Management of inferior vena cava tumor thrombus in locally advanced renal cell carcinoma

Abstract

Abstract:The diagnosis of renal cell carcinoma is accompanied by intravascular tumor thrombus in up to 10% of cases, of which nearly one-third of patients also have concurrent metastatic disease. Surgical resection in the form of radical nephrectomy and caval thrombectomy represents the only option to obtain local control of the disease and is associated with durable oncologic control in approximately half of these patients. The objective of this clinical review is to outline the preoperative evaluation for, and operative management of patients with locally advanced renal cell carcinoma with venous tumor thrombi involving the inferior vena cava. Cornerstones of the management of these complex patients include obtaining high-quality imaging to characterize the renal mass and tumor thrombus preoperatively, with further intraoperative real-time evaluation using transesophageal echocardiography, careful surgical planning, and a multidisciplinary approach. Operative management of patients with high-level caval thrombi should be undertaken in high-volume centers by surgical teams with capacity for bypass and invasive intraoperative monitoring. In patients with metastatic disease at presentation, cytoreductive nephrectomy and tumor thrombectomy may be safely performed with simultaneous metastasectomy if possible. In the absence of level one evidence, neoadjuvant targeted therapy should continue to be viewed as experimental and should be employed under the auspices of a clinical trial. However, in patients with significant risk factors for postoperative complications and mortality, and especially in those with metastatic disease, consultation with medical oncology and frontline targeted therapy may be considered.

En bloc laparoscopic radical nephrectomy with inferior vena cava thrombectomy: A single‐institution experience

“…Although targeted therapy was beneficial in this patient, it appears to have limited effects on RCC with an IVC thrombus . Therefore, targeted therapy might be considered only in patients at a significantly high risk of perioperative mortality …”

Sarcomatoid Variant of Urothelial Carcinoma of the Renal Pelvis with Inferior Vena Cava Tumour Thrombus: A Case Report and Literature Review

“…Renal cell carcinoma (RCC) is known to have a predisposition for vascular invasion, and in 10–25% cases tumour thrombus may extend into the inferior vena cava [13]. However, urothelial carcinoma arising from the renal pelvis rarely invades IVC.…”

The role of transesophageal echocardiography in the management of renal cell carcinoma with venous tumor thrombus

“…Currently, no available systemic therapies have achieved a significant clinical response, and none are curative when used alone. While multiple studies have investigated the use of neoadjuvant systemic therapy to decrease tumor thrombus burden, this has demonstrated mixed results and could potentially cause a harmful delay in surgical resection which may result in tumor progression . Interestingly, operative mortality increases from 2% to as much as 9.3% when IVC extension is present .…”