Prognostic Implications of Vena Caval Extension of Renal Cell Carcinoma

Abstract

Vena caval extension of renal cell carcinoma occurs in 4 to 10 per cent of the patients and usually is considered a poor prognostic sign. To ascertain the true effect of vena caval extension on survival a retrospective analysis was done of 27 patients who had undergone radical nephrectomy and removal of vena caval thrombus between 1970 and 1980. An additional 46 cases were collected from series in the literature and composite statistics were compiled. Extension to the vena cava alone had a limited impact on prognosis (survival for 2 years--81 per cent, 5 years--53 per cent, median--81 months). Capsular invasion negatively influenced survival (2-year survival 66 per cent). Disease in the regional lymph nodes had a much greater impact on survival, with a 2-year survival rate of 35 per cent and no patient survived 5 years (median survival 24 months). Only 5 per cent of the patients with distant metastases survived 2 years and none survived 5 years (median survival 8.5 months). In conclusion, the prognosis of patients with vena caval tumor thrombus is influenced primarily by known adverse prognostic factors: capsular invasion, nodal disease and distant metastases. Aggressive surgery in patients with gross nodal involvement or distant metastases is unwarranted since it contributes nothing to survival and only 7 per cent of the patients had significant signs or symptoms secondary to the vena caval thrombus itself. Patients with vena caval extension alone have a cure rate approaching that of patients with stage I renal carcinoma following radical nephrectomy and complete removal of the vena caval thrombus.

Cavoatrial Extension of Renal Cell Cancer: Results of Operative Treatment in Helsinki University Hospital between 1990 and 2000

“…Patient 7 was a high-risk patient with a history of chronic obstructive pulmonary disease and stroke, but patient 3 had no previous medical history. Peri-operative mortality rates of up to 40 % have been reported (8,22,23), but again, as the number of patients in these reports is small the statistics may represent stochastic variation and extensive conclusions should not be drawn.…”

Renal Vein and Vena cava Involvement Does Not Affect Prognosis in Patients with Renal Cell Carcinoma

“…Also, in this group of patients, prognosis is mainly affected by the simultaneous occurrence of local tumor invasion, lymph node involvement and distant metastases [11, 16, 25]. Most authors have reported the 5-year survival rate to be between 47 and 68% for patients with vena caval invasion without lymphatic or hematogenous metastases treated with radical nephrectomy and complete thrombus removal [11, 12, 13, 14, 15, 16, 17]. …”

“…Radical surgery, aimed at obtaining the complete removal of the cancer, plays a positive role in patients with RCC extending into the renal vein or vena cava without lymph node involvement or distant metastases [11, 12, 13, 14, 15, 16, 17]. …”

Inferior Vena Caval Tumor Extension in Renal Cell Carcinoma

“…How ever, in these early studies all patients were included in analysis irrespective of local tumor extension and of lymph node or distant metastasis. The advent of TNM tumor staging has allowed stratification of risk factors and more precise prognostic appraisal, and more recent 1 Paper held on the occasion of Annual Meeting of the Swiss Uro logical Society in 1989. reports reflect an improved prognosis for patients with inferior vena caval involvement [6][7][8], Indeed, Skiner et al [9] drew attention to the fact that the prognosis for such patients does not depend on the thrombus, but pro vided operation was radical with removal of thrombus, on the local extent and on the degree and nature of met astatic spread. Thus, if the kidney tumor and inferior vena caval tumor thrombus can be completely removed, patients with an intracapsular nonmetastatic renal cell carcinoma have better 5-year actuarial survival (55%) than patients with tumor infiltration into the fat capsule of the kidney without caval thrombus [6,10,11], The extension of the tumor into the inferior vena cava may thus be considered as the sole extrarenal manifestation of kidney cell carcinoma which, provided there is radical clearance of tumor, does not affect prognosis.…”

“…Whereas tumor thrombus in the renal vein does not constitute a particular operative problem, involvement of the inferior vena cava may give rise to major technical difficulty and operative mortality rises to between 3 [7] and 11 % [6].…”