Bland thrombus association with tumour thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption

Abstract

E 4 4 9What ' s known on the subject? and What does the study add? The surgical implications of renal cell carcinoma with coexisting bland and tumour thrombi of the inferior vena cava is not well described. In this study we review our experience managing these tumours. On multivariate analysis, we found that the presence of bland thrombus was associated with an increased need for surgical interruption of the inferior vena cava. OBJECTIVE• To study the role of interruption of the inferior vena cava (IVC) in patients with renal cell carcinoma (RCC) and associated bland and tumour thrombi. METHODS• We reviewed 129 consecutive patients with the preoperative diagnosis of RCC with tumour thrombus who underwent radical nephrectomy and tumour thrombectomy in one academic institution between May 1997 and February 2011. RESULTS• Percentages of patients with levels I, II, III and IV tumour thrombus were 29%, 13%, 48% and 9%, respectively.• The perioperative mortality rate was 2.3%. There were 29 (22%) perioperative complications recorded.• In all, 19 patients underwent surgical interruption of the IVC by ligation or segmental resection, including one level II, 14 level III and four level IV thrombi.• A total of 15 patients (12%) had bland thrombus associated with the tumour thrombus; four of these underwent intraoperative IVC fi lter placement and eight underwent surgical IVC interruption.• Advanced level of tumour thrombus was the only signifi cant factor predicting association of bland thrombus (odds ratio [ OR ] = 2.09, 95% confi dence interval [ CI ] : 1.082 -4.037, P = 0.028).• On multivariate analysis, level of thrombus (OR = 3.1, 95% CI: 1.30 -7.74, P = 0.011) and association of bland thrombus (OR = 9.07, 95% CI: 2.42 -34.01, P = 0.001) were signifi cant factors for IVC interruption. CONCLUSIONS• Surgical interruption of the IVC is a feasible option in selected patients with chronic IVC obstruction. Association of bland thrombus with tumour thrombus should alert the surgical team to the potential for a challenging surgery.• Precise preoperative imaging to assess the degree of venous obstruction and to help with differentiation between bland and tumour thrombus is key to achieving a surgical outcome with minimal morbidity. KEYWORDSrenal tumour , tumour thrombus , inferior vena cava fi lter , pulmonary emboli , tumour thrombus emboli , bland thrombus emboli Study Type -Therapy (case series) Level of Evidence 4

Transplantation techniques for the resection of renal cell carcinoma with tumor thrombus: A technical description and review

“…Still other tumors with complete chronic obstruction can be managed with total interruption of the IVC with either stapling or oversewing [29]. In a recent analysis by our group, level of thrombus (OR ϭ 3.1, 95% CI: 1.30 -7.74, P ϭ 0.011) and the presence of bland thrombus (OR ϭ 9.07, 95% CI: 2.42-34.01, P ϭ 0.001) were significant risk factors for the need for IVC resection [30].…”

Development of a surgical safety checklist for the performance of radical nephrectomy and tumor thrombectomy

“…Of note, one report showed no 5-year survivors in the setting of incomplete local resection [27]. In a recent report from our group, we observed that the presence of a bland thrombus increases the likelihood that IVC wall invasion is present requiring IVC resection [13]. In the setting of a large, long-standing thrombus, collaterals may be present and likely preclude the need for IVC replacement.…”

“…The presence of a coexisting bland thrombus increases the possibility that the patient will need to undergo an IVC resection, or less preferably placement of an IVC filter [13]. Magnetic resonance imaging (MRI) is currently the gold standard for detecting a tumor thrombus level with 100% sensitivity [14].…”

“…Concomitant bland thombus is present in 15-20% of cases with level II-IV tumors [13]. While some groups advocate for the preoperative placement of an IVC filter to prevent an embolic event, we disagree with this practice as it risks incorporation of the filter into the thrombus.…”

Tumour Thrombi in the Suprahepatic Inferior Vena Cava: The Cardiothoracic Surgeons’ View

“…The cardiothoracic surgeon is increasingly involved [19,37] were previously excluded from their management [10,16,51]. We believe that preemptive cardiothoracic consultation is instrumental in developing such standard of care.…”