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Journal of Pediatric Surgery
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Journal of Pediatric Surgery
Long-term physiologic and oncologic outcomes of inferior vena cava thrombosis in pediatric malignant abdominal tumors
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Amos Loh a,b, Michael Bishop , Matthew Krasin ª, Andrew M. Davidoff a,e, Max R. Langham Jr. a, e,f,*
a Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN 38105, United States
b Department of Paediatric Surgery, KK Women’s and Children’s Hospital, Singapore
” Department of Oncology, St. Jude Children’s Research Hospital, Memphis, TN 38105, United States
d Department of Radiological Sciences, St. Jude Children’s Research Hospital, Memphis, TN 38105, United States
e Department of Surgery, The University of Tennessee Health Science Center, Memphis, TN 38103, United States
f Division of Pediatric Surgery, Le Bonheur Children’s Hospital, Memphis, TN 38103, United States
ARTICLE INFO
Article history: Received 21 April 2014
Received in revised form 24 November 2014 Accepted 24 November 2014
Key words: Inferior vena cava Venous thrombosis Venous thrombectomy Pediatric solid tumor Tumor thrombus
ABSTRACT
Background: The long-term physiologic and oncologic outcomes of treatment for inferior vena cava (IVC) throm- bosis in children with malignant abdominal tumors are unclear.
Methods: We conducted a retrospective review of children with malignant IVC tumor thrombosis treated at our institution between January 1996 and December 2011. Extent of tumor thrombus was classified using the Hinman system. Disease stage, management, and oncologic and physiologic outcomes and complications were evaluated.
Results: We identified 15 patients (median age, 4.7 years): 12 with Wilms tumor, 2 with hepatoblastoma, and 1 with adrenocortical carcinoma. Neoadjuvant chemotherapy changed Hinman levels in 2 (13%) patients. IVC thrombus resection was complete in 6 (40%) patients, partial in 7 (47%) patients, and not performed in 1 (6.7%) patient. On follow-up imaging, 8 (53%) patients’ IVCs were patent, 6 (40%) had residual thrombus, and 1 (6.7%) was surgically interrupted. Three (20%) patients had perioperative complications, and 2 (13%) experi- enced transient effects related to IVC occlusion.
Conclusions: Surgical management of tumor thrombus in the vena cava of children with solid abdominal tumors is challenging. Evidence on which to base strong treatment recommendations is lacking. Few long-term physio- logic complications were observed.
@ 2015 Elsevier Inc. All rights reserved.
The presence of tumor thrombus in the inferior vena cava (IVC) may complicate treatment planning of children with a variety of malignant abdominal tumors. Wilms tumor, rhabdoid tumor of the kidney, hepatoblastoma, hepatocellular carcinoma and adrenocortical carcino- ma are the solid abdominal malignancies most often associated with IVC thrombosis [1-4]. Complete resection of the IVC thrombus directly affects tumor stage and the subsequent need for adjuvant therapy for these tumors [1-4]. The risks and benefits of surgical clearance of tumor thrombus are less clear.
Adherent inferior vena caval tumor thrombi have been treated with chemotherapy with or without radiation therapy either before or after surgical therapy. Surgical options for removing adherent tumor include stripping of the vessels intima with preservation of the cava, resection of the thrombus with part of the IVC wall, or resecting a portion of the IVC with or without reconstruction. These interventions may be associated
with caval occlusion or narrowing. While some information on physio- logic outcomes of adults treated for malignant IVC thrombosis exists [5-7] few reports address results in children [8].
In this study, we describe our experience with surgical management of malignant IVC thrombi in children with malignant abdominal tumors, and describe their long-term oncologic and physiologic outcomes.
1. Methods
A retrospective chart review was performed of patients who were managed for malignant abdominal tumors with IVC thrombi at St. Jude Children’s Research Hospital between January 1996 and December 2011. The study was approved by the institutional review board. All pe- diatric patients with an IVC thrombus and primary liver, renal, or adre- nocortical tumor were included in the study. Data on the type and stage of tumor, the site and extent of IVC thrombus, chemotherapy (neoadju- vant and adjuvant), radiation therapy (dose and site), and surgical man- agement of the IVC thrombus were reviewed. The extent of the IVC thrombus was classified according to the Hinman system: level I, infrahepatic thrombus; level II, thrombus above the hepatic veins but below the diaphragm; and level III, thrombus at or above the level
* Corresponding author at: UT Le Bonheur Pediatric Specialists, Outpatient Center, 51 N. Dunlap St., Suite 235, Memphis, TN 38105, United States. Tel .: + 1 901 287 5316; fax: + 1 901 287 4434.
E-mail address: mlangham@uthsc.edu (M.R. Langham).
of the diaphragm [9]. Outcome variables assessed included patient and disease free survival, and any identifiable problem related to IVC obstruction.
All patients at St. Jude undergo active follow-up until death, or a dis- ease free interval of 5 years. Patients free of disease for 5 years are en- rolled in the St. Jude LIFE and After Completion of Therapy (ACT) Clinics and are then seen yearly until 10 years after diagnosis or 18 years of age, whichever is later. This comprehensive follow-up in- volves full clinical evaluations with laboratory and imaging studies when indicated.
Survival outcomes were analyzed for the 12 patients with Wilms tu- mors. Overall survival (OS) distributions were estimated by the Kaplan- Meier method and compared with the log-rank (Mantel-Cox) test. OS was defined as the time from diagnosis by biopsy to death caused by a disease. The nominal significance level was set at 0.05. Patients who died without experiencing an event at their date of death and patients who were still alive without experiencing an event at their last follow- up were censored in the estimates. SPSS version 16.0 (IBM Corp., New York, NY) was used for statistical analysis.
2. Results
2.1. Surgical management of IVC thrombus and related morbidity
Fifteen children (9 females/6 males) with malignant solid tumors of the abdomen with IVC thrombi were identified. The extent of tumor and resection performed are illustrated in Fig. 1. Tumor resection and thrombectomy were performed in the same sitting in 12 patients, in subsequent operations in 2 patients, and no thrombectomy was per- formed in 1 patient. Resection of visible IVC thrombus was judged to be complete in 6 patients and partial in 7 patients, and no resection was performed in 1 patient; the extent of thrombus resection was un- known in 1 patient. Two patients required partial caval resection and re- construction because of adherent thrombus-a Gore-Tex® vascular patch was used in patient 12, and venoplasty was performed in patient 13. Patient 15 had large azygous collaterals, and had a segment of thrombosed cava excised without reconstruction. Cardiopulmonary by- pass was employed in patients 6 and 8, and anticipatory aortocaval can- nulation was performed in patient 14 without actual cardiopulmonary bypass. Patients 2 and 4 had Hinman level 3 tumors that were managed by clamping the lower portion of the right atrium during the thrombectomy and did not have cardiopulmonary bypass. IVC surgery was performed at our institutions in 9 patients, while 6 patients underwent surgery at other institutions before referral. No patient re- ceived long-term anticoagulation after IVC surgery. The median follow-up duration was 1.9 years (range: 0.6-15.6 years).
Perioperative complications occurred in 3 patients. Patient 5 had in- traoperative hemodynamic decompensation requiring cardiopulmo- nary resuscitation. Patient 8 had postoperative dehiscence of a median sternotomy wound, which was reclosed. Patient 13 had a bile leak from segment 1 that required reexploration and a hepaticojejunostomy on postoperative day 7. None of these patients experienced long-term sequelae from these perioperative complications.
Five of six patients who had complete resection of their IVC throm- bus had a patent IVC at follow-up (Table 1). Patient 15 had resection of the cava without reconstruction. Both patients who underwent caval resection and reconstruction (patients 12 and 13) remained patent. None of these patients received boost radiation to the vena cava, and none had subsequent venous complications or physiologic sequelae.
Three of the 7 patients who had partial resection of IVC thrombus had a patent IVC at follow-up and 4 had obstruction of the vena cava. The 6 patients with Wilms tumor and partial resection of IVC thrombus received between 9 and 30 Gy of additional radiation to the vena cava. Half of these patients maintained caval patency and half did not. Patient 11 did not have the extent of resection of IVC thrombus recorded and
had a patent IVC on follow-up. Patient 10 had no attempt at thrombus resection and had an occluded vena cava.
Physiologic sequelae related to IVC occlusion occurred in 2 of the 7 patients who had a partial thrombus resection. Patient 9 had preopera- tive bilateral lower-limb deep venous thrombosis that resolved with anticoagulation with low molecular weight heparin. That patient died of widespread metastatic disease 1.9 years after resection. Patient 14 de- veloped Budd-Chiari syndrome and veno-occlusive disease, which manifested as pleural effusions, persistent ascites, and lower extremity swelling that resolved after 10 months of therapy. This child was alive with widespread metastatic disease 2.1 years after resection.
2.2. Oncologic management and outcomes
2.2.1. Wilms tumor
Twelve patients had Wilms tumor. At diagnosis, 7 patients had a level I thrombus, 1 patient had a level II thrombus, and 4 patients had level III thrombus; one extended to the junction of the IVC and right atri- um (patient 4) and three extended into the right atrium (patients 2, 6, and 14).
Three patients (4, 5, and 10) had unfavorable histology and all died of disease 0.6 to 2.1 years after resection. Nine patients had favorable histology. Two (patients 7 and 9) died of disease 1.9 and 2.2 years after resection. Patient 14 is alive with disease 2.1 years after nephrecto- my with atrial and partial caval thrombectomy leaving some tumor in the retrohepatic cava, which was subsequently treated with a 30 Gy IVC boost. This patient’s course has been complicated by flank, liver and lung recurrences, veno-occlusive disease, and Budd-Chiari physiol- ogy with ascites. Patients 2 and 11 were lost to follow-up 1.6 and 2.6 years after resection. Patient 11 was known to have a liver recur- rence treated with radiation therapy before being lost to follow-up.
Four patients with favorable histology are alive with no evidence of disease 8.0 to 15.8 years after resection. Two had complete resection of the tumor thrombus and two had partial resection. Pathology at the time of resection showed 3 of the 4 had viable tumor in their thrombus at the time of resection. The two with partial thrombus resection had a subsequent boost of radiation to the cava, while the two with complete resection had standard radiation therapy for local stage. These 4 (pa- tients 1, 3, 6, and 12) are on long-term follow-up in the ACT clinic.
Ten patients received preoperative chemotherapy, 2 patients (pa- tients 1 and 5) with Hinman level I thrombus received upfront surgery. Interestingly, of the 4 patients with level III thrombus (patients 2, 4, 6, and 14), none had retraction of the thrombus to level II or below.
Adjuvant radiation therapy was used for Stage III (local) disease in 11 patients. The doses of radiation administered to the flank or abdo- men ranged from 9 to 12 Gy. Three patients who had partial resection of tumor thrombus with viable tumor on histology received boosts to the vena cava of 9 to 30 Gy. No complications from radiation therapy were detected in our series.
Overall survival for the 12 patients with Wilms tumors was signifi- cantly associated with IVC patency on follow-up imaging (P = 0.03) and histologic type (favorable versus unfavorable histology, P = 0.01). OS was not associated with Hinman level, viability of tumor thrombus, and completeness of surgical thrombectomy, (P = 0.39, 0.70, and 0.98, respectively, log-rank test).
2.2.2. Hepatoblastoma
Patients 13 and 15 had stage IV hepatoblastoma. Biopsy and 4 courses of cisplatin, 5-flurouracil, vincristine and doxorubicin (C5VD) were administered before definitive surgery per treatment guidelines from AHEP 0731. In both cases, tumor thrombus was Hinman level 3, and in both cases the thrombus decreased in size and retracted to Hinman level 2. Hepatic resections were performed with vascular isola- tion of the liver using a Pringle maneuver, and clamping the cava above the tumor at the diaphragm, and below the tumor at or below the level of the renal veins without cardiopulmonary bypass. In case 13 the cava
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Patient 6
Patient 7
Patient 8
Patient 9
Patient 10
Patient 11
Patient 12
Patient 13
Patient 14
Patient 15
was repaired with a venoplasty and the right hepatic (segment 7) vein was re-implanted into the repaired cava. In case 15 the left hepatic vein margin was closed with the atrial cuff so as not to obstruct venous outflow from the residual liver. Tumor thrombus was extracted from the infrahepatic cava at the junction with the renal vein and the cava closed above the renals. Large azygous veins drained the kidneys ade- quately to prevent any venous hypertension, and the cava was therefore not reconstructed. No viable tumor was identified on histologic exami- nation of the tumor thrombus of either patient. Both patients received 2 courses of consolidation C5VD after resection. Pulmonary metastases disappeared with chemo and neither patient required metastectomy.
No radiation therapy was used for these two patients. At the time of study patient 15 was alive and NED 2.2 years after resection, and patient 13 was alive with no evidence of hepatoblastoma 2.7 years after resec- tion but had had a metachronous renal cell carcinoma resected, which recurred and required re-resection despite additional chemotherapy.
2.2.3. Adrenocortical carcinoma
Patient 8 was referred with recurrent adrenocortical carcinoma, which included pulmonary metastases and a Hinman III level tumor thrombus extending into the right atrium. This patient was treated with a median sternotomy, resection of the tumor thrombus that was
| no. | Patient | Sex | Age (years) | Diagnosis | Hinman level | Extent of resection of IVC thrombus | Radiation therapy | Histology of thrombi | IVC, RA patency on follow-up imaging | Imaging modality | Imaging follow- up (years) | Survival outcome (years) | Long-term sequelae |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | F | 5.2 | FH WT stage II | 1ª | Complete | Nil | Viable | Patent | MRI | 15.6 | NED | Nil | |
| tumor | (15.8) | ||||||||||||
| 2 | M | 2.3 | FH WT | III (RA) | Partial | 10.8 Gy | Viable | Patent, | CT | 1.0 | LTFU | Nil | |
| stage III | (flank), | tumor | residual | (1.6) | |||||||||
| 21.6 Gy (IVC) | atrial | ||||||||||||
| thrombus | |||||||||||||
| 3 | F | 1.4 | FH WT | II | Partial | 12 Gy | Viable | Patent | US | 10.3 | NED | Chronic kidney | |
| stage III | (abdomen), | tumor | (15.8) | disease | |||||||||
| 9 Gy (IVC) | |||||||||||||
| 4 | M | 4.1 | UH WT | III (IVC/RA | Partial | 12 Gy (flank), | No viable | Nonpatent | CT | 1.8 | DOD | Nil | |
| stage III | junction) | 27 Gy (IVC) | tumor | (1.9) | |||||||||
| 5 | F | 6.0 | UH WT | 1ª | Complete | 10.5 Gy | Viable | Patent | CT | 2.0 | DOD | Nil | |
| stage III | (abdomen) | tumor | (2.1) | ||||||||||
| 6 | F | 15.8 | FH WT | III (RA) | Partial | 12 Gy (flank), | Unknown | Patent but | US | 8.9 | NED | Lung recurrence | |
| stage IV | 19.5 Gy (IVC) | with | (13.5) | (resected); | |||||||||
| (local stage III) | septation | impaired | |||||||||||
| lung function | |||||||||||||
| 7 | F | 3.6 | FH WT | I | Complete | 10.5 Gy | No viable | Patent | CT | 2.0 | DOD | Flank, lung | |
| stage IV | (flank), | tumor | (2.2) | recurrence | |||||||||
| (local stage III) | 12 Gy (lungs) | ||||||||||||
| 8 | F | 15.4 | Recurrent | III (RA) | Partial | Nil | Viable | Nonpatent | CT | 0.7 | DOD | Nil | |
| adrenocortical | tumor | (1.2) | |||||||||||
| carcinoma | |||||||||||||
| stage IV | |||||||||||||
| 9 | F | 10.4 | FH WT Stage IV | I | Partial | 10.5 Gy | Viable | Nonpatent | CT | 1.6 | DOD | Bilateral femoral | |
| (local stage III) | (abdomen), | tumor | (1.9) | DVT; lung, liver, | |||||||||
| 12 Gy (flank | brain, vertebral | ||||||||||||
| boost), | recurrences | ||||||||||||
| 7.2 Gy (liver), | |||||||||||||
| 12 Gy (lungs) | |||||||||||||
| 10 | F | 4.2 | UH WT | I | Not performed | 9 Gy | NA | Nonpatent | CT | 0.6 | DOD | Progressive | |
| stage IV | (abdomen), | (0.6) | pulmonary | ||||||||||
| (local stage III) | 12 Gy (lungs) | disease | |||||||||||
| 11 | F | 7.7 | Local relapse | I | Unknown | 10.8 Gy | Unknown | Patent | MRI | 2.6 | LTFU | Liver recurrence | |
| FH WT stage V | (flank) | (2.6) | (treated with | ||||||||||
| radiation 10.5 Gy) | |||||||||||||
| 12 | M | 13.9 | FH WT | I | Complete | 10.5 Gy | Viable | Patent | CT | 4.1 | NED | Chronic kidney | |
| stage IV | (abdomen), | tumor | (8.0) | disease | |||||||||
| (local stage III) | 12 Gy (lungs) | ||||||||||||
| 13 | M | 2.2 | HB (mixed) | III (RA)b | Complete | Nil | No viable | Patent | US | 2.0 | NED | Metachronous | |
| stage IV | tumor | (2.5) | renal cell | ||||||||||
| carcinoma (resected) | |||||||||||||
| 14 | M | 3.7 | FH WT | III (RA) | Partial | 10.5Gy | Viable | Nonpatent | US | 1.7 | AWD | Budd-Chiari syndrome, | |
| stage IV | (abdomen), | tumor | (2.1) | VOD, radiation-induced | |||||||||
| (local stage III) | 30 Gy (IVC), | gastritis; flank, liver | |||||||||||
| 12 Gy (lungs) | and lung recurrences | ||||||||||||
| 15 | M | 3.4 | HB (mixed, | III (RA)b | Complete (IVC | Nil | No viable | Nonpatent | MRI | 1.7 | NED | Nil | |
| teratoid | excision) | tumor | (IVC | (2.2) | |||||||||
| features) | interruption) | ||||||||||||
| stage IV | |||||||||||||
WT: Wilms tumor, FH: favorable histology, UH: unfavorable histology, HB: Hepatoblastoma, IVC: inferior vena cava, RA: right atrium, MRI: magnetic resonance imaging; CT: computed tomography; US: ultrasound; NA: not available; IVC: inferior vena cava, RA: right atrium, DVT: deep vein thrombosis, DOD: died of disease, NED: no evidence of disease, AWD: alive with disease, VOD: veno-occlusive disease.
a Upfront surgery performed without neoadjuvant chemotherapy.
b Tumor thrombus retracted to level II with neoadjuvant chemotherapy.
judged to be incomplete in the retrohepatic IVC with direct repair of these structures. A pulmonary metastectomy was done simultaneously. This patient died of progressive disease 1.2 years after resection.
3. Discussion
The treatment of tumor thrombus in the vena cava of children with solid abdominal malignancies is a rare but complex clinical problem with little published evidence to inform treatment decisions. The goal of this study is to provide teams faced with treatment planning for this difficult clinical scenario with detailed information on the treatment and outcomes of a series of children with vena caval tumor thrombus.
Surgical options depend on level and adherence of the thrombus to the caval wall. Hinman level III thrombus has been reported in 25%-37.5% of Wilms tumors with caval extension [10-12]. Adherent thrombus has been reported in 43.7%-61.7% of Wilms tumors with vascular extension [8]. In our 15 patients removal of all visible tumor thrombus without resection of at least a portion of the caval wall was possible in only 1 patient who had a Hinman level 1 thrombus.
For level I infrahepatic thrombus, control of the infrahepatic vena cava above the thrombus, with control of the renal veins, and IVC below the thrombus allows clamping and tumor extraction usually in- volving resection of a portion of the caval wall. This can be accomplished safely with little risk of hemodynamic instability. Primary repair of the
resulting caval defect should focus on maintenance of caval caliber. Ischemic time to the kidneys is rarely a problem and blood loss is usually minimal.
Treatment of level II or level III thrombus is more challenging. Vascu- lar control requires clamping the cava above the liver, which is usually associated with hypotension that may be profound. This also mandates at least some period of hepatic ischemia, intestinal venous congestion and renal venous obstruction. Reconstruction is difficult at this level. Graft reconstruction in oncologic resection has been well described in adults, particularly in the context of liver resections [5-7,13] and is es- sential in patients with hemodynamic compromise after caval clamping. Venous pressure in the unaffected proximal renal vein [14] and urine output and hemodynamic parameters after caval clamping have been used as intraoperative tests to predict the requirement for caval recon- struction. In our experience the need for reconstruction is usually obvi- ous based on the patient’s response to clamping of the suprahepatic vena cava.
In patients with hemodynamic stability the need for IVC replace- ment or reconstruction is more controversial [15,16]. Success with re- section of the cava without reconstruction has been reported in cases where satisfactory venous collaterals have developed in adults [17], and children [18,19]. Adverse events with this approach are variable [20,21], but may include postoperative leg swelling and late venous se- quelae [22]. Extensive retroperitoneal dissection can reduce collateral circulation and may increase the risk of late venous thrombosis and renal dysfunction [23-26].
For level III thrombi at or above the level of the diaphragm, the sur- geon must obtain control at the level of the right atrium. If this cannot be done without interfering with the tricuspid valve, cardiopulmonary by- pass may be necessary [27].
The progressively increasing complexity and potential morbidity of these surgical procedures have led to a strategy of neoadjuvant therapy for stable patients with the aim of shrinking and consolidating the tumor, simplifying surgical removal. In our patients significant change in Hinman level 3 thrombi occurred in 2 children with hepatoblastoma but did not occur in 4 patients with Wilms tumor. Importantly no child receiving neoadjuvant chemotherapy had a pulmonary embolism. This is in agreement with others who found that while tumor thrombus re- solved in only 10%-13% of assessed Wilms tumors treated with neoad- juvant chemotherapy [8,28], embolism or major complications of the approach were rare.
Most of our Wilms tumor patients received preoperative chemo- therapy. The 20% complication rate we found in these children is com- parable to the NWTS-4 experience where patients with neoadjuvant chemotherapy had complication rates of 13.2% [4,29]. In contrast, upfront resection in the NWTS-4, NWTS-3, and NWTS-1 studies has been associated with complications in 26%, 43%, and 73% of patients, re- spectively [8,30], and achieved complete removal of thrombus in only 9%-23% of patients. Although caval thrombus resection is a technically challenging procedure, the incidence of surgical mortality is not high. In 165 patients with IVC thrombus in the NWTS-4 study, no periopera- tive deaths were reported [8]. In our series, 1 patient required intraop- erative cardiopulmonary resuscitation, but it was not clear whether this was because of an aggressive attempt at resection. In the 12 patients with Wilms tumors we reviewed, vena cava patency on follow-up but not completeness of thrombectomy was associated with better survival. This is a novel finding. Previous studies have not captured this variable, which was not part of NWTS-4 data. The clinical and biological signifi- cance of this observation is uncertain. The patency of the IVC on follow-up may reflect the response of residual tumor to adjuvant thera- py, or may reflect the degree of invasiveness of tumor into the caval in- tima and media.
Our study was limited by its retrospective nature and small number of patients many of whom had advanced-stage and/or relapsed disease. The interpretation of outcomes for these children was complicated by the mixture of tumor types and disease stages. The small number of
patients precluded multivariable analysis. The lack of association of sur- vival with thrombus viability, completeness of resection or Hinman level may be artifacts imposed by the limitations of the study.
The strengths of the study lay in the structured long-term follow-up provided at our institution, which allowed the best description to date of the impact of treatment for malignant tumor thrombus on patient well-being. It was striking that most short-term morbidity was not di- rectly related to the vascular portion of the case, and that longer-term morbidity occurred in children with incomplete resection of the tumor thrombus and subsequent caval occlusion.
Our work also points out the desirability of a prospective, multi- institutional observational study designed to accurately document and track the oncologic and physiologic outcomes of IVC tumor thrombosis in children with primary abdominal malignancies, as well as to investi- gate the significance of new variables of interest, such as viability of tumor thrombus on histology and caval patency on follow-up.
On the basis of this patient series we agree with others who recom- mend that patients with Wilms tumor or hepatoblastoma who have caval thrombus receive neoadjuvant chemotherapy [12,27]. While the reduction of Hinman level with neoadjuvant chemotherapy is unpre- dictable, pulmonary embolism was rare, and surgical complications were lower than reported in studies utilizing only primary resection. Pa- tients with complete surgical clearance of tumor thrombus had no long term venous complications which were observed in a minority of pa- tients with partial resection. When complete resection of tumor throm- bus was not achieved partial thrombectomy and treatment of residual thrombus with adjuvant radiation therapy resulted in salvage of two children with advanced-stage favorable histology Wilms tumor.
Acknowledgments
The authors thank Ms. Liza Emanus and Ms. Sandra Grimes for administrative support.
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