surgical excisionafter chemotherapy. Atriotomy with cardiovascular by-pass is the one of themost common method for this procedure. Herein, we aimed to present a caseof Wilms’ tumor with a tumor thrombus extending into the right atrium totallyexcised with retrohepatic cavatomy.A 3.5 year-old girl was admitted with the symptom of dysuria. Theexaminations revealed a mass consistent with Wilms’ tumor in the middleand lower poles of the left kidney. Doppler ultrasound and Echocardiographicexaminations showed a tumor thrombus extending into the right atrium andsome pulmonary nodules which were interpreted to be metastasis. Wilms’tumor was histopathologically diagnosed by an open biopsy. After threecourses of chemotherapy imaging studies revealed that the atrial axtentionof the tumor thrombus persisted. The tumor thrombus was found to befibrotic on the magnetic resonance imaging scan of the patient. Therefore,nephroureterectomy along with the excision of the tumor thrombus from theinferior vena cava was done with intraoperative continuous trans-esophagealechocardiography (TEE). The suprarenal and retrohepatic vena cava wereexposed by dissecting and ligating all short hepatic veins and completelymobilizing the right lobe of the liver. The thrombus was dissected out viaVertical cavatomy at the retrohepatic level. TEE confirmed complete removalof the thrombus from the atrium; Vena cava was then repaired. There wasno need for a blood transfusion, or cardiovascular by-pass (CPB) during theoperation.Total exposure of the retrohepatic and subdiaphragmatic vena cava usingtransplantation techniques is an effective method for the excision of a tumorthrombus without sternotomy, atriotomy and CPB, avoiding possible intra- andpostoperative complications in selected cases of Wilms’ tumor with intraatrialthrombus extension. The case emphasises the importance of multidisciplinarycommunication and collaboration.

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