A 26-year-old male patient was referred to the Urology Department of UNICAMP with a history of right inguinal pain for one year, hypogastric irradiation and progressive deterioration during an 8-month period.
During this period, the patient lost 4 kg of weight.
Physical examination revealed a palpable nodule in the right testicle, whose presence was confirmed by transrectal ultrasound (2.2 cm nodule with microcalcifications).
A computed tomography of the abdomen and thorax showed a tumor thrombus in the inferior vena cava, which began 3 cm below the mouth of the renal veins and spreads to the periaortic lymph node diameter up to 5 cm.
The anatomopathological result of the right radical orchidectomy was an embryonal carcinoma pT1.
Staging was completed with an echocardiogram, which revealed the presence of a thrombus in the right atrium, confirmed by magnetic resonance imaging (MRI).
On admission, the patient had 8.84 ng/ml of alpha-fetoprotein, 7.596 mU/ml of beta chorionic acid and 3.442 U/l of lactate dehydrogenase.
The patient was submitted to chemotherapy with PEb (cisplatinum, topdressed and bleomycin).
During the first cycle, the patient developed pulmonary thromboembolism, confirmed by ventilation/perfusion scintigraphy.
Oral anticoagulation was established with dicumarol (Marevan® 10 mg/day).
Four cycles of chemotherapeutic treatment were performed and MRI control showed nonpredictability of liver and lung metastases.
The atrial thrombus returned extensive and limited to the inferior vena cava and to the retrohepatic portion within about 3 cm. Serum levels of tumor markers remained unchanged (8 cm × retroperitoneal).
The treatment of choice for residual disease was surgical resection.
The V incision was performed on the right and an interaortocaval and paraaortic lymphadenectomy was performed.
Total cardiac arrest (during 16 min), extracorporeal circulation (for 58 min) and deep hypothermia (minimum temperature, 20oC) were performed before venous thrombus resection.
After the piggyback maneuver, to expose the retrohepatic portion of the vena cava, a cavotomy and resection of the intravenous thrombus were performed.
Since the thrombus was firmly attached to the vein wall, the lesion had to be resected, which caused extensive deepithelialisation.
During surgery, it was observed that the thrombus was limited to the inferior vena cava, without cardiac invasion, which confirmed the findings of preoperative MRI.
No blood transfusions were required during surgery (hemoglobin 10.5 g/dl at the end of the procedure).
Anticoagulant treatment was maintained for 6 months due to extensive deepithelialisation.
The pathological laboratory reported a thrombus rich in histiocytes and cholesterol crystals.
Lymph nodes showed extensive coagulative necrosis, foci of calcification fibrosis and chronic inflammatory processes, as well as absence of viable cells.
The thrombus contained undifferentiated tumor tissue.
The patient showed good clinical evolution and was discharged on the tenth postoperative day.
Currently, she is asymptomatic after a follow-up period of 26 months and does not present tumor recurrence.
Serum markers were normalized.
