Vena Caval Involvement by Renal Cell Carcinoma

Abstract

In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level 1); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.

Venous spread of renal cell carcinoma: MDCT

“…The renal vein is reported to be involved in 23-25%, while IVC was involved in up to 10% cases [4,11]. It is also recorded that thrombus spread into the right atrium is evident in 2 -16% cases [24][25][26].…”

Prognostic relevance of intracaval neoplastic extension for patients with renal cell cancer

“…prognostic importance of VCT compared with other tumour characteristics has been diÃcult to determine Skinner et al [3] reported 53 patients with VCT of RCC and correlated, besides cranial extension of the tumour because previous investigations have not analysed all important tumour characteristics by univariate or multithrombus, several other tumour characteristics (fatty tissue infiltration, regional lymph node and distant metastvariate analysis. Indeed, the negative prognostic influence of fatty tissue infiltration and lymph node or distant ases, and local extension of the tumours) with the longterm survival of the patients.…”

“…Introduction long-term survival rate [3][4][5][6]; right atrial propagation of a tumour thrombus was a particularly unfavourable In Europe, about 27 000 new cases of RCC and 14 000 deaths from RCC are registered each year; 40% of patients prognostic factor [3][4][5]. However, comparing earlier investigations of the prognostic importance of VCT is present with regional lymph node or distant metastases on first diagnosis.…”

Precise control of caval and hepatic vessels: Surgical technique to treat level III caval thrombus concomitant to renal cell carcinoma

“…Although thoraco-abdominal incision is widely accepted, this procedure cannot effectively reduce operative risks when post-hepatic IVC and surrounding subsidiary veins are not isolated. 15 The key steps in this technique are to completely isolate the retro-and supra-hepatic IVC, and the first hepatic pedicle, and to clamp the IVC and hepatic pedicle to ensure a bloodless surgical field for thrombectomy and vascular suture. Furthermore, clamping time should be as short as possible to reduce ischemia-related complications.…”

“…The mean age was 59.2 ± 12.2 years (range: 38-76). The mean tumour diameter was 12.8 ± 3.4 cm (range: [6][7][8][9][10][11][12][13][14][15][16][17] and the mean size of the tumour thrombus in the proximal end IVC was 11.6 ± 1.9 cm (range: 9-15). Preoperative chest, abdomen, and pelvic computed tomography (CT) scan, upper abdominal 3-dimensional imaging, and IVC angiography were performed on all patients (Fig.…”