The surgical management and prognosis of renal cell cancer with IVC tumor thrombus: 15-Years of experience using a multi-specialty approach at a single UK referral center.

Abstract

OBJECTIVES: Surgical management of renal cell carcinoma (RCC) invading the inferior vena cava (IVC) remains a technical challenge. However, radical surgery is the only potentially curative treatment. We set out to review our experience of using a multi-specialty approach to these patients over the last 15 years. PATIENTS AND METHODS: Fifty patients with RCC and IVC invasion underwent surgery at our institution (mean age: 59 years). Tumor thrombus was infrahepatic/levels I and II: n = 24, intrahepatic/level III: N = 14, or suprahepatic/level IV: n = 12. Infra- and intrahepatic caval tumors were resected using an abdominal approach and liver transplant techniques without cardiopulmonary bypass (CPB). CPB was used only with level IV thrombus. RESULTS: There were no intraoperative deaths. Median operating time was 6 hours and blood loss 3.5 liters (l). Staging was T3b: n = 34, T3c: n = 10 and T4: n = 6. Median time spent in HDU and hospital were 2 and 12.5 days, respectively. Perioperative mortality was 4%. Metastatic disease (P < 0.001) and level IV thrombus (P < 0.05) were significant negative prognostic factors. Forty of the 50 patients did not have metastasis. With mean follow-up of 38 months, the non-metastatic group had 2-year estimated Kaplan-Meier survival of 82.0% falling to 62.4% at 5 years. Conversely, in the metastatic group, estimated 2-year survival was 26.6% falling to 0% by 5 years. CONCLUSION: Surgical treatment of RCC involving the IVC is possible with acceptable morbidity and mortality. Long-term survival can be expected in over 60% of non-metastatic patients at 5 years. These cases benefit from a multidisciplinary surgical approach. Level III thrombus can be successfully managed without CPB.