Purpose or Case Report: HISTORY AND CLINICAL COURSE:A 16-year-old male presented with worsening abdominal pain, non-bloody diarrhea, and unintentional weight loss. On exam, he had diffuse abdominal tenderness and unnoticed left testicular swelling. US demonstrated a heterogeneous left testicular mass; CT demonstrated a large heterogeneous left testicular mass with extensive tumor thrombus propagating along the left gonadal vein, into the renal vein, the IVC, right atrium, right ventricle with several metastatic pulmonary emboli. The patient underwent left orchiectomy, and pathology showed testicular mixed germ cell tumor with immature teratoma and yolk sac components. The patient was referred to our institution for further management of his intravascular and intracardiac tumor components, given the patient’s pathology fell under an intermediate category based on the “Intermediate Germ Cell Consensus classification” which supports treatment with curative intent given an 80% long-term survival rate.
PROCEDURE:An open surgical approach was used to remove tumor tissue from the right heart and supra-hepatic IVC. Percutaneous endovascular thrombectomy was then used to remove the tumor from the infra-hepatic IVC and the left renal vein 24 hours after the cardiac surgery.
Step 1: Distal Embolic Control: A single disc from an Inari Flow Triever device was deployed, via the right internal jugular vein, below the level of the hepatic veins to provide distal embolic control throughout the procedure. This is an alternative application for this device.
Step2: IVC tumor removal: An Inari Clot Triever device was deployed via the right common femoral vein. Multiple 360-degree sweeps throughout the IVC to ensure intravascular tumor removal as validated on follow-up IVC venography.
Step 3: Left renal vein tumor removal: The left renal vein thrombus was removed using a combination of the Flow Triever and aspiration catheter systems. IVUS and left renal venogram confirmed the tumor removal.
FOLLOW-UP:The hospital course was uneventful. The patient was anticoagulated with a tight INR goal of 1.5-2 to balance the need for anticoagulation and avoiding the risk of bleeding from recent cardiac surgery. Chemotherapy with Bleomycin, Cisplatin, and Etoposide was initiated upon discharge and will be reviewed by surgical oncology for retroperitoneal nodal clearance later. This case demonstrates the multi-disciplinary team approach to caring for a complex case of an extensive testicular tumor in a pediatric patient.
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