A 14-month-old female was referred to our hospital with a history of an enlarging abdominal mass noted by her parents for 3 days. Physical examination revealed an abdominal mass with clear and smooth margins extending from the right upper quadrant to the right hemipelvis. Routine blood tests were normal apart from mild anaemia and urine analysis did not show hematuria. Ultrasonography of the abdomen revealed a unilateral 10.8 × 7.2 × 9.2 cm solid tumor in the right kidney, whereas the contralateral kidney was normal. Computed tomography (CT) revealed a large lesion arising from the inferior aspect of the right kidney, occupying the right flank and extending across the midline. Enhanced CT detected duplication of IVC below the renal veins and compression and displacement of the right IVC caused by the enormous tumor (Fig. ). An additional movie file shows this in more detail [see Additional file ].\nNeither intravascular extension nor invasion to adjacent organs and regional lymph nodes was detected by CT. Chest radiography was reported normal.\nWith the presumptive diagnosis of WT, a right-sided radical nephrectomy was performed. Final pathology was consistent with favorable histology, stromal-predominant (60%) WT. The renal vessel and IVC were tumor free. The renal hilar and para-aortic lymph nodes were also free from tumor and the final pathological stage was Stage I. According to the regimen of the National Wilms’ Tumor Study Group 5, the patient received postoperative chemotherapy with dactinomycin and vincristine. CT imaging at 3 months postoperatively showed no evidence of residual or recurrent disease. Interestingly, the right IVC played a dominant role and the left IVC seemed to disappear in postoperative enhanced CT (Fig. ). An additional movie file shows this in more detail [see Additional file ]. During the follow-up of 18 months, no local recurrence or metastasis has been observed.
A 67-year-old woman with hepatitis C was found to have a liver tumor located in segment 8 during follow-up computed tomography (CT) for pyogenic spondylitis. She also had a past medical history of cirrhosis due to hepatitis C infection and diabetes mellitus. Laboratory examination showed normal levels of carcinoembryonic antigen, carbohydrate antigen 19–9, and α-fetoprotein but elevated protein induced by vitamin K antagonist-II at a level of 106 mAU/mL. Other laboratory studies showed the following: total bilirubin 0.6 mg/dL, albumin 3.2 g/dL, prothrombin time 13.7 s, aspartate aminotransferase 28 IU/L, alanine aminotransferase 22 IU/L, blood urea nitrogen 16 mg/dL, and creatinine 0.54 mg/dL. The Child-Pugh score was grade A (6 points), and the indocyanine green retention rate at 15 min was 16.6%. A diagnosis of hepatocellular carcinoma (HCC) located in segment 8 was indicated by CT (Fig. ), magnetic resonance imaging (Fig. ), and ultrasonography. The tumor was attached to the MHV. CT scans also showed multiple varices (Fig. ). MHV resection was necessary to obtain sufficient surgical margins. Central bisectionectomy (S4, S5, and S8 resection) was suggested but could not be tolerated because of her poor liver function and low future liver remnant volume, which preoperatively was only 56% by CT volumetry. Therefore, we decided to perform partial hepatectomy with MHV resection. Preoperative CT scans revealed the existence of duplicated IVC (Fig. ), so we chose to use the left IVC as the graft for reconstructing the MHV.\nThe surgery started with an inverted L-shaped incision. Intraoperative ultrasonography confirmed a 3.5-cm tumor that was touching the MHV. After mobilization of the right lobe, the liver parenchyma was transected, preserving the right hepatic vein and right anterior glissonian pedicle. A 3-cm portion of the MHV was resected around the tumor to obtain sufficient surgical margins. Immediately before resecting the MHV, we harvested the left IVC for use as the graft. After incising the retroperitoneum beside the Treitz ligament, the LRV, which had ramified from the IVC, was detected. The left IVC, which had ramified 3 cm peripherally from the origin of the LRV, was then isolated and harvested for 5 cm from the confluence of the LRV. The cut ends of the left IVC were closed with 4–0 polypropylene running sutures. The venous graft was anastomosed first to the proximal end of the MHV and then to the distal end using 6–0 polypropylene (Fig. ). A good Doppler flow through the graft was confirmed after the reconstruction. The operation required 394 min, and the estimated blood loss was 1,894 mL.\nMacroscopic evaluation showed a 35-mm bile-stained tumor (Fig. ). Histologic examination revealed moderately differentiated HCC without direct invasion of the MHV and a tumor-free surgical margin (Fig. ). The tumor was classified as stage II (T2N0M0) according to the TNM staging system for HCC. The patient recovered uneventfully and was discharged on postoperative day 12.\nThe patency of the reconstructed MHV was confirmed postoperatively by ultrasonography and dynamic CT (Fig. ). Laboratory examination 2 years after surgery showed normal levels of total bilirubin (0.6 mg/dL), albumin (4.0 g/dL), aspartate aminotransferase (24 IU/L), alanine aminotransferase (24 IU/L), prothrombin time of 13.5 s, blood urea nitrogen (15 mg/dL), and creatinine (0.46 mg/dL).\nNew lesions were found in the left lobe of the liver 4 months after surgery and in the right lobe 26 months after surgery. Both lesions were treated using transabdominal catheter embolization.