Team approach to rare cardiovascular, renal surgery

Steve Enfinger, 57, recently retired and enjoying a round of golf, had no reason to believe anything was seriously wrong one day in July 2001 when he was overcome with pain. “I fell to the ground; I thought I had pulled a muscle,” the Denton resident said. It appeared to be no more than a simple strain until a few days later when Mr. Enfinger saw blood in his urine. After visiting several specialists, Mr. Enfinger was referred to Dr. Arthur Sagalowsky, Professor of Urology and Surgery at UT Southwestern Medical Centre. Dr. Sagalowsky diagnosed Mr. Enfinger with renal cell carcinoma.

Cancers of the kidney and renal pelvis are the 12th leading cause of cancer deaths in the United States. Mr. Enfinger had a rare complication, however. His tumour had a large clot growing out of the renal vein up the vena cava and into his heart.Mr. Enfinger underwent a complex surgery at UT Southwestern Medical Centre combining the skills of cardiovascular surgeons in the Heart, Lung and Vascular Clinical Centre and renal surgeons in the Harold C. Simmons Comprehensive Cancer Centre to remove his right kidney, affected lymph nodes and most of the massive tumour that had grown into the vena cava, the largest vein in the body. His case, along with 45 others, was examined for a review of patient outcomes in a study appearing in the June issue of the Journal of Thoracic and Cardiovascular Surgery.Surgeons at UT Southwestern have taken a team approach involving urology, cardiothoracic surgery, interventional radiology and medical oncology to treat patients with this rare and complex type of kidney tumour and have recorded some of the most successful patient outcomes nationally.”We now have experience as a group of doctors taking care of these high-risk surgical patients with terrific success rates compared with other clinics that perform similar surgeries,” said Dr. Michael DiMaio, Associate Professor of Cardiovascular and Thoracic Surgery. “Our five-year survival rate was among the highest of recent reviews of this type of surgery.”The one-year survival rate for patients is 78 percent, while two- and five-year survival rates are 69 percent and 56 percent, respectively. The surgery has been performed 46 times at UT Southwestern since the early 1990s. “This achievement underscores an excellent approach to patient care in which two of our most distinguished surgeons have collaborated on a very complex procedure,” said Dr. John McConnell, executive vice president for health system affairs. “We are pleased to be among the most innovative in the country and a top referral centre for this kind of surgery.”Dr. DiMaio, senior author of the study, and Dr. Sagalowsky have worked together for more than seven years on patients with this type of cancer. The complex surgery involves removal of the cancerous kidney and removal of the tumour clot. The latter may require surgery inside the chest cavity with partial or even complete heart bypass. The combined kidney and cardiovascular procedure can last from 12 to 14 hours, and the surgeons must work simultaneously on the patient.”We believe the team approach is the key to our good outcomes,” Dr. Sagalowsky said.In addition to the state-of-the art surgery, UT Southwestern patients also receive the latest drug therapies by medical oncologists to prevent recurrence or stop the growth of remaining tumour cells in cases where it was not feasible to remove the entire kidney tumour clot, Dr. Sagalowsky said.Mr. Enfinger, for example, still has a small inoperable tumour mass below the vena cava, near the spot where the vein enters the liver. That tumour has been petrified by regular injections of the drug interferon.”The treatment at UT Southwestern is awesome,” Mr. Enfinger said. “I’m glad I had some of the best doctors in the country.”(Source: Journal of Thoracic and Cardiovascular Surgery: UT Southwestern Medical centre: June 2006).