Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus and review of the literature

Background: The successful excision of a renal cell carcinoma (RCC) invading the inferior vena cava (IVC) remains a technical intraoperative challenge and requires careful preoperative surgical management planning. Although a radical operation remains the mainstay of the therapy for RCC, optimal management of patients with RCC causing IVC tumor thrombus remains unresolved. In this chapter, we review our experience over the past 12 years with 18 patients who had RCC causing IVC tumor thrombus. Methods: Between July 1990 and October 2001, 18 patients with RCC with IVC tumor thrombus underwent surgical treatment. The mean patient age was 54.2 years and the male to female ratio was 1. The cephalad extension of the tumor was infrahepatic in 9 patients, intrahepatic in 6, and suprahepatic with right atrial extension in 3 patients. All tumors were resected via the inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) were used in 3 patients. Results: The mortality rate was 5.5 % (1 patient was lost on the 11th postoperative day). Complications occurred in 5 patients. The remaining 17 patients (94.4 %) were successfully discharged from the hospital. Two of them died of tumor progression at the 43rd and 54th postoperative months. The 10-year Kaplan-Meier survival estimate was 75.6, with a mean follow-up of 64.1 months. The presence of lymph node metastases and perinephric spread seemed to possess an adverse effect on the survival in our patients. Although the groups in this series included small numbers of patients, there was no significant difference in survival with regard to the different levels of tumor thrombus extension into the vena cava. Conclusions: Surgical treatment is the preferred approach to patients with RCC and IVC tumor thrombi as it provides markedly better results when compared with the other therapeutical modalities. Our experience confirms that RCC with extension into the IVC is a potentially curable condition provided complete removal is achieved. The level of extension of the tumor thrombus dictates the surgical techniques used for successful removal of the tumor thrombus. The treatment of patients with caval involvement and metastatic disease at presentation needs to be carefully individualized. We believe that complete surgical excision of the tumor and the resulting thrombus and metastases, if present, with appropriate preoperative staging and a well-planned surgical approach, using CPB and DHCA when necessary, provide an acceptable long-term survival with a good quality of life expectation.