Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus.
BACKGROUND
The optimal management of patients with renal cell carcinoma with inferior vena cava tumor thrombus remains unresolved. Traditional approaches have included resection with or without the use of cardiopulmonary bypass. Chemotherapy has played a minor role except for biotherapeutic agents used for metastatic disease.


METHODS
From January 1989 to January 1996, 37 patients with renal cell carcinoma and inferior vena cava tumor thrombus underwent surgical resection. The 27 men and 10 women had a median age of 57 years (range, 29 to 78 years). Thirty-six patients presented with symptoms; 21 had hematuria. Distant metastases were present in 12 patients. Tumor thrombi extended to the infrahepatic inferior vena cava (n = 16), the intrahepatic inferior vena cava (n = 16), the suprahepatic inferior vena cava (n = 3), and into the right atrium (n = 2). All tumors were resected by inferior vena cava isolation and, when necessary, extended hepatic mobilization and Pringle maneuver, with primary or patch closure of the vena cavotomy. Cardiopulmonary bypass was necessary in only 2 patients with intraatrial thrombus.


RESULTS
Complications occurred in 11 patients, and 1 patient died 2 days postoperatively of a myocardial infarction (mortality, 2.7%). Twenty patients are alive; overall 2- and 5-year survival rates were 61.7% and 33.6%, respectively. For patients without lymph node or distant metastases (stage IIIa), 2- and 5-year survival rates were 74% and 45%, respectively. The presence of distant metastatic disease (stage IV) at the time of operation did not have a significant adverse effect on survival, as reflected by 2- and 5-year survival rates of 62.5% and 31.3%, respectively. Lymph node metastases (stage IIIc) adversely affected survival as there were no long-term survivors.


CONCLUSIONS
Resection of an intracaval tumor thrombus arising from renal cell carcinoma can be performed safely and can result in prolonged survival even in the presence of metastatic disease. In our experience, extracorporeal circulatory support was required only when the tumor thrombus extended into the heart.
Nesbitt
J C
JC
Department of Thoracic and Cardiovascular Surgery, The University of Texas M. D. Anderson Cancer Center, Houston 77030, USA.
Soltero
E R
ER
Dinney
C P
CP
Walsh
G L
GL
Schrump
D S
DS
Swanson
D A
DA
Pisters
L L
LL
Willis
K D
KD
Putnam
J B
JB
D000328:Adult; D000368:Aged; D002292:Carcinoma, Renal Cell / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000556:secondary* / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000150:complications / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D007813:Laparotomy; D007902:Length of Stay; D008113:Liver Neoplasms / Q000556:secondary; D008175:Lung Neoplasms / Q000556:secondary; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D009360:Neoplastic Cells, Circulating; D009392:Nephrectomy; D013125:Spinal Neoplasms / Q000556:secondary; D015996:Survival Rate; D013927:Thrombosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D014682:Vena Cava, Inferior / Q000601:surgery*