Intra‐atrial extension of renal and adrenal tumors: Diagnosis, management, and prognosis

Intra‐atrial tumor thrombus arising from a renal or adrenal tumor is a serious development. Preoperative recognition by computed tomographic scanning and cavography is important, and these investigations should be considered even in patients without symptoms of venous obstruction, especially if the tumor is right‐sided and greater than 7 cm in diameter. We report here our experience with the management of 3 patients with intra‐atrial tumor thrombus (2 adrenal, 1 renal). A combined midline and median sternotomy approach is preferred and cardiopulmonary bypass is essential. Moderate hypothermia and liver inflow occlusion may also be necessary. This technique provides effective vascular control for resection of the tumor and its intravascular extension, and is simpler than profound hypothermia, total body exsanguination, and complete circulatory arrest. Perioperative endoscopic examination of the interior of the inferior vena cava and hepatic veins, under bloodless conditions, helps to ensure that there has been complete removal of the thrombus. A review of 28 reported patients who have had removal of intra‐atrial thrombus suggests that long‐term survival is rare, but the possibility of symptom relief makes this procedure worthwhile.