Surgical management of abdominal tumor thrombus in children: Rethinking staging and strategy

Inferior vena cava (IVC) tumor thrombus in pediatric abdominal malignancies presents substantial surgical challenges. We evaluated operative strategies, outcomes, and the adequacy of current thrombus classification systems in guiding surgical planning.

Children undergoing surgery for abdominal solid tumors with IVC thrombus over a 10-year period were retrospectively reviewed. Thrombus extent was assessed radiologically and intraoperatively, and surgical techniques and outcomes were analyzed.

Eleven patients (median age 85 months) were included: eight with Wilms tumor, two with adrenocortical carcinoma, and one with neuroblastoma. Origin of thrombus was renal vein in 9 and adrenal vein in 2. Caudal propagation to the iliac bifurcation occurred in one patient, and contralateral renal vein involvement in two. Complete tumor and thrombus resection was achieved in all cases. En bloc resection was feasible in eight patients, whereas three required sequential thrombectomy and tumor excision to reduce hemorrhagic risk. Cavotomy with primary repair of IVC was performed in nine patients. One patient required patch repair of IVC. Another patient had segmental cavectomy. Cardiopulmonary bypass was necessary in two patients due to extensive or adherent thrombus. No major intraoperative complications or early mortality occurred. Median hospital stay was seven days, and nine patients remain in complete remission.

Complete resection of IVC tumor thrombus in children is feasible with favorable outcomes. Current staging systems have limitations in reflecting surgical complexity. Other parameters like caudal extension, venous wall invasion, and degree of luminal involvement should be incorporated to better guide operative planning.