Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study

Abstract

Background Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings. Methods Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I–IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus. Results Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively. Conclusion An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

T.H.R.O.B.V.S. Score – A Comprehensive Model to Predict the Surgical Complexity of Renal Cell Carcinoma With Tumor Thrombus

“…We recommend the following before formulating a comprehensive treatment plan for patients: 5) IVC angiography can be considered in patients with severe IVC occlusion and formation of collateral circulation to determine the extent of tumor thrombus and collateral circulation, to reduce intraoperative blood loss. If the tumor thrombus seriously invades the vascular wall and the formation of collateral circulation is good, segmental resection of IVC can be considered to eradicate the tumor completely, but the complexity of operation increases accordingly (11,13).…”

“…We recommend the following before formulating a comprehensive treatment plan for patients: (1) Detailed consultation and physical examination; (2) Urinary ultrasound: Patients with Mayo grade IV tumor thrombus should undergo preoperative echocardiography and intraoperative transesophageal ultrasound; (3) Plain and enhanced CT urography; (4) Plain and enhanced MRI of IVC within one week before operation to determine the level of tumor thrombus; (5) IVC angiography can be considered in patients with severe IVC occlusion and formation of collateral circulation to determine the extent of tumor thrombus and collateral circulation, to reduce intraoperative blood loss. If the tumor thrombus seriously invades the vascular wall and the formation of collateral circulation is good, segmental resection of IVC can be considered to eradicate the tumor completely, but the complexity of operation increases accordingly ( 11 , 13 ).…”

“…However, there is no quantitative tool to help surgeons make a proper determination with patients in advanced RCC with VTT ( 10 ). Most surgical decisions currently rely on qualitative indicators ( 11 – 13 ), which are far from standardized. It is detrimental to the reproducibility of treatment decisions and the growth of less-experienced surgeons.…”

The role of intraoperative transesophageal echocardiography in the management of renal cell carcinoma with atrial thrombus – case report

“…Vascular invasion above the diaphragm, including the RA, is described as stage IV in the Mayo classification (3) . IVC invasion occurs in 4% to 10% of cases, whereas about 1% to 3% of patients present with thrombus reaching the RA (4) . In cases of small, solid atrial tumor thrombus, treatment involves surgery through a transabdominal approach.…”

“…IVC invasion occurs in 4% to 10% of cases, whereas about 1% to 3% of patients present with thrombus reaching the RA ( 4 ) . In cases of small, solid atrial tumor thrombus, treatment involves surgery through a transabdominal approach.…”